The Numbers That Keep Moving the Wrong Way
A 74-year-old woman is postoperative day 1 from open reduction and internal fixation of a left hip fracture after a fall at home. She takes metoprolol for hypertension. Her trend: 06:00 HR 88, BP 132/76; 10:00 HR 104, BP 112/64; 14:00 HR 118, BP 92/58, RR 22, temperature 36.4 °C, SpO2 95% on room air. Urine output is 15 mL/hour for the last three hours through an indwelling catheter. Hemoglobin went from 11.0 to 8.4 g/dL. The hip dressing is dry, but the surgical drain has put out 120 mL of serosanguineous fluid in four hours. She is pale with cool fingertips, rates her pain 3/10, and says, "I'm just tired." Her active orders include enoxaparin 40 mg daily, morphine PCA, ketorolac 30 mg IV every 6 hours scheduled, and 0.9% sodium chloride at 75 mL/hour. The UAP reports she "seemed fine this morning."
1. What is happening, and what are your first five actions?
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This is occult postoperative hemorrhage with early hypovolemic shock, most likely a retroperitoneal or intracapsular bleed after hip fixation - the dressing and drain are not the whole story. The evidence: falling hemoglobin (11.0 to 8.4), rising pulse with falling blood pressure, oliguria at 15 mL/hour, cool pale extremities, and a patient who minimizes her symptoms. Her metoprolol blunts the tachycardia, so the true clinical picture may be worse than the heart rate suggests. "Just tired" in a postoperative older adult is a red flag, not reassurance.
- Stay, and get help. Call for the rapid response team and notify the surgeon; send the UAP for the vital-sign machine and the crash cart.
- Oxygen, position supine with legs elevated, and continuous or every-5-minute vital signs including mental status.
- Volume: ensure two large-bore patent IVs; give a crystalloid bolus per protocol or standing order; hang the ordered maintenance fluid at the ordered rate, not faster on your own.
- Blood: draw a stat hemoglobin, type and screen, crossmatch, and coag studies; prepare for transfusion.
- Hold the drugs that worsen bleeding or mask the picture (see next question), keep strict intake and output, and reassess perfusion, urine output, and mentation every 15 minutes until stable.
Document the trend, not just the latest set of vitals.
2. Which of her existing orders do you carry out, question, or hold, and why?
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- Ketorolac 30 mg IV every 6 hours scheduled - hold and question. An NSAID in a hypovolemic, bleeding, elderly postoperative patient adds bleeding, acute kidney injury, and GI risk. Scheduled NSAIDs after orthopedic surgery are a common, correctable hazard.
- Enoxaparin 40 mg daily - hold pending the surgeon. Prophylactic anticoagulation in an actively bleeding patient needs a decision from the prescriber, not a routine administration.
- Morphine PCA - question. Opioids drop blood pressure and produce sedation that hides worsening shock. If she needs it, use the smallest dose and reassess her sedation scale and respiratory rate; a patient this hypotensive may need a different route or agent.
- 0.9% sodium chloride at 75 mL/hour - continue. That is maintenance, not resuscitation; ask for a bolus order rather than turning up a maintenance rate on your own.
- Metoprolol - question with the prescriber. It is likely contributing to the masked heart rate, and holding versus continuing is a prescriber decision, not yours.
- Request: stat CBC, type and screen, coagulation studies, and a repeat hemoglobin after any transfusion.
State the concern and the order you want when you call: "Her hemoglobin has dropped 2.6 grams and she is oliguric - I am holding the ketorolac and enoxaparin and I need a fluid bolus order and crossmatch."
3. The UAP says, "She was fine this morning, I don't understand what changed." How do you explain the change, and what monitoring do you set up for the next shift?
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Explaining it: bleeding is cumulative and silent. She compensated for hours with vasoconstriction and a rising heart rate, and her beta blocker blunted the tachycardia. Compensation eventually fails, and the blood pressure falls late - which is exactly why the 14:00 numbers look sudden when the trend was there at 10:00. Older adults also have blunted thirst, lower renal reserve, and often report fatigue rather than pain or dizziness.
Monitoring for the next shift:
- Vital signs every 15 minutes until stable, then at least hourly, with a documented early-warning score and clear escalation thresholds written down.
- Strict hourly urine output with a goal of at least 0.5 mL/kg/hour; report two consecutive hours below that.
- Mental status and sedation scale with every vital sign - new confusion may be her first sign of worsening perfusion.
- Hemoglobin recheck after transfusion or in 4 hours; watch the drain and check for flank or groin swelling and pain that suggests a retroperitoneal bleed.
- Pain assessment - increasing hip or flank pain out of proportion deserves a call, not a PRN.
- Teach the UAP what "fine this morning" cannot rule out and require an immediate report for any change in alertness, urine output, or color.
Tell the oncoming nurse the trend and what has already been escalated, and do not let the next shift restart the ketorolac from the MAR without a prescriber's decision.