Benign paroxysmal positional vertigo

93 year old female

7 systems

Integumentary:
-color WDL
-skin intact
-no edema
-generalized bruising on right arm

Neuro/psych:
-alert and oriented x4
-mood cheerful
-Hx of depression
-Hx of TIA and cerebral infarction without residual deficits

Cardiac: -rhythm regular
-heart rate normal
-S1 and S2 sounds present, no extra heart sounds
-no murmur
-Hx of HTN

GI:
-abdomen round and soft
-bowel sounds present in all four quadrants and normal
-globus sensation in throat
-no swallowing difficulty with soft

GU:
-independent management of bladder
-urine WDL
-overactive bladder

Musculoskeletal:
-no edema
-gait problem due to right leg being shorter than left leg (hip dysplasia)
-uses manual wheelchair to ambulate, can self transfer

Pulmonary:
-lung sounds clear bilateral
-no shortness of breath
-no wheezing or rales

Hip fracture as a result of a fall

Hip dysplasia right hip

Patho: -fracture resulting from sudden injury are the most common fractures
-the force causing a fracture may be direct or indirect
-manifestations of fracture include pain, tenderness at site of bone disruption, loss of function, swelling, abnormal mobility, and deformity of the affected part
-intertrochanteric fractures are usually treated with open reduction and internal fixation
-weight bearing is usually restricted for 3 months until the fracture has healed
(Norris, 2020, p. 1194-1195)

Patho: -most common cause of pathologic vertigo
-usually develops after the fourth decade of life
-brief periods of vertigo, usually lasting less than 1 minute, that are precipitated by a change of head position
-commonly occurs in bed when the person rolls into a lateral position, bending over and straightening up, extending the head to look up, getting in and out of bed, or sudden twist or turn of the head
-people with BPPV have movement of otoliths from the utricle into the endolymph of the semicircular canal that continue to move even when the head is stationary, these movements cause the vestibular system to be more
-usually there is a several second delay between head movement and onset of vertigo
-symptoms usually subside with continued movement due to the movement causing the debris to be redistributed throughout the endolymph system and away from the posterior semicircular canal
(Norris, 2020, p. 531-532)

Patho:
-an abnormality in development of the hip leading to a wide variety of hip problems in infants and children
-can lead to hips that are unstable, sublimated, malformed, or completely dislocated
-can be partial or full dislocation
-hip dislocation is seen in 1 in every 1000 live births
-left hip is more common than right due to left occipital intrauterine positioning of most infants
-disorder is six times more common in female than male infants
-occurs most frequently in first born children
(Norris, 2020, p. 1225)

References:
Casani, A. P., Gufoni, M., & Capobianco, S. (2021). Current insights into treating vertigo in older adults. Drugs Aging, 38(8), 655–670. https://doi.org/10.1007/s40266-021-00877-z
Cleveland Clinic. (2021, January 21). Hip fracture. https://my.clevelandclinic.org/health/diseases/17101-hip-fracture
Martin, P. (2024, April 30). 5 pressure injuries (bedsores) nursing care plans. Nurseslabs. https://nurseslabs.com/pressure-ulcer-nursing-care-plans/#h-5-promoting-optimal-nutrition-status
Mayo Clinic. (2022, August 5). Benign paroxysmal positional vertigo (BPPV). Mayo Clinic.
Norris, T. L., Tuan, R. L., & Porth, C. M. (2020). Porth’s Essentials of Pathophysiology. Wolters Kluwer.
Wagner, M. (2023, February 26). Vertigo (dizziness) nursing diagnosis & care plan. NurseTogether. https://www.nursetogether.com/vertigo-nursing-diagnosis-care-plan/
Wayne , G. (2024, April 29). Risk for injury & patient safety nursing care plan and management. Nurseslabs. https://nurseslabs.com/risk-for-injury/#Interventions-preventing-the-risk-of-injury-due-to-impaired-mobility

Etiology/Risk factors (Cleveland Clinic, 2021)

Etiology/Risk factors (Mayo Clinic, 2022)

Etiology/Risk factors (Norris, 2020, p. 1225)

Diagnostics (Mayo Clinic, 2022)

Diagnostics
(Cleveland Clinic, 2021)

Diagnostics
(Norris, 2020, p. 1225-1226)

Age 65 or older*

Age 50 or older*

Female*

Head injury*

Damage to inner ear*

Long periods of laying supine

Patient experiences dizziness prompted by eye or head movements: patient experiences dizziness with quick head movements

Nystagmus: patient experiences involuntary eye movements during vertigo episodes

Electronystagmography or videonystagmography

MRI

Dizziness with eye movements that occur when the patient lies on their back with their head turned to one side and tipped slightly over the edge of the bed: patient experiences dizziness with eye movements when supine

Being the first born child*

Female*

Breech positioning in 3rd trimester*

Being a large baby for gestational age

Family history of hip dysplasia

Infant swaddling

Female gender*

Post menopausal*

Sedentary lifestyle*

Medications that lower blood pressure or cause drowsiness*

Osteoporosis*

Vitamin D and/or calcium deficiency*

Health condition such as dementia or Parkinson's disease that increase fall risk (vertigo)*

Fall*

Motor vehicle crash

Repeated use/stress fracture

X-ray: displaced intertrochanteric fracture of left femur from gourd level fall

MRI

CT scan

Touch foot or leg to assess sensation and possible nerve damage

Smoking

Alcohol abuse

Poor vision*, wrong prescription in glasses

Ultrasound

Clinical examination of hip: hip dysplasia was diagnosed by a doctor in her 40s after observing her uneven hips and legs

Observable asymmetry of the hip: right hip appears shorter

Observable asymmetry of the gluteal folds

Shortening of the thigh so one knee is higher than the other: right leg is 2-3 inches shorter than the left leg

Ortolani maneuver

Barlow maneuver

Galeazzi test

Radiograph

  1. Impaired physical mobility
  1. Risk for falls

patient uses wheelchair

  1. Risk for knowledge deficit

Patient will verbalize understanding of causes of vertigo and related injury as well as how to manage her disorder within one week.

  1. Risk for pressure ulcer

Patient will use adaptive devices to increase mobility throughout her stay.

The patient uses safety measures to minimize potential for injury throughout the duration of her stay.

Coordinate with a physical therapist for strengthening exercises and gait training to increase mobility (Wayne, 2024)

Educate patients about safety ambulation, including using safety measures such as grab bars in the bathroom, use of non slip, well-fitting footwear, and encourage clients to request assistance when needed (Wayne, 2024)

To ensure propulsion with legs or arms and the ability to reach the floor, ensure that the chair or wheelchair fits the patient’s build, abilities, and needs, eliminating footrests and minimizing problems with shearing (Wayne, 2024)

Educate the patient on the need for moving slowly when changing positions and standing up to allow their equilibrium to adjust (Wagner, 2023)

Encourage the patient to use assistive devices properly to support balance (Wagner, 2023)

Instruct patient to squat instead of being over to pick something up and move head very slowly to decrease risk of triggering vertigo (Wagner, 2023)

Patient will remain free of pressure injuries throughout the duration of her stay.

Assess the surface that the clients spend the majority of time on (mattress and wheelchair) for the need for pressure relief device to reduce risk of skin breakdown (Martin, 2024)

Administer oral nutritional supplements as indicated to meet protein and caloric needs (Martin, 2024)

Inform the patient of the advantage of wearing eyeglasses and hearing aids. Encourage to have vision and hearing checked regularly (Wayne, 2024)

Have the patient wear proper footwear (Wayne, 2024)

Provide appropriate room lighting, especially at night (Wayne, 2024)

DEXA scan: meets criteria for osteoporosis and has history of fragility fracture

Medications

Absorbic acid/Vitamin C 500mg tablet PO QD

multivit-min-FA-lycopene-lutein/Centrum Silver 0.4mg-300mcg-250mcg tablet PO QD

Omeprazole/Prilosec 40mg tablet PO

Cyanocobalamin/Vitamin B12 1000mcg tablet PO QD

Oxybutynin/Ditropan 5mg tablet PO QD

Sertraline/Zoloft 50mg tablet PO QD

Fluticasone, umeclidinium, vilanterol/Trelegy Ellipta inhaler 1 puff PO QD

Apixaban/Eliquis 2.5mg tablet PO BID

Calcium citrate/Citracal 315mcg 2 tablets PO BID

Latanoprost/Xalantan 0.005% eye drops 1 drop in left eye QD

Acetylsalicylic acid/Aspirin 81 mg tablet PO QD

Metoprolol tartrate/Lopressor 12.5mg tablet PO QD

Vitamin D-3/Cholecalciferol 2000 unit capsule PO QD

Lidocaine/Lidoderm 5% topical patch 1 patch each shoulder QD on 8am off 8pm

Albuterol sulfate HFA/ProAir HFA 2 inhaler 2 puffs PO Q6H PRN for wheezing

Acetaminophen/Tylenol 650mg tablet Q8H PRN for pain

Magnesium hydroxide/Milk of Magnesia 400mg/5mL 1 ounce PO QD PRN for consitpation

Atorvastatin/Lipitor 20 mg tablet PO QD HS

increased risk of gait disturbances

can lead to the development of cataract

can cause dizziness and blurred vision

Assess the skin on admission and daily for an increasing number of risk factors (Martin, 2024)

reduce clotting d/t Hx of TIA

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