Post-op Day 1: Tachycardia With a Normal Blood Pressure
A 68-year-old man is on post-operative day 1 after an open right hemicolectomy. He has a midline incision, an epidural catheter for analgesia, a nasogastric tube on low intermittent suction, and a urinary catheter. His chart at 07:00 shows: temperature 37.9 C, heart rate 104/min, BP 118/70 mmHg, respiratory rate 20/min, SpO2 96% on room air, urine output 25 mL/hr, pain 2/10 at rest. He has received 3 L of crystalloid since surgery. At 11:00 the nurse notes heart rate 122/min, BP 112/66 mmHg, respiratory rate 24/min, urine output 10 mL/hr over the last hour, and the patient is drowsy but rousable. The epidural infusion is running at 6 mL/hr of bupivacaine 0.125% with fentanyl. The surgical registrar is in theatre and will not answer for at least 40 minutes.
1. Interpret the 11:00 observations. What is the most likely explanation and what is the immediate nursing priority?
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The trend is the message, not any single number. BP has drifted down (118/70 to 112/66) while HR has climbed (104 to 122) and urine output has fallen from 25 to 10 mL/hr. A rising HR with a falling urine output and a soft-but-lower BP on day 1 after major bowel surgery points first to hypovolaemia - third-space loss, ongoing insensible loss via the NG tube and an open abdomen, plus inadequate replacement. The normal-ish BP is not reassuring: a young-to-middle-aged adult can compensate, and this man is 68, so his reserve is limited. He may be in compensated shock now and decompensate quickly.
Second possibility to keep open: epidural-related hypotension from sympathetic blockade, and opioid effect contributing to drowsiness and a raised respiratory rate is less likely (opioids lower RR). Sepsis is possible but there is no fever yet and the timeline is short.
Immediate priorities:
- Escalate now - do not wait 40 minutes. Call the registrar's mobile, the on-call surgical resident, and the rapid response/critical care outreach team. Document the call and the time.
- Full set of observations including a manual BP, capillary refill, skin temperature, and a repeat urine output check to confirm the catheter is not blocked or kinked.
- Check the epidural site and level of block; check for a wet dressing or a dislodged catheter, and stop or reduce the epidural infusion only on instruction - do not remove it unilaterally.
- Prepare for fluid resuscitation: large-bore IV access, bloods including FBC, U&E, lactate, and group and save.
- Sit the patient up only if tolerated; keep him safe and monitored, and do not leave him alone.
The examiner is looking for: recognise compensated shock from the trend, act on the deterioration rather than the absolute numbers, escalate past the unavailable doctor, and confirm the urine output reading is real.
2. The patient's urine output remains 8 mL/hr and he becomes more drowsy. The registrar still has not responded. What should the nurse do next, and what does the DOH scope of practice require here?
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This is now a time-critical deterioration. The nurse should:
- Activate the rapid response team / medical emergency team if the hospital has one. In the UAE, DOH standards require hospitals to have an escalation process and the nurse is expected to use it without waiting for permission.
- Notify the nurse in charge and the on-call surgical consultant - go up the chain, not sideways. Record who was called, when, and what was said.
- Continue monitoring and supportive care within scope: oxygen if SpO2 falls, strict fluid balance, hourly urine output, repeat observations every 15 minutes, and prepare for urgent fluid bolus and possible transfer to a higher level of care.
- Do not independently prescribe or administer a fluid bolus without an order unless there is a standing protocol or a medical emergency where the nurse is initiating resuscitation under local policy. The nurse can and should prepare the equipment and the patient.
- Do not remove the epidural or the NG tube without instruction.
Scope of practice point: DOH's nursing scope of practice framework allows the nurse to assess, monitor, escalate, and initiate emergency measures within an agreed protocol, but prescribing and definitive management remain with the physician. The defensible action is documented, timely escalation - not waiting, and not acting outside scope. The nurse who documents the deterioration, the calls, and the times is protected; the nurse who waits for a doctor who is not answering is not.