Day 2 After Hip Fracture Repair: Orthostatic Drop and Falling Urine Output
Mrs. A is 79 years old, weighs 62 kg and is on the second day after open reduction and internal fixation of a right hip fracture. She has a morphine PCA, IV normal saline at 100 mL/h, and enoxaparin. At 07:00 her blood pressure is 118/70 mmHg lying, and 94/56 mmHg after sitting on the edge of the bed for two minutes; her heart rate rises from 88 to 116 beats/min and she says she feels light-headed. Urine output was 180 mL over the previous 8 hours through an indwelling catheter. The dressing is dry and intact, the drain holds 20 mL in 8 hours, and haemoglobin has fallen from 11.8 to 9.2 g/dL. She has not opened her bowels since surgery and has PRN oxycodone due for hip pain rated 6/10. The unit is short-staffed and a new graduate asks you what to do first.
1. Interpret her vital signs, urine output and haemoglobin together. What is the most likely explanation, and what is your first priority?
Read the worked answer
Do the arithmetic before deciding what it means
- Urine output: 180 mL ÷ 8 h = 22.5 mL/h. Minimum acceptable is 0.5 mL/kg/h ≈ 31 mL/h (she is producing about 0.36 mL/kg/h) → oliguric.
- Orthostatic change: systolic falls 24 mmHg, diastolic 14 mmHg, heart rate rises 28 beats/min, and she is symptomatic. A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing is abnormal; this is real, not a positional artefact.
- Haemoglobin 11.8 → 9.2 g/dL is a 2.6 g/dL fall in 48 hours, with a dry dressing and an almost-empty drain.
Interpretation: intravascular volume depletion with suspected concealed post-operative bleeding (haematoma or retroperitoneal loss) until proven otherwise. Third-spacing and inadequate intake can contribute but do not explain a 2.6 g/dL drop.
First priority - keep her safe and stop the orthostatic stress:
- Help her lie down immediately; do not allow her to walk to the bathroom.
- Recheck BP, HR, SpO2 and conscious state supine, then reassess orthostatics only when safe.
- Focused assessment: new or different hip/thigh pain, swelling or tenseness of the thigh, flank or abdominal distension, dressing and drain site, and any bruising.
- Escalate to the surgeon now; request CBC, coagulation profile and group-and-save; prepare for a fluid bolus and possible transfusion per orders.
- Document the orthostatic readings, the calculated urine output and the time of escalation.
A fall in haemoglobin plus oliguria plus symptomatic orthostasis is a trigger to act, not to 'recheck in the morning'.
2. The new graduate offers the PRN oxycodone before the repeat blood pressure is done. How do you respond, and what must be assessed before any opioid is given?
Read the worked answer
Withhold until the volume status is addressed - then reassess, do not simply refuse.
Why timing matters here:
- Opioids cause venodilation and can blunt the compensatory tachycardia; in a patient who is already 24 mmHg down on standing, a dose given now can precipitate a fall or a further pressure drop.
- Respiration is also at risk: PCA morphine plus a PRN oxycodone is a stacked opioid load, and her sedation level has not been checked.
Assess before giving (and document):
- Sedation score (e.g. POSS/AVPU) - not just 'awake'.
- Respiratory rate, depth and SpO2.
- Pain score and location - new or escalating hip pain may signal a haematoma rather than routine post-operative pain.
- Current BP/HR supine after she has been lying down.
Then: once she is normotensive supine, give the smallest effective dose per the order (or ask the prescriber to reduce it), reassess pain and sedation in 30–60 minutes, and continue multimodal analgesia (paracetamol, positioning, ice) so the opioid requirement falls. Explain your reasoning to the new graduate - the teaching point is 'assess, then give', not 'opioid = bad'.
3. The ward is short-staffed. Which of the following can be delegated to the unlicensed assistive personnel (UAP), and what must stay with you: (a) repeating the orthostatic vital signs, (b) documenting intake and output, (c) walking her to the bathroom, (d) checking the thigh for swelling and haematoma?
Read the worked answer
Assign by task stability, not by how busy you are.
| Task | Decision | Reasoning |
|---|---|---|
| (a) Repeat orthostatic vitals | Not now - RN | Vital-sign measurement can be a delegated skill in many settings, but this patient is unstable and the result requires immediate interpretation and a decision about escalation. Delegation of monitoring is inappropriate for a patient whose condition is changing. |
| (b) I&O documentation | Yes - UAP | Objective, task-based, no clinical judgement; you still review and interpret the totals. |
| (c) Walk to the bathroom | No - RN | She has symptomatic orthostatic hypotension; assisted standing is a clinical decision. Provide a bedpan or urinal and bed rest until reassessed. |
| (d) Check for swelling/haematoma | No - RN | Assessment and interpretation of a wound site is an RN responsibility and cannot be delegated. |
What you keep: assessment, interpretation, escalation to the surgeon, medication decisions and the care plan. What you must also do: tell the UAP exactly why (so they can recognise the danger in future), and escalate the staffing shortfall to the charge nurse - a patient who is bleeding is not a problem that 'working faster' solves.