MENIERE’

S DISEASE
BSN 3Y2-4S
CASE SCENARIO
45-year-old male patient was first
admitted to a hospital on December 2016
because of a severe vertigo attack
accompanied by right sensorineural hearing
loss. This patient had suffered from
fluctuating right sensorineural hearing loss
with vertigo since 1999. Audiogram
revealed a severe sensorineural hearing
loss at 35.0 dB, with a predominance of
low frequency impairment in the right ear
(Figure1). The vertigo improved with
FIGURE 1
conventional steroid injections given for • Together with continuous line and 〔 indicate hearing level of
one week, but hearing loss did not improve. air conduction, and bone conduction in right ear respectively.
• Together with dotted line and 〕 indicate hearing level of air
conduction, and bone conduction in left ear respectively.
CASE SCENARIO
Thereafter, oral betahistine, adenosine triphosphate disodium (ATP), and isosorbide were
prescribed, and vertigo disappeared. Since April 2016, however, a few times per month
the patient has experienced vertigo spells that were intractable to conventional medical
therapy (Figure2). Head CT, MRI, and MRA were normal. After four months, we inserted a
tympanic ventilation tube into the right tympanic membrane. His vertigo did not
improve in the following 15 months. In June 2020, the patient received intratympanic
injection of dexamethasone three times within six weeks. Dexamethasone treatment,
however, was not effective. An audiogram performed in October 2020 revealed that the
patient's right-side hearing level deteriorated to 62.5 Db (Figure3). The doctor
recommended alternative therapies including Meniett therapy and intratympanic
gentamicin injection.
CASE SCENARIO

FIGURE 2 FIGURE 3
• Together with continuous line and 〔 indicate hearing Audiogram on October 2020.
level of air conduction, and bone conduction in right ear
respectively.
• Together with dotted line and 〕 indicate hearing level
of air conduction, and bone conduction in left ear
respectively.
ETIOLOGY: UNKNOWN
Modifiable Risk Non-Modifiable Risk
Factors Factors
 Pressure changes in
 Age
atmosphere
 Gender
 Dietary changes
 Family History
 Stress
 Allergies
 Trauma to head or ear
 Over production of
endolymph
 Decreased reabsorption
of endolymph
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION

Patient based
● Recurring episodes of vertigo: a spinning sensation that starts and stops
spontaneously. Severe vertigo can cause nausea.
● Hearing loss: Hearing loss in Meniere's disease may come and go, particularly
early on.

Book based
● Ringing in the ear (tinnitus). Tinnitus is the perception of a ringing, buzzing,
roaring, whistling or hissing sound in ear.
● Feeling of fullness in the ear. People with Meniere's disease often feel pressure
in an affected ear (aural fullness).
DIAGNOSTIC FINDINGS
  Result Reference value Impression
Audiogram (2016) 35.0 dB 0-25 dB Increase
Audiogram (2020) 62.5 dB 0-25 dB Increase
CT scan - - normal
MRI - - normal
MRA - - normal

● Audiometric Testing - An audiometry exam tests how well your hearing functions.
It tests both the intensity and the tone of sounds, balance issues, and other issues
related to the function of the inner ear.
*Book based*
Electronystagmogram (ENG) test – it measures normal eye movement and
involuntary rapid eye movements called nystagmus. It also checks the muscles that
control eye movements. ENG checks how well the eyes, inner ears, and brain help you
keep your balance and position (such as when you change from lying down to
standing).
MEDICAL
MANAGEMEN
T
 Client Based
MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
GENERIC NAME PHARMACOKINET Treatment of • Betahistine is • Serum 1. Caution is
Oral Betahistine ICS Ménière's contraindicated concentration recommended
Betahistine comes syndrome for patients with may be when using
BRAND NAME in both a tablet pheochromocyto increased by betahistine and
Serc form as well as an ma (a rare, MAOIs (e.g. MAO inhibitors
oral solution, and is usually selegiline). (including MAO-B
CLASSIFICATION taken orally. It is noncancerous • Therapeutic selective)
Antivertigo rapidly and (benign) tumor effects may be concomitantly.
preparations completely that develops in decreased by 2. Betahistine
absorbed. The an adrenal antihistamines. dihydrochloride
DOSAGE & mean plasma gland). • May decrease should not be used
FREQUENCY elimination half-life • Patients with the concurrently with
Initially, 8-16 mg tid is 3 to 4 hours, and bronchial asthma bronchodilator antihistamines.
or 24 mg bid, excretion is virtually or a history of effects of β2 3. The lactation
adjusted according complete in the peptic ulcer need agonists. mother should be
to individual urine within 24 to be closely weighed against
response. hours. monitored. the benefits of
Maintenance: 24-48 nursing and the
mg daily. Max: 48 PHARMACODYNA potential risks for
mg daily. As MICS the child.
betahistine It is a weak agonist 4. Betahistine
mesilate: 6-12 mg on the H1 receptors dihydrochloride
tid. located on blood should be
MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
vessels in the inner administered with
ear. This gives rise caution to patients
to local vasodilation with a history of
and increased peptic ulcer,
permeability, which bronchial asthma,
helps to reverse the and porphyria.
underlying problem
of endolymphatic
hydrops. More
importantly,
betahistine has a
powerful
antagonistic effect
at H3 receptors,
thereby increasing
the levels of
neurotransmitters
histamine,
acetylcholine,
norepinephrine,
serotonin, and
GABA released
from the nerve
endings. The
MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
increased amounts
of histamine
released from
histaminergic nerve
endings can
stimulate receptors.
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
GENERIC NAME: PHARMACODYNA Prevention of Hypersensitivity to Alcohol: may cause 1. Monitor blood
ISOSORBIDE MICS angina that may nitrates; severe severe hypotension pressure and
•It works by cause anginal anemia; closed- and cardiovascular intensity and
BRAND NAME: relaxing the blood attacks. angle glaucoma, collapse. duration of
Imdur, Monoket, vessels and postural Aspirin: may response to drug.
ISMO increasing the •It reduces excess hypotension, head increase nitrate 2. Assess for and
supply of blood and fluid levels in the trauma, cerebral serum levels. report possible S&S
CLASSIFICATION oxygen to the heart body and treats hemorrhage. Calcium Channel of toxicity, including
PHARMACOLOGI while reducing its edema. Blockers: may orthostatic
C CLASS: Nitrates workload. cause orthostatic hypotension,
THERAPEUTIC hypotension. syncope, dizziness,
CLASS: •Increase the palpitations, light-
•Antianginals osmolity of plasma headedness,
•Osmotic Diuretics leading to severe headache,
absorption of water blurred vision, and
DOSAGE & from ocular tissues, difficulty breathing.
FREQUENCY: this process is 3. Instruct the
Immediate transient till the patient to avoid
Release: osmotic equilibrium alcohol ingestion
20 mg orally twice a is reestablished. It and aspirin unless
day, 7 hours apart may also decrease specifically
the aqueous permitted by
Extended Release: humour production physician.
30 to 60 mg orally through central 4. Maintain correct
once a day in the nervous system dosing interval and.
pathway
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
morning pathway do not withdraw
drug abruptly.
STOCK DOSE: PHARMACOKINET
10 mg, 20 mg ICS
tablets; 30 mg, 60 •Completely and
mg, 120 mg rapidly absorbed
sustained release from GI tract.
tablets •Metabolized in
liver by conjugation
to inactive
metabolites.
•Excreted primarily
by kidneys.
•Half-Life: 4–5 h.
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
GENERIC NAME: Converts Adenosine is a  Hypersensitivit Drug-drug. Patient Monitoring
Adenosine Paroxysmal prescription drug y to drug •Monitor heart
Triphosphate Supraventricular used for conversion  Second- or  Decreased rhythm for new
Disodium (ATP) Tachycardia to sinus rhythm of third-degree blood levels of arrhythmias after
(PSVT) to normal Paroxysmal AV block ketoconazole administering dose.
BRAND NAME: sinus rhythm by Supraventricular  Sinus node with rifampin •Check vital signs.
Adenocard and slowing conduction Tachycardia  Increased blood Assess for chest
disease
Adenoscan through (PVST) including levels of pain or pressure,
AtrioVentricular that associated with  Bronchoconstri dyspnea and
ctive lung cyclosporine
CLASSIFICATION: (AV) node and accessory bypass and risk to sweating.
Anti-arrhythmic interrupting reentry tracts (Wolff- disease •Watch for
  toxicity
pathway. Also used Parkinson-White  Increased bronchoconstriction
DOSAGE & as a diagnostic Syndrome). PRECAUTIONS: in patients with
Use cautiously in duration of
FREQUENCY: agent in thallium asthma,
adrenal
Adults scanning.  Asthma, angina emphysema or
suppression
• 6mg by  Elderly patients bronchitis.
rapid IV/IO bolus PHARMACODYNA with •Ask patient if he
 Pregnant
followed MICS: patients corticosteroids has recently used
immediately by a Adenosine binds to Children  Decreased aloe, buckthorn,
20mL saline flush. A1, one of multiple absorption if cascara sagrada,
If conversion Adenosine taken with guarana, rhubarb
doesn’t occur within receptors which in anticids, root or senna. If
1 to 2mins then the SA Node it histamine-2 responsive is
administer 12mg by blocks L-type blockers and positive, notify
rapid IV/IO bolus. Calcium Channels PPI. prescriber.
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
May repeat the and reduces Patient Teaching
12mg dose once if Calcium influx •Advise patient to
needed. The initial which may lead to a report problems at
dose should be ↓ to ↓ firing rate known infusion site.
3mg in patients as Negative •Tell patient he may
taking Chronotropic Effect experience 1 to
carbamazepine or 2mins of flushing,
dipyridamole in PHARMACOKINET chest pain,
those with a ICS: pressure and
transplanted heart • Adenosine is breathing difficulty
or in those administered during
receiving the drug intravenously. administration.
by central venous • Rapid metabolism Assure him that
access. of adenosine these effects will
results in an subside quickly.
Neonates extremely short •Advise patient to
• 0.05 to 0.1 plasma half-life minimize GI upset
mg/kg/dose by (less than 10 by eating small,
rapid IV/IO bolus seconds with frequent servings of
followed intravenous doses). healthy food and
immediately by a Due to this short drinking plenty of
saline flush. If half-life, it is not fluids.
conversion doesn’t known how •As appropriate,
occur within 1 to adenosine is review all other
2mins, additional excreted. significant and life-
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
boluses may be threatening adverse
administered at reactions,
incrementally interactions
higher doses especially those
increasing by 0.05 related to the
to 0.1 mg/kg with drugs, foods, herbs
each dose up to a and behaviors
maximum of 0.3 mentioned above.
mg/kg/dose.
•Studies have
shown that initial
doses of 0.05
mg/kg/dose and 0.1
mg/kg/dose
terminated the
arrhythmia in less
than 10% and less
than 37% of
pediatric patients
who received these
doses, respectively.
•The median
effective dose was
approximately
0.2mg/kg/dose.
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
Generic Name Reduces •Inner ear disorders •Hypersensitivity to •Barbiturates, 1.Question for
Dexamethasone inflammation by (Meniere’s disease) drug, benzyl phenytoin, rifampin: hypersensitivity to
suppressing •Macular edema alcohol, bisulfites, decreased any corticosteroids.
Brand Name polymorph nuclear following branch dexamethasone 2.Obtain baselines
EDTA, creatinine,
Apo- leukocyte retinal vein effects for height, weight,
polysorbate 80, or
Dexamethasone, migration, reversing occlusion or central methylparaben •Digoxin: increased blood pressure,
Dexasone, Ozurdex increased capillary retinal vein serum glucose,
•Systemic fungal risk of digoxin toxicity
permeability, and occlusion; electrolytes.
Classification stabilizing noninfectious infections •Ephedrine: 3.Monitor I&O, daily
Pharmacologic leukocyte uveitis affecting •Active or increased weight, serum
class: lysosomal posterior segment suspected ocular or dexamethasone glucose.
Glucocorticoid membranes. Also of eye periocular clearance 4.Assess for
Therapeutic class: suppresses •Allergic and infections, edema.
advanced •Estrogen, hormonal
Anti-inflammatory immune response inflammatory contraceptives: 5.Evaluate food
(by reducing conditions glaucoma blocking of tolerance.
Dosage/Frequency lymphatic activity), •Cerebral edema (intravitreal implant) dexamethasone 6.Monitor daily
8 mg/2cc (3 times stimulates bone •Suppression test metabolism pattern of bowel
within 6 weeks) marrow, and for Cushing’s activity, stool
promotes protein, syndrome •Fluoroquinolones:in consistency.
Stock Dose fat, and •Acute altitude creased 7.Report
•Elixir: 0.5 mg/5 ml carbohydrate sickness dexamethasone hyperacidity
•Intravitreal implant: metabolism. •Bacterial blood level and promptly.
0.7 mg meningitis effects 8.Check vital signs
•Oral solution: 0.5 Pharmacokinetics Bronchopulmonary at least twice daily.
mg/5 ml, 1 mg/ml •Rapidly absorbed dysplasia in 9.Be alert to
 MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
•Solution for from GI tract after preterm infants •Live-virus infection (sore
injection (sodium PO administration •Hirsutism vaccines: throat, fever, vague
phosphate): 4 •Suppression test decreased antibody symptoms).
mg/ml, 10 mg/ml, Pharmacokinetics for detection, response to 10.Assess
20 mg/ml, 24 mg/ml •Rapidly absorbed diagnosis, or vaccine, increased emotional status,
•Tablets: 0.25 mg, from GI tract after management of risk of adverse ability to sleep.
0.5 mg, 0.75 mg, 1 PO administration. depression reactions
mg, 1.5 mg, 2 mg, •Widely distributed. •Loop and thiazide
4 mg, 6 mg •Protein binding: diuretics: additive
High. hypokalemia
•Metabolized in •Nonsteroidal anti-
liver. inflammatory drugs:
•Primarily excreted increased risk of GI
in urine. adverse effects
•Minimally removed •Somatrem,
by hemodialysis. somatropin:
•Half-life: 3–4.5 hrs. decreased
response to these
drugs Drug-
diagnostic tests.
•Calcium,
potassium:
decreased levels
•Cholesterol,
glucose: increased
MEDICATIONS ACTION INDICATION CONTRAINDICATI DRUG TO DRUG NURSING
ONS INTERACTIONS CONSIDERATION
levels result threatening adverse
•Nitroblue reactions,
tetrazolium test: interactions
false negative especially those
result related to the
drugs, foods, herbs
and behaviors
mentioned above.
 Book Based
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
Generic Name PHARMACOKINET For Edema caused Hypersensitivity to •CNS: dizziness, •Monitor blood
Hydrochlorothiazide ICS: by heart failure, drug, other drowsiness, lethargy, pressure, fluid
Absorption of renal dysfunction, thiazides, headache, insomnia, intake and output,
BRAND NAME: hydrochlorothiazide cirrhosis, nervousness and daily weight.
sulfonamides, or
is reduced in corticosteroid tartrazine •CV: chest pain, •Assess electrolyte
Dyazide patients with therapy, or orthostatic levels, especially
congestive heart estrogen therapy potassium. Monitor
Renal hypotension,
CLASSIFICATION: failure. Peak for signs and
plasma For Mild to decompensation or •GI: nausea, vomiting symptoms of
Thiazide Dieuretics concentrations are moderate anuria hypokalemia.
observed within 1 hypertension •Metabolic: •Monitor blood urea
dehydration
DOSAGE: to 5 hours of nitrogen and
dosing, and range creatinine levels.
Capsules: 12.5 mg from 70 to 490 •Check blood
ng/mL following glucose level in
Oral solution: 10 oral doses of 12.5 diabetic patients.
mg/ml, 100 mg/ml to 100 mg. •Assess for signs
and symptoms of
Tablets: 12.5 mg, PHARMACODYNA gout attacks in
25 mg, 50 mg, 100 MICS: patients with gouty
mg Increases sodium arthritis.
and water excretion •Advise patient to
by inhibiting sodium take with food or
reabsorption in milk if GI upset
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
distal tubules; occurs.
promotes excretion •Tell patient to take
of chloride, early in day to
potassium, avoid nighttime
magnesium, and urination.
bicarbonate. Also, •Instruct patient to
may produce track intermittent
arteriolar dilation, doses on calendar.
reducing blood •Tell patient to
pressure. weigh himself daily,
at same time on
same scale and
wearing same
clothes.
•Instruct patient to
report decreased
urination, swelling,
unusual bleeding or
bruising, dizziness,
fatigue, numbness,
and muscle
weakness or
cramping.
•Instruct patient to
move slowly when
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
sitting up or
standing, to avoid
dizziness from
sudden blood
pressure
decrease.
•Caution patient to
avoid driving and
other hazardous
activities until he
knows how drug
affects
concentration and
alertness.
 MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
GENERIC NAME: PHARMACOKINET •Anxiety •Contraindicated in BodyWhole: Throat •periodically
Diazepam ICS: •Acute alcohol patients and chest pain. monitor LFTs, CBC,
Absorption withdrawal hypersensitive to and renal function
CNS: Drowsiness,
BRAND NAME: After oral •Muscle spasm drugs and in infants in patients receiving
fatigue
Valium administration •Status epilepticus, younger than age 6 repeated or
>90% of diazepam severe recurrent months(oral form) CV: Hypotension, prolonged therapy
CLASSIFICATION: is absorbed and the seizures tachycardia, edema, •Monitor HR, BP,
•myasthenia gravis,
central nervous average time to cardiovascular and mental status
system agent; achieve peak severe respiratory collapse changes. Patients
benzodiazepine plasma insufficiency, are at an increased
anticonvulsant; concentrations is 1 severe hepatic EENT:Blurred vision, risk for falls.
insufficiency, or diplopia, nystagmus.
anxiolytic – 1.5 hours with a
range of 0.25 to 2.5 sleep apnea GI:, nausea,
DOSAGE: hours. Absorption is syndrome constipation, dry
delayed and •acute-closure mouth
Injection: 5 mg/Ml decreased when glaucoma
administered with a Respiratory:Hiccups,
Oral solution: moderate fat meal. coughing,
5mg/5ml Distribution laryngospasm.
Diazepam and its Other:Pain, venous
Tablets: metabolites are thrombosis, phlebitis
2mg,5mg,10mg highly bound to at injection site.
plasma proteins
(diazepam 98%).
Diazepam and its
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
metabolites cross
the blood-brain and
placental barriers
and are also found
in breast milk in
concentrations
approximately one
tenth of those in
maternal plasma
(days 3 to 9 post-
partum). In young
healthy males, the
volume of
distribution at
steady-state is 0.8
to 1.0 L/kg.
Metabolism
Diazepam is N-
demethylated by
CYP3A4 and 2C19
to the active
metabolite N-
desmethyldiazepa
m, and is
hydroxylated by
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION
CYP3A4 to the
active metabolite
temazepam. N-
desmethyldiazepa
m and temazepam
are both further
metabolized to
oxazepam.
Temazepam and
oxazepam are
largely eliminated
by glucuronidation.
Elimination
The initial
distribution phase is
followed by a
prolonged terminal
elimination phase
(half-life up to 48
hours).

PHARMACODYNA
MICS:
A benzodiazepine
that potentiates the
MEDICATIONS ACTION INDICATION CONTRAINDICATI ADVERSE NURSING
ONS EFFECTS CONSIDERATION

effects of GABA,
depresses the
CNS, and
suppresses the
spread of seizure
activity.
MEDICATIONS ACTION INDICATION CONTRAINDIC DRUG TO ADVERSE NURSING
ATIONS DRUG EFFECT CONSIDERATI
INTERACTION ON
Generic Name Promethazine is •Promethazine •< 2 years old CNS •Sedation •Take drug
Promethazine an antagonist of is used for the patients Depressants- •Confusion exactly as
histamine H1, treatment of •Lactation may increase, •Disorientation prescribed.
Brand Name post-synaptic allergic •Hypersensitivity prolong, or •Blurred vision •Give IM
Phenergan, mesolimbic symptoms, often to promethazine intensify the •Hallucinations injections deep
Phenadoz dopamine, alpha given at night andother sedative action •Muscle spasms into muscle and
adrenergic, because of its phenothiazines of other central- •Euphoria do not
Classification muscarinic, and marked sedative •Patients nervous-system •Excitation administer
Pharmacologic NMDA effects. receiving depressants, •Extrapyramidal subcutaneously.
class: receptors. The •It is usually therapy with such as alcohol, symptoms •Avoid
Phenothiazines antihistamine given orally for monoamine sedatives/hypno (tremors, jerky taking/drinking
Therapeutic action is used to the treatment of oxidase tics. movements, alcohol.
class: treat allergic allergic inhibitors muscle rigidity) •Avoid driving or
Antihistamines reactions. conditions but (MAOI) Epinephrine- •Tachycardia engaging in
Antiemetics Antagonism of can be given by •Patients with because of the •Photosensitivity other activities
Dosage/Freque muscarinic and deep narrow angle potential for •Dry mouth that may cause
ncy: NMDA receptors intramuscular glaucoma and Promethaine to •Impotence danger to the
contribute to its injection or slow bladder neck reverse •Urinary patient.
Allergic use as a sleep intravenous obstruction epinephrine’s retention •Avoid
Conditions aid, as well as injection vasopressor prolonged
PO/PR: 25 mg for anxiety and in effect, exposure to
at bedtime or tension. emergencies. epinephrine sun, or use a
12.5 mg before Antagonism of •Used as an should NOT be sunscreen or
meals and at histamine H1, anaethetic pre- used to treat covering
medication to
MEDICATIONS ACTION INDICATION CONTRAINDIC DRUG TO ADVERSE NURSING
ATIONS DRUG EFFECT CONSIDERATI
INTERACTION ON
bedtime muscarinic, and produce hypotension garments.
(dosage range, dopamine sedation, associated with •Report sore
6.25-12.5 mg receptors in the reduce anxiety Promethazine throat, fever,
q8hr) medullary and also to Tablets and unusual
vomiting center reduce post Suppositories bleeding or
Nausea & make operative overdose. bruising, rash,
Vomiting promethazine nausea and weakness,
PO/PR: 12.5-25 useful in the vomiting. Monoamine tremors,
mg q4-6hr PRN treatment of •Taken before Oxidase impaired vision,
nausea and travelling, and is Inhibitors dark urine, pale
IV/IM: 12.5-25 vomiting. effective in (MAOI) - Drug stools, yellowing
mg q4-6hr PRN preventing interactions, of the skin or
Pharmacokinetic motion including an eyes.
Motion Sickness s sickness. increased
25 mg PO/PR incidence of
30-60 minutes •Completely extrapyramidal
before absorbed from effects, have
departure and the been reported
q8-12hr PRN; gastrointestinal when some
on succeeding tract MAOI and
travel days, 25 phenothiazines
mg PO/PR •Promethazine are used
every morning is 93% protein concomitantly.
and every bound in serum,
MEDICATIONS ACTION INDICATION CONTRAINDIC DRUG TO ADVERSE NURSING
ATIONS DRUG EFFECT CONSIDERATI
INTERACTION ON
evening mostly to
albumin.
Preoperative
Sedation •The elimination
50 mg PO/PR half life of
on night before promethazine is
procedure or approximately
25-50 mg IV/IM 12-15h.
combined with
reduced doses
of analgesics
and atropinelike
drugs

Postoperative
Sedation
25-50 mg
IV/IM/PO/PR
combined with
reduced doses
of analgesics
and atropinelike
drugs
MEDICATIONS ACTION INDICATION CONTRAINDIC DRUG TO ADVERSE NURSING
ATIONS DRUG EFFECT CONSIDERATI
INTERACTION ON
Stock Dose
tablet
•12.5mg
•25mg
•50mg

suppository
•12.5mg
•25mg
•50mg

injectable
solution
•25mg/mL
•50 mg/mL
MEDICAL TREATMENT:
Meniett Therapy (Vibrator Therapy)
It is a low-pressure pulse generator that transmit
vibration via external auditory canal. Vibration
alter inner ear fluid dynamics by their effects on
the oval and round windows. Mechanism still
unknown.
Regular treatments with the Meniett device is an air-
pressure generator than can reduce the vertigo
symptoms of Ménière’s disease and improve
quality of life. Most doctors prescribe 3 Meniett
treatments a day, 5 minutes each time. The
Meniett device is small, portable and easy to use
just about anywhere for a short time each day.
SURGICAL MANAGEMENT
Patient-based
Tympanic Ventilation Tube (right tympanic membrane)
• Myringotomy tube, Tympanostomy tube, or Pressure
Equalization (PE)
 provide an alternative airway
 allow for drainage
 equalize the pressure inside the ear
• Tilted head  external auditory meatus  speculum placed into
the external auditory canal  cerumen is removed  incision (3-5
mm) of the tympanic membrane using myringotomy knife  tube
(3, 5 or 7 mm) is placed in the eardrum  creates an airway 
release the serous or mucoid effusion
• use of phenol and topical lidocaine (adults)
• general anesthesia (children)
• ear tubes fall out within 6 to 9 months and the holes heal
spontaneously but some tubes need to be removed and some
holes need to be closed surgically
SURGICAL TREATMENT
Book Based
1. Endolymphatic Sac Decompression
 A treatment that is performed to maintain the hydrostatic pressure and endolymph homeostasis
in the inner ear for patients with Meniere's disease. This procedure can reverse the damage to
the ear while maintaining the balance of your hearing levels.
2. Vestibular Nerve Sectioning
 A process of cutting the vestibular part of the cochleovestibular cranial nerve. This is generally
done in an attempt to eliminate recurrent attacks of vertigo.
3. Labyrinthectomy
 A surgical procedure for the management of poorly compensated unilateral peripheral vestibular
dysfunction in the presence of a nonserviceable hearing ear. Relief from vertigo is achieved at
the expense of the residual hearing in the ear to be operated.
 SIGNIFICANT FINDINGS
• Severe vertigo attack accompanied by right
sensorineural hearing loss
• Audiogram revealed a severe sensorineural
hearing loss at 35.0 dB, with predominance
of low frequency impairment in the right
ear.
• An audiogram performed in October 2020
revealed that the patient’s right- sided
hearing level deteriorated to 62.5 dB
NURSING
CARE
PLAN
Ineffective coping related to personal
vulnerability and unmet expectations
stemming from vertigo
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective coping Short-term Independent: Independent: • Client will be
"Napanghihinaan related to personal 1. Set a working 1. An ongoing able to verbalize
na ko ng loob dahil vulnerability and After 1-2 hours of relationship with relationship if he needed
sa mga unmet nursing the patient through establishes trust, help
nararamdaman ko" expectations intervention the continuity of care. reduces the feeling • The Client is
stemming from patient will be : of isolation, and cleared of self-
Objective: vertigo - verbalizes ability may facilitate destructive or
- Use of forms of to cope ask for coping. other destructive
coping that impede help when needed actions.
adaptive behavior - remains free of 2. Assist patient set 2. Involving • Patient can fulfill
[including destructive realistic goals and patients in decision therapeutic
inappropriate use behavior toward identify personal making helps them needs by
of defense self of other skills and move toward effective
mechanisms, - communicate knowledge. independence. verbalization of
verbal needs and emotions,
manipulation] negotiates with 3. Provide chances 3.Verbalization of formulation of
- Inability to meet other to meet to express actual or perceived alternatives, and
role needs concerns, fears, threats can help resource use.
expectations/basic feeling, and reduce anxiety and
needs Long-term expectations. open doors for
- Poor ongoing
concentration After 1-2 weeks of communication.
- Risk-taking nursing
intervention Patient 4.Use empathetic 4. Acknowledging
communication. and
will meet empathizing
psychological creates a
requirements as supportive
manifested by environment that
appropriate enhances coping.
verbalization of
feelings, 5. Convey feelings 5. An honest
formulation of of acceptance and relationship
options, and understanding. facilitates problem-
utilization of Avoid false solving and
resources. reassurances successful coping.
False
reassurances are
never helpful to the
patient and only
may serve to
relieve the
discomfort of the
care provider.

6. Encourage 6. Participation
patient to make gives a feeling of
choices and control and
participate in increases self-
planning of care esteem.
and scheduled
activities.

7.Consider mental 7. Interventions

and physical that improve body
activities within the awareness such as
patient’s ability exercise, proper
(e.g., reading, nutrition, and
outings, crafts, muscular
exercise, sports, relaxation may be
games, dinners helpful for treating
out, and social anxiety and
gatherings). depression.

8.Assist patients
with accurately 8. It can be helpful
evaluating the for the patient to
situation and their recognize that he
own or she has the
accomplishments skills and reserves
of strength to
. effectively manage
the situation. The
patient may need
help coming to a
realistic
 perspective of the
situation.

9. Provide 9. Patients who are

information the coping ineffectively
patient wants and have reduced
needs. Do not give. ability to absorb
more than the information and
patient can handle. may need more
guidance initially.

Dependent: Dependent:
As ordered by the
physician

1. Recommend 1. Meniett therapy

Menniet Therapy may prevent
vertigo attacks and
substantially
reduce its
frequency in MD
patients. It may
also alleviate the
functional deficit.
2. Give 2. A medication
intratympanic intended to
gentamicin purposefully
injection damage the inner
ear to stop dizzy
. spells in Meniere's
disease

Collaborative Collaborative
1. Refer for 1. Arranging for
counseling as referral assists the
necessary. patient in working
with the system,
2. Refer to medical and resource use
social services for helps to develop
evaluation and problem-solving
counseling. and coping skills.
2. This will promote
adequate coping
as part of the
medical plan of
care.
 DISTURBED SENSORY PERCEPTION:
(AUDITORY) HEARING LOSS RELATED
TO MENIERE’S DISEASE AS EVIDENCE
BY AUDIOGRAM: RIGHT SIDE HEARING
LEVEL DETERIORATED TO 62.5 Db,
VERTIGO AND DIZZINESS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: DISTURBED Short term: Independent: Independent: Short term:

“Hindi ko kayo SENSORY After 3 hours of 1. Assess the level 1. As a baseline Within 3 hours of
masyado maring PERCEPTION: nursing of hearing impaired data for further nursing
sa kanang tenga (AUDITORY) intervention the (mild, moderate, intervention interventions the
ko” as verbalized HEARING LOSS patient will be able severe) patient was able to:
by the patient. RELATED TO to:
MENIERE’S • Patient will be 2. Provide 2. To encourage • Patient is able to
Objective: DISEASE AS able to conductive effective demonstrate
• Difficulties EVIDENCE BY demonstrate environmental communication understanding
hearing AUDIOGRAM: understanding (calm and quiet) between the by a written,
• Audiogram: RIGHT SIDE by a written, patient and the verbal, or signed
right-side HEARING LEVEL verbal, or signed nurses, patient response
hearing level DETERIORATED response relatives.
deteriorated to TO 62.5 Db, • Determined the
62.5 dB VERTIGO AND • Determine the 3. Speak in normal 3.Pressing for minimal volume
• Dizziness or DIZZINESS minimal volume tones and avoid response may of the patient
Vertigo the patient can talking to fast. result in frustration can hear and
• Right hear and Avoid pressing for in patient understand a
sensorineural understand a response person.
hearing loss. person
4. Assist patient to 4. To help the Long term:
Long term: choose the best patient to have a
hearing aids better lifestyle in After 2 days of
After 2 days of according to the communicating nursing
nursing severity of the with the people interventions the
interventions the condition around patient was able to:
the patient will be 5. Assess 5. Surrounding
able to: environmental may affect the
factors (room noise ability to
• Use of form of level) communicate • Use form of
communication communication
to get needs 6. Assess 6. Specialized and needs met
met and relate conditions or services may be and relate
effectively with situations that may required to meet effectively with
the person and hinder the patient's needs. When air the person and
his/her ability to use or does not pass over his/her
environment understand vocal cords, environment.
language sounds are not
(tracheostomy, oral produced
or nasal intubation)

Collaborative: Collaborative:
1. Refer to 1. Specialized
appropriate services may be
resources required to meet
(speech therapist, needs.
group therapy or
psychiatric
counseling)
2. Assess 2. Individuals who
knowledge of have no formal
patient, family, or training in sign
caregiver language usually
understanding of develop
sign language as mechanisms for
appropriate. communication but
since
communication is
such a critical
aspect of
everyone's life,
consider formal
training for patient
and caregivers to
enhance
communication.
Risk for injury related to altered mobility
because of gait disturbance and vertigo
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury Short term: Independent: Independent: Short term:
“Nahihilo ako related to altered Within 2 hours of 1. Assess for 1. History provides Within 2 hours of
kapag gumagalaw mobility because of nursing vertigo, including basis for nursing
ako, umiikot ung gait disturbance interventions the history, onset, intervention interventions the
paningin ko, and vertigo patient will be able description of patient was able to:
konting galaw lang to: attacks, duration,
ng ulo ko para na frequency, and any 1. Remained free
akong tutumba” as 1. Demonstrate associated ear of any injuries
verbalized by the exercise therapy symptoms (hearing associated with
patient that help reduce loss, tinnitus, aural imbalance and/or
vertigo fullness) falls
Objective: 2. Demonstrate 2. Demonstrated
• Audiogram: measures that help 2. Assess extent of 2. Extent of exercise therapy
right-side reduce vertigo disability in relation disability indicates that help reduce
hearing level 3. Identify factors to activities of daily risk of failing vertigo
deteriorated to such as aura that living 3. Demonstrated
62.5 dB may contribute to measures that help
• Dizziness or possibility of injury 3. Teach or 3. Exercises reduce vertigo
Vertigo 4. Verbalize reinforce hasten labyrinthine 4. Identified factors
• Impaired understanding of vestibular/balance compensation, such as aura that
balance the medication to therapy as which may contribute to
• Difficulties alleviate symptoms prescribed decrease vertigo possibility of injury
hearing of vertigo and gait 5. Assumes safe
• Right disturbance position when
sensorineural vertigo is present
hearing loss. :
 4. Administer, or 4. To alleviate 6. Keep head still
teach of acute symptoms of when vertigo is
antivertiginous vertigo present
medications and/or
Long term: vestibular sedation Long Term:
After 8hours of medication; instruct After 8 hours of
nursing patient about the nursing
interventions the side effects interventions the
patient will be able patient was able to:
to: 5. Encourage 5. Decreases
patient to sit down possibility of failing
1. Remains free of when dizzy and injury 1. Verbalized
any injuries understanding of
associated with 6. Place pillow on 6. Movement the medication to
imbalance and/or each side of head aggravates vertigo alleviate symptoms
falls to restrict of vertigo
movement

7. Assist patient in 7. Recognition of

identifying aura aura may trigger
that suggests an the need to take
impending attack medication before
an attack occurs,
thereby minimizing
the severity of
effects
8. Recommend 8. Sensation of
that the patient vertigo decreases
keep eyes open and motion
and stare straight decelerates if eyes
ahead when lying are kept in a fixed
down and position
experiencing
vertigo
Anxiety related to change in health status
and disability effects of vertigo
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety related to Short term: Independent: Independent: Short term:

“Nangangamba change in health After an hour of 1. Assess Level of 1. Guides After an hour of
ako kasi parang status and nursing Anxiety therapeutic nursing
naapektuhan na disability effects of intervention, the intervention and interventions, the
yung pamumuhay vertigo patient will be able participation in self- goal is met.
ko dahil sa sakit to: care. Past coping Patient was able to
ko, lagi na siya skill can relieve
nasa isip ko di • Verbalize anxiety • Verbalized
mawala wala" as awareness of awareness of
verbalized by the feelings of 2. Identify the 2. Distorted feelings of
patient anxiety client's perception perceptions of the anxiety
• Appear relaxed of the threat situation may • Appear relaxed
Objective: and report that represented by the magnify feelings. and report that
• Severe vertigo anxiety is situation Understanding anxiety is
attack reduced to a client’s point of reduced to a
accompanied by manageable view promotes manageable
right level more accurate plan level
sensorineural of care
hearing loss in Long term Long Term
2016suffered 3. Be available to 3. Establishes
from fluctuating After 5hrs of the client for rapport, promotes After 5hrs of
right nursing listening and expression of nursing
sensorineural
intervention the talking feelings, and helps interventions
hearing loss with
vertigo since patient will be able client look at patient was able to
1999. to: realities of the
• Audiogram • Identify healthy illness or treatment • Identified
revealed a ways to deal without confronting healthy ways to
severe with and issues they are not deal with and
sensorineural express anxiety ready to deal with. express anxiety
hearing loss at properly properly
35.0 dB • Use resources/ 4. Encourage 4. Promotes • Used resources/
predominance support system patient to discuss awareness and support system
of low frequency effectively anxiety and understanding of effectively
impairment in explore concern relationship
the right ear about vertigo between anxiety
attacks level and behavior.
• The patient
seems to be 5. This helps the
bothered by his 5. Provide accurate client to identify
illness information about what is reality
the situation based.

6. Increased
6. Provide knowledge helps to
information about decrease anxiety
vertigo and its
treatment
7. Stressful
7. Provide comfort situations may
measures exacerbate
 symptoms of the
condition

8. Educate patient 8. Improved stress

about stress management can
management reduce the
techniques or frequency and
make appropriate severity of some
referral. vertiginous attacks.

9. Instruct patient 9. Patient

in aspects of knowledge helps to
treatment regimen decrease anxiety

Dependent: Dependent:

1. Instruct the 1. Short-term use

patient in the of antianxiety
appropriate use of medications can
antianxiety enhance patient
medications coping and reduce
Benzodiazepine physiological
Buspirone HCl manifestations of
(BuSpar) anxiety.
Selective serotonin
reuptake inhibitors
(SSRIs)
Nonselective beta-
blockers and
alpha-2-receptor
agonists

2. Tell the patient 2. Stimulants (e.g.,

to limit use of caffeine, nicotine,
central nervous theophylline,
system stimulants. terbutaline sulfate,
amphetamines,
and cocaine) can
increase physical
symptoms of
anxiety.
DISCHARGE
PLAN
Medication
Intratympanic Gentamicin Injection
● Disability is lessened in patients with Menieres after TTG treatment.
● Dizziness may reoccur one year later, requiring another series of
injections.
● The long-term effect on hearing is presently unclear but most likely
accelerates hearing loss. Patients should not expect improvement in
hearing.
● It is not unusual to experience feelings of ear fullness, tinnitus or even
dizziness after the procedure, although these should settle quickly. It is
not particularly painful.
The low dose method involves using 1-2 injections of gentamicin, waiting a
month between injections. This variant stops vertigo 66-80% of the time,
with no significant side effects at all. The 2nd injection is given only if there
has been a serious vertigo after at least 1 month post initial treatment-
usually 2 months. Occasionally a 3rd dose is given. Usually this results in
complete vestibular loss.
Medication

Although it does seem reasonable that the low dose protocol might have
more recurrence (at 1 year+), it is very easy to get another "touch up"
injection at 1-2 years, but it is impossible to get one's hearing back after it has
been damaged by the more intense protocol.

1. Administer, or educate about administration of, antivertiginous

medications and/or vestibular sedation mechanism; instruct patients about
side effects. (to alleviates acute symptoms of vertigo)
2. Administer , or educate about administration pf, antiemetic medications
as prescribed and needed. Educate patients about side effects. (Antiemetic
medications reduce nausea and vomiting, reducing fluid losses and
improving oral intake.)
Exercise

● Regular basis exercise like yoga or walking

● Head movements to perform while standing twice a day
15 to 20 times for each head movement.
● Turn head side to side first with15 seconds open eyes
then with 15 seconds closed eyes while sitting down on
the chair
● Keeping eyes focused on outstretched one finger
● Avoid over-extend exercise
Treatment

● Explain the importance of continued treatment at home

● Instruct the patient to take his medicine at the right time, right dose
as prescribe by the physician.
● Explained the patient about meniett therapy and the procedure .this
a regular treatment that can reduce the vertigo symptoms of
Meniere's disease and improved the quality of life of the patient.
● Explained the procedure for installing meniett device you need a
small ventilation tube placed in your eardrum that allows the
micropressure pulses to reach the middle- and inner ear. Ventilation
tubes are commonly used in the treatment of ear conditions. The
tube will be checked periodically to make sure it is still in place and
not blocked. When a ventilation tube is removed, the eardrum
usually heals completely.
Health Teaching
1. Explain to the client about his disease.
2. Explain the causes of Meniere’s disease and its treatment.
3. The things to do during an attack of vertigo
 Lie down and hold your head very still until the feeling passes. This may help you cope
with vertigo.
4. Explain the importance of avoiding stimulants and vasoconstrictions such as caffeine,
alcohol, tobacco, and stress, along with any other conditions that trigger an attack.
5. Discuss the need for a low in sodium to reduce fluid buildup in the inner ear.
6. Discuss medications that may be prescribed to prevent attacks or self-administration of
appropriate medications. Take your medicines exactly as prescribed.
7. Discuss the importance of Follow-up. This is the key part of the treatment and safety.
8. Discuss, prepare and assist the client with surgical options.
a) Labyrinthectomy
b) Endolynmphatic
Out-patient

● Regular Follow up check up with the

health care provider.
● Contact the health care provider
immediately if severe symptoms
happened.
 Meniere’s disease is thought be caused by problems with
DIET fluids in the inner ear. By controlling the fluid in the inner ear
with diet = we can reduce symptoms.

● Instruct the patient to eat consistently throughout the day. Do not go

longer than 4 hours without eating. Encourage the patient to eat
approximately the same amount of food at each meal and do not skip
meals. If patient eats snacks, have them at regular times.
● Instruct the patient to limit or avoid alcohol 1 drink max per day, this can
help prevent migraines. 1 drink = 12 oz. of regular beer or 5 oz. wine or
1.5 oz (shot) of liquor.
● Encourage the patient to limit caffeine. Avoid things like coffee, tea,
soda, energy drinks, chocolate, and diet pills. Caffeine will stimulate the
nervous system and make migraines and tinnitus worse.
● Instruct the patient to refrain from tobacco. The nicotine in cigarettes
and other tobacco products can constrict the blood flow to the inner
ear, making all symptoms worse.
DIET

● Avoid MSG (monoSODIUM glutamate) - which is form of sodium that is a common

migraine trigger. Common foods that contain MSG include Asian foods, Ramen
noodles, and Accent seasoning.
● Instruct the patient to have a low sodium diet. Sodium causes fluid retention and
can make your symptoms worse in your inner ear. The core element to the hydrops
diet for Meniere's is a reduced sodium input -- generally between 1500-2000 mg.
Low Sodium Diet- 2,000 mg sodium limit can help alleviate symptoms. Foods
naturally low in sodium include: fresh fruits and vegetables, unprocessed grains,
fresh meats, poultry, and fish.
● Instruct the patient to avoid fluids that contain large amounts of sugar and salt, such
as soda or concentrated juices, which make you retain water. Instead, drink water,
milk, and low-sugar fruit juices evenly throughout the day.
● Try to avoid foods with concentrations of simple sugars, such as table sugar, honey,
high-fructose corn syrup, candy, and chocolate. Encourage the patient to focus on
foods with higher levels of complex sugars, such as legumes, like nuts, beans, and
lentils, whole grains, brown rice, and sweet potatoes instead.
THANK YOU!