Day 1 after hernia repair: falling blood pressure on a night shift
Night shift in a 30-bed Community Health Centre in Haryana. You are the Healthcare Assistant on duty with one staff nurse. A 58-year-old man is Day 1 after an open inguinal hernia repair. At 18:00 his observations were BP 126/78 mmHg, pulse 78/min regular, respirations 16/min, SpO2 98% on room air, temperature 37.0 C, pain score 2/10. The wound dressing was dry and the drain held 30 mL of serosanguineous fluid. At 20:45 he calls you: he feels dizzy when he sits up and is thirsty. The dressing is still dry; the drain now holds 60 mL. At 21:00 you measure BP 96/60 mmHg, pulse 112/min, respirations 24/min, SpO2 95% on room air, temperature 37.4 C. The staff nurse is in the labour room and the duty doctor is 20 minutes away. Ward policy says the nurse in charge must be told of any abnormal vital sign within 15 minutes, and that you may not give any medicine on your own.
1. Which of the 21:00 findings are abnormal, what pattern do they form, and what would make you more or less worried?
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Compare each value with the 18:00 baseline rather than with a textbook range alone:
- Systolic BP fell 30 mmHg (126 to 96) and diastolic fell 18 mmHg; pulse pressure narrowed from 48 to 36 mmHg.
- Pulse rose 34/min (78 to 112) and respirations rose from 16 to 24.
- SpO2 fell 3 points to 95% and temperature rose 0.4 C.
The pattern matters more than any single number: tachycardia plus a falling BP with a narrowing pulse pressure, thirst and dizziness on sitting up points to intravascular volume loss. Pain is only 2/10, so pain does not explain the tachycardia. A dry dressing does not exclude bleeding, because blood can track into the abdominal wall or retroperitoneum. Other explanations are drain losses with poor oral intake, or early sepsis, but a temperature of 37.4 C with no rigors makes sepsis less likely at this moment.
More worrying: a further fall on repeat measurement, cold clammy skin, confusion, falling urine output, or respirations continuing to climb. Less worrying: a normal repeat reading with the arm supported and the correct cuff size, or a recent opioid or antihypertensive that was not recorded.
2. List, in order, what you will do between 21:00 and 21:10 and give a reason for each step. State two things you must not do.
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- Keep him lying down, do not let him walk to the toilet. Reason: postural dizziness means he can faint and fall; a fall on Day 1 also threatens the repair.
- Repeat BP, pulse and respirations after 2 minutes lying, with the cuff at heart level and the correct size. Reason: one reading can be a measurement error, and a trend decides the urgency.
- Inform the staff nurse in the labour room immediately, by phone or by message through a colleague, and ask her to contact the duty doctor now. Reason: policy is a 15-minute escalation, and the doctor needs 20 minutes to arrive, so waiting wastes the window.
- Keep him nil by mouth and remove nothing from the drain; note the drain volume and check the dressing and abdomen for distension. Reason: if he needs theatre, an empty stomach matters, and a concealed bleed may show as a tense abdomen.
- Recheck observations every 5 to 10 minutes and write them with times. Reason: the next reading is the evidence the doctor will act on.
Must not do: give oral fluids or any medicine on your own; leave him unattended, or record a value you did not actually measure.
3. Write the record entry you would make at 21:10 and the spoken report you would give, using SBAR.
Read the worked answer
Record entry should be contemporaneous, objective, timed and signed: '21:00 - patient reported dizziness on sitting and thirst. BP 96/60, P 112 regular, RR 24, SpO2 95% RA, T 37.4 C. Dressing dry, drain 60 mL serosanguineous. Kept supine, legs not elevated above 30 degrees, nil by mouth. Staff nurse informed 21:05; duty doctor informed 21:06. Repeat obs 21:10 - BP 92/58, P 118. Signature, designation.'
Spoken report (SBAR):
- Situation: 'Bed 4, Day 1 hernia repair, BP has dropped and pulse is up.'
- Background: 'Baseline 18:00 was 126/78, pulse 78; he is Day 1, drain went from 30 to 60 mL, dressing dry, pain 2/10.'
- Assessment: 'I think he is volume depleted, possibly bleeding; he is thirsty and dizzy and the repeat reading is 92/58 with a pulse of 118.'
- Recommendation: 'Please come now or tell me what to do; he is nil by mouth and I am repeating obs every 5 minutes.'
Reasoning: the record must show what you saw, did and when, because 'doctor informed' with a time is what protects the patient and you. Interpretation goes in the spoken report, not as fact in the notes; if you write a suspicion, write it as 'reported to doctor', not as a diagnosis.