Postoperative Deterioration Mistaken for Anxiety

The findings suggest hypovolemia from postoperative bleeding until proven otherwise. The heart rate has risen from a baseline of 72 to 104–116, blood pressure has fallen from 138/76 to 96/54, urine output is only 15 mL/hr for 3 hours, hemoglobin has dropped from 12.4 to 8.9 g/dL, and lactate is elevated at 2.9 mmol/L. A 2 cm area of fresh bloody drainage on the dressing supports ongoing blood loss, possibly retroperitoneal or deep surgical bleeding after hip arthroplasty. Ketorolac increases bleeding risk and is a plausible contributor. The low-grade temperature and tachypnea could also fit early sepsis, but the hemoglobin drop and hypotension make bleeding the immediate priority.

"Anxiety" is unsafe because it frames a physiologic deterioration as psychological and can delay escalation. A patient who says "I'm just tired" may be showing reduced perfusion and early decompensation, not calmness. The nurse should treat the vital-sign trend and laboratory data as the primary data, not the patient's self-report alone.

In the next 30 minutes:

1. Stay with the patient or ensure continuous observation; call the rapid response team now because of hypotension, tachycardia, low urine output, falling hemoglobin, and elevated lactate.
2. Assess ABCs, mental status, skin temperature and cap refill, pain, dressing and drain output, and bleeding under the patient. Check orthostatic blood pressure only if safe; do not delay escalation.
3. Ensure a patent IV; the 20-gauge line may be inadequate for rapid volume resuscitation. Start a second large-bore IV per protocol or delegate that task.
4. Give oxygen to maintain SpO2 at least 94%, and apply continuous pulse oximetry and cardiac monitoring.
5. Notify the surgeon and the rapid response team with a concise SBAR; request orders for fluid bolus, repeat hemoglobin and lactate, type and screen, coagulation studies, and blood product availability.
6. Hold ketorolac and any other anticoagulant or antiplatelet agent until the surgeon is notified.
7. Prepare for possible transfer to a higher level of care; do not leave the patient alone.

Document the trend, the exact interventions, who was notified, and the response.

"Situation: Mr. [name], 72-year-old postoperative day 1 after total hip arthroplasty, is hypotensive and tachycardic with a falling hemoglobin. I am calling a rapid response.

Background: baseline BP 138/76, HR 72. Overnight HR 104–116, BP now 96/54, urine output 15 mL/hr for 3 hours, SpO2 93% on room air, temperature 38.1°C. He received ketorolac 30 mg IV at 22:00. Hemoglobin is 8.9 from 12.4, lactate 2.9, and the dressing has fresh bloody drainage.

Assessment: I am concerned about postoperative bleeding and hypovolemic shock; sepsis is also possible, but the hemoglobin drop and hypotension make bleeding the priority. He is drowsy and says he is 'just tired.'

Recommendation: I need immediate bedside evaluation, a second large-bore IV, a fluid bolus per protocol, repeat hemoglobin and lactate, type and screen, and notification of the surgeon. Please help me decide whether to transfer to a higher level of care."

State clearly what you want: "I need you at the bedside now and I need the surgeon called." Use closed-loop communication and read back orders.