Postoperative Day 1 After Emergency Laparotomy: Pain, Sepsis, or Hypovolaemia?
A 58-year-old man is on the first postoperative day after an emergency laparotomy for a perforated appendix. His history includes type 2 diabetes and hypertension. At 06:00 his vital signs are: heart rate 118/min, blood pressure 92/58 mmHg, respiratory rate 24/min, temperature 38.4°C, and SpO2 96% on room air. His urine output through an indwelling catheter has been 15 mL/hr for the past three hours. The abdominal dressing is dry and intact, but the abdomen is distended and firm. Capillary refill is 4 seconds, and his hands are cool. He rates incisional pain 6/10 and received IV morphine 2 hours ago. Current orders include Ringer lactate at 75 mL/hr, cefotaxime IV, paracetamol PRN, and morphine PRN. The staff nurse is also caring for four other patients and must decide what to do first.
1. Which findings in this scenario point to hypovolaemia or sepsis rather than expected postoperative pain or fever? Explain your reasoning and state what else you would assess at the bedside within the next 10 minutes.
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The combination of tachycardia (118/min), hypotension (92/58 mmHg), oliguria (15 mL/hr for 3 hours), prolonged capillary refill, cool extremities, and fever on postoperative day 1 suggests inadequate circulating volume with possible sepsis, not simply pain or a normal postoperative fever. Pain alone can raise heart rate and blood pressure, but it does not usually cause hypotension and oliguria. Fever of 38.4°C after surgery for a perforated appendix raises concern for intra-abdominal infection or an anastomotic leak. Distension and firmness may indicate ileus or a collection but do not explain the perfusion deficit. At the bedside I would reassess mental status, repeat the blood pressure manually, check capillary refill and urine colour, inspect the dressing and drain sites, palpate the abdomen gently, check the IV site and infusion rate, and obtain a finger-stick glucose because he is diabetic.
2. List, in priority order, the nursing actions you would take in the next 30 minutes, including what you would do before giving the next PRN morphine dose.
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Priority is circulation and sepsis before comfort. I would call for help, stay with the patient, position him supine with legs elevated if tolerated, apply oxygen if SpO2 falls below 94%, and increase the crystalloid rate only after confirming with the surgeon or rapid-response team, because the current order of 75 mL/hr is likely insufficient. I would obtain a full set of vital signs, strict hourly urine measurement, and a fluid balance chart. I would draw blood cultures and lactate if ordered before antibiotics, and administer cefotaxime on time. I would not give the next PRN morphine before reassessing perfusion and pain; if pain is still 6/10 and blood pressure is stable after fluid resuscitation, a reduced dose may be appropriate. I would document everything and escalate.
3. Write the SBAR report you would give the surgical resident.
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Situation: This is the staff nurse on the surgical ward. Mr X, 58 years old, day 1 after laparotomy for perforated appendix, has become hypotensive and oliguric. Background: He has type 2 diabetes and hypertension; he is on Ringer lactate at 75 mL/hr, cefotaxime, and PRN morphine. Assessment: Heart rate 118/min, blood pressure 92/58 mmHg, respiratory rate 24/min, temperature 38.4°C, SpO2 96% on room air, urine output 15 mL/hr for 3 hours, capillary refill 4 seconds, abdomen distended and firm, dressing dry. I am concerned about hypovolaemia and possible intra-abdominal sepsis. Recommendation: Please review him now; I need an order for a fluid bolus, blood cultures, lactate, and a full blood count. I will continue monitoring and have the theatre list available if he deteriorates.