The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Potential condition: Retinopathy

Actions to take: Orient the client to the environment; Call for an ophthalmological exam

Parameters to monitor: Blood glucose; Visual acuity

Rationale:

Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.

The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.

Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.