Post-operative Vital Signs That Need Escalation
At 6:00 a.m. you record observations for Mrs. K, 58, on day 2 after open abdominal surgery. Temperature is 38.1 °C, pulse 112/min and regular, blood pressure 96/60 mmHg in the right arm, respiratory rate 24/min, SpO2 94% on room air, and she is drowsy but rousable. Her usual blood pressure is 130/80 mmHg. She has an IV line with Ringer's lactate running at 60 mL/hour, a urinary catheter, and a dry dressing at the midline incision. The drainage bag shows 20 mL of dark urine in the last 6 hours. She says she feels a bit weak and has mild abdominal pain. The staff nurse is attending another patient who has fallen. The ward has a working pulse oximeter and a manual sphygmomanometer.
1. Which findings are abnormal, and why is the combination more important than any single reading?
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Abnormal findings
- Temperature 38.1 °C is a fever.
- Pulse 112/min is tachycardia; her pain and fever may contribute, but it is not normal.
- Blood pressure 96/60 mmHg is low for her, especially against a usual 130/80 mmHg. The systolic drop is about 34 mmHg.
- Respiratory rate 24/min is raised; normal adult resting rate is about 12–20/min.
- SpO2 94% on room air is borderline low and should be rechecked.
- Urine output 20 mL in 6 hours is very low and suggests poor perfusion or catheter problems.
- Drowsiness is a change in mental state and must not be dismissed as just being tired after surgery.
Why the cluster matters
A single abnormal value may have a simple explanation. Together, fever, tachycardia, relative hypotension, tachypnoea, low urine output and drowsiness suggest possible sepsis, bleeding or hypovolaemia after abdominal surgery. The GDA does not diagnose, but must recognise the pattern and escalate immediately. Waiting for the next routine round could allow deterioration.
2. What immediate actions should you take, including repeat measurements and escalation?
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- Stay with Mrs. K and call the staff nurse now. If the nurse cannot come, use the ward's escalation protocol or call the doctor. A fallen patient elsewhere does not make this observation less urgent.
- Repeat the observations properly. Use the correct cuff size, support the arm, and repeat BP in the other arm. Recheck pulse, respiratory rate for a full minute, SpO2 with a warm finger and good probe placement, and temperature.
- Check for obvious causes you can see: is the IV running and the site swollen? Is the catheter tubing kinked or the bag below the bladder? Is the dressing soaked with blood? Is the abdomen distended? Is she confused or difficult to rouse?
- Ask about pain, breathing, dizziness and thirst. Do not give food or drink.
- Report using SBAR: Situation, Background, Assessment, Recommendation. State the exact values, her baseline BP, the low urine output and the change in drowsiness.
- Document the time, values, repeat values, who was informed and the response.
Why: repeat measurements rule out technique error before escalating, but they must not delay the call to the nurse. The low urine output and BP drop are red flags that need medical review, not just another set of observations.
3. What should you not do, and how would you hand over this patient at the end of your shift?
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Do not
- Do not give oral fluids or food; she may need surgery or further investigation.
- Do not adjust the IV rate or stop the IV without an order.
- Do not give paracetamol or any medicine to bring down the fever on your own.
- Do not remove the catheter or change the dressing unless instructed.
- Do not record only the first set of values and omit the repeat readings.
- Do not reassure the family that everything is normal before medical review.
Handover
Use SBAR and include:
- Situation: Mrs. K, 58, day 2 after open abdominal surgery, observations at 6:00 a.m. showed fever, tachycardia, low BP, tachypnoea, low SpO2 and drowsiness.
- Background: usual BP 130/80, IV Ringer's lactate at 60 mL/hour, catheter, midline dressing, 20 mL dark urine in 6 hours.
- Assessment: repeat BP and observations, catheter and dressing checked, nurse informed at 6:05 a.m., doctor called or not.
- Recommendation: medical review, strict fluid balance, repeat observations as ordered, watch for bleeding or sepsis.
Why: clear handover prevents the next shift from treating these values as minor. It also protects you legally by showing what you observed and whom you told.