Deteriorating Postoperative Patient at 02:15
At 02:15 on a 28-bed medical-surgical unit, you are the only patient care technician for 12 patients. Mr. H, age 68, is postoperative day 1 after an open reduction and internal fixation of the left hip. His 22:00 vitals were BP 138/78, HR 82, RR 16, SpO2 97% on room air, temp 37.2 C. He has an indwelling urinary catheter, a dry surgical dressing, and a morphine PCA. At 02:15 you find him drowsy but arousable. He says, 'I feel a little off.' Vitals: BP 92/54, HR 118, RR 24, SpO2 93% on room air, temp 37.8 C. The dressing appears dry, but the sheet beneath his hips is damp and he says he 'must have sweat.' The catheter bag has drained 90 mL since 20:00. Three call lights are on, and the nurse is in another room with a patient who is vomiting.
1. Which findings form the most concerning pattern, and what should you do in the first five minutes? Explain your priorities.
Read the worked answer
Pattern: The concerning cluster is a systolic drop of 46 mm Hg from his baseline, tachycardia (118), tachypnea (24), SpO2 down to 93%, low-grade fever, and oliguria (90 mL in roughly six hours is far below expected output). The 'sweat' matters: damp bedding under a postoperative hip can be blood, and a dry visible dressing does not rule out bleeding tracking underneath the patient.
First five minutes:
- Stay with him and use the call bell for help; do not ambulate him, even to the bathroom.
- Recheck the BP manually on the other arm and count the pulse and respirations yourself; a single automated reading can be wrong, but it cannot be dismissed.
- Look under him: lift the sheet and inspect the bedding and the posterior dressing/flank for blood; check the catheter tubing for kinks and the bag for output and color.
- Apply continuous pulse oximetry if available and keep him safe in bed.
- Call the nurse by phone or have a coworker pull her out; do not wait for the 04:00 round.
Reasoning: The technician's job is not to diagnose hypovolemia. It is to recognize a trend that does not fit, gather the confirming data, and escalate without delay. Hypotension plus tachycardia plus oliguria after orthopedic surgery is a bleeding or fluid-shift picture until proven otherwise.
2. The nurse is still occupied. Write the SBAR report you would give, using the numbers above.
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S - Situation: 'Mr. H in 412, post-op day 1 hip ORIF, has a BP of 92/54 with HR 118, and I am worried about him.'
B - Background: 'Baseline at 22:00 was 138/78, HR 82, SpO2 97% on room air. He has a PCA, a Foley, and a hip dressing that looks dry. No known bleeding disorder.'
A - Assessment: 'He is drowsy but arousable and says he feels off. He is tachypneic at 24, SpO2 93% on room air, temp 37.8. The sheet under his hips is damp; he called it sweat, but I have not confirmed it is not blood. The Foley has drained only 90 mL since 20:00.'
R - Recommendation: 'Can you come now? I rechecked the pressure manually and I am staying with him. Do you want me to get a second cuff, keep him flat, or call the charge nurse?'
Reasoning: Give numbers, not adjectives. State what you did and what you need. SBAR is a request for a decision, not a narrative.
3. The nurse says, 'Document it and I will round in 30 minutes.' What is your response, and what do you do while waiting?
Read the worked answer
Document objectively and escalate; do not simply wait. Say: 'I will chart it now. I am not comfortable waiting 30 minutes with a 46-point systolic drop and a heart rate of 118. Can you at least come look, or should I call the charge nurse?'
Then:
- Stay with the patient or arrange for someone to stay.
- Recheck vitals in 10 to 15 minutes and record the recheck.
- Do not write 'nurse notified' unless you actually notified her; chart the time, what you reported, and her response.
- Do not give fluids, pain medication, or anything else on your own.
- If she remains unavailable and the patient worsens, use the chain of command: charge nurse, then house supervisor.
Reasoning: 'Document it' is appropriate; 'and wait' is not, because this is a change that can deteriorate quickly. The record must be accurate and contemporaneous, and the escalation must be real, not implied.