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PRIORITY PROBLEM: NEUROVASCULAR IMPAIRMENT - Coggle Diagram
PRIORITY PROBLEM: NEUROVASCULAR IMPAIRMENT
POTENTIAL COMPLICATION(S)
Convulsions
More cerebral damage due to risk of aspiration and lack of oxygen delivered in the brain
Actions to prevent
Administer medications when ordered
Provide a low stimulus environment
Manage ICP
Actions to overcome complication
Have the orders for an emergency dose written down so nurse knows how much to administer if it is not stored in amount needed/ ADMINISTER MEDICATIONS DURING SEIZURE TO END IT
Maintain patent airway during seizures
Bag patient if needed after seizure to ensure oxygen is being delivered to brain
Have suction ready during a seizure
Call for help if no one else hears the alarms or goes to the room; do not leave patient alone; ensure a safe environment
Blindness
Could occur due to damage to occipital lobes
Actions to prevent
Manage ICP
RELEVANT CUES (PT FINDINGS)
CCS 9-13
Seizures
Respiratory difficulty as evidenced by decreased oxygen saturation levels, retractions, paradoxyl breathing
Weakened/ lack of reflexes
Cranial fractures
Cerebral edema
PRIORITY NURSING ACTIONS
The nurse must
Take vital signs every hour
Administer dextrose and obtain order from physician
Do neuro checks every hour
Assess respiratory rate and effort, titrate oxygen and maintain patent airway
Administer Keppra and Phenobarbital at the appropriate times
Implement seizure precautions and provide an environment with low stimulus
Administer blood after physician gets consent and draw labs to be monitored