Post op cea - Nursing Case Study

Pathophysiology

• Primary mechanism: Post-operative carotid endarterectomy (CEA) patients may experience nerve injury due to surgical manipulation. The hypoglossal and vagus nerves are most commonly affected, leading to complications such as voice changes, swallowing difficulties, and tongue deviation.

• Secondary mechanism: Post-CEA patients may have impaired blood flow due to clot formation or arterial narrowing. This can lead to brain ischemia, resulting in neurological symptoms like weakness, numbness, or even stroke.

• Key complication: Hematoma formation can occur after CEA, which can compress the trachea, leading to breathing difficulties. Early recognition and management are crucial to prevent airway obstruction.

Patient Profile

Demographics:

65-year-old, Male, Retired Teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes Mellitus

• Current medications: Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Mild discomfort at the site of surgery

• Key symptoms: Slight swelling at the surgical site, occasional discomfort

• Vital signs: Blood pressure 130/85 mmHg, pulse 78 bpm, temperature 98.6 F, respiratory rate 16 breaths per minute

Section 1

Change in patient status:

The patient was observed throughout the day, and it was noted that his discomfort seemed to increase, especially while swallowing. He reported a mild sore throat and a change in his voice, which had become slightly hoarse. On further assessment, the nurse noted a slight bulge at the site of the incision, pointing towards a possible hematoma formation. His blood pressure was stable at 130/85 mmHg, pulse rate 80 bpm, and his temperature slightly elevated at 99.2 F.

Promptly, the nurse notified the healthcare team about the changes in the patient's condition. The team ordered further diagnostic tests, including a Doppler ultrasound to assess blood flow in the carotid artery and a CT scan to assess the extent of the hematoma. This careful monitoring and early recognition of the patient's symptoms allowed for timely intervention and prevented the possibility of more severe complications. The nurse's vigilance exemplified the importance of continuous patient monitoring in the postoperative period, particularly in procedures like CEA where minor complications can potentially escalate quickly.

Section 2

New Diagnostic Results:

The results from the Doppler ultrasound confirmed the presence of a hematoma at the incision site, with no significant disruption to the blood flow in the carotid artery. The CT scan further affirmed the size of the hematoma, which was small and not immediately threatening. The scan also revealed that the swelling was causing slight pressure on the patient's vocal cords, which explained the hoarseness in his voice.

The healthcare team reviewed the results and decided on a conservative management plan, given the patient's stable vitals and the non-threatening nature of the hematoma. They prescribed a mild analgesic to manage the patient's discomfort and advised the patient to limit his talking to reduce strain on his vocal cords. The patient was also scheduled for regular ultrasounds to monitor the hematoma. The nurse reinforced these instructions to the patient, emphasizing the importance of rest and frequent monitoring. These diagnostic results underscored the significance of early detection and intervention in ensuring optimal patient outcomes and preventing complications in the postoperative phase.

Section 3

Initial Assessment Findings:

The nurse performed an initial assessment during the next scheduled rounds. The patient's vital signs were stable: Blood pressure was 120/80, heart rate was 75 beats per minute and regular, respiratory rate was 16 breaths per minute and unlabored, and his temperature was 98.6°F. The patient reported a pain level of 2 on a scale of 0 to 10 after taking the prescribed analgesic. On examination, the hematoma at the incision site was unchanged in size, and the skin around it remained intact without signs of infection such as redness, warmth, or drainage. The nurse noted that the patient's voice was still hoarse, but he had been compliant with the advice to limit his talking.

Change in Patient Status:

Two days later, the patient reported feeling an increase in discomfort at the site of the hematoma, rating his pain level at 5 out of 10, despite regular use of the analgesic. His vital signs remained within normal limits. The nurse observed that the hematoma appeared slightly larger and more firm to touch. She promptly informed the healthcare team of these changes. The physician ordered an immediate ultrasound to reassess the hematoma. The new developments made it clear that reassessment and reevaluation of the patient's condition were crucial to managing his postoperative course and avoiding potential complications. The nurse emphasized to the patient the importance of reporting any changes in his condition promptly, reinforcing the role of effective communication in ensuring optimal care.

Section 4

New Diagnostic Results:

The ultrasound results revealed that the hematoma had indeed increased in size, indicating the possibility of a slow bleed. However, the patient's blood pressure remained stable at 122/78, and his heart rate was regular at 76 beats per minute. His hemoglobin levels, which had been stable at 13 g/dL postoperatively, had dropped to 11.5 g/dL, suggesting that the patient was losing blood. The physician decided to revise the patient's pain management strategy, introducing a stronger analgesic, and ordered a CT scan to further assess the hematoma.

Response to Interventions:

Following the introduction of the stronger painkiller, the patient reported a decrease in his pain level, which dropped to a 3 out of 10. He appeared more comfortable and was able to engage more actively in postoperative exercises. The CT scan confirmed the ultrasound findings, showing an increase in the size of the hematoma. However, it also showed no signs of active bleeding, which was a positive sign. The team decided to continue monitoring the patient closely, with daily labs and vital checks, and to hold off on any surgical intervention unless the hematoma continued to grow or the patient's condition deteriorated. The nurse continued to encourage the patient to report any changes in his condition immediately.

Section 5

Change in Patient Status:

Three days after the introduction of the stronger analgesic, the patient showed signs of improvement. His pain level remained at a 3 out of 10, and he was actively participating in his postoperative exercises. His blood pressure continued to be stable at 124/80, while his heart rate was regular at 72 beats per minute. However, he reported feeling slightly dizzy when moving from a lying to a standing position, which was a new symptom. His appetite had also decreased, resulting in a weight loss of 2 pounds since his surgery.

New Diagnostic Results:

To address the new symptoms, the physician ordered a CBC and a metabolic panel. The results showed that his hemoglobin levels had slightly increased to 12 g/dL, suggesting that his body was compensating for the blood loss. However, his albumin levels were slightly below normal at 3.2 g/dL, which could explain his symptoms of dizziness and weight loss. The physician decided to introduce a high-protein diet and to continue monitoring the patient's vital signs and lab values closely. The nurse was instructed to assist the patient with postural changes to prevent falls and to monitor his food intake.