During change of shift bedside assessment, the oncoming nurse sees that the trachea of a patient, who is postop carotid endarterectomy, is not midline, and the patient is drooling. The offgoing nurse states the dressing was not removed to evaluate the site as, “We are not supposed to.” The oncoming nurse removes the dressing and sees a hematoma along with a shift of the patient’s trachea.

1.

What CUES (Assessment) can the nurse assess?

2.

What HYPOTHESIS (Diagnosis) will the nurse consider?

3.

What ACTION (Plan and Implement) will be most effective for the nurse to take to assure the patient’s safety in this situation?

4.

How will the nurse evaluate the patient’s OUTCOME (Evaluation) for the purpose of arriving at a satisfactory clinical outcome?