Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease?
A.
Acute confusion related to delirium and disorientation
B.
Nausea related to constant sensation of noxious taste
C.
Autonomic dysreflexia related to distention of bowel or bladder
D.
Risk for falls related to unsteadiness and loss of balance
The correct answer and Explanation is :
The correct answer is D. Risk for falls related to unsteadiness and loss of balance.
Explanation:
Ménière’s disease is a disorder of the inner ear that leads to episodes of vertigo (spinning sensation), hearing loss, tinnitus (ringing in the ears), and a feeling of fullness in the ear. The disease affects the vestibular system, which is responsible for balance, making the patient prone to falls.
Why “Risk for falls” is the priority?
Patients with Ménière’s disease often experience unpredictable vertigo attacks, which can severely impair their ability to maintain balance. During these attacks, the individual may lose control, increasing their vulnerability to injury. The risk for falls is heightened due to:
- Vertigo: Sudden onset of dizziness and spinning can make standing or walking safely difficult.
- Unsteadiness: Even between vertigo attacks, balance problems persist, contributing to fall risk.
- Hearing loss: Impaired hearing can further disorient the patient, affecting their spatial awareness.
In nursing, safety is always a top priority, and preventing injury from falls is critical in patients with balance disorders like Ménière’s disease. Managing this risk involves measures such as:
- Assisting the patient with mobility.
- Ensuring a safe environment (clear pathways, proper lighting).
- Educating the patient about recognizing early signs of an attack to sit or lie down promptly.
Why the other options are incorrect:
- A. Acute confusion is unrelated to Ménière’s disease as it doesn’t typically cause delirium or cognitive issues.
- B. Nausea is a symptom but is secondary to the vertigo and not the primary concern compared to the risk of falls.
- C. Autonomic dysreflexia is not associated with Ménière’s disease, as it is a complication of spinal cord injury.
Prioritizing the risk for falls aligns with patient safety and the most immediate concern in Ménière’s disease management.