Post-operative handover: low urine output and PCA
You are the night nurse on a 28-bed surgical ward. At 19:40 you receive a telephone handover from the recovery nurse about Mr Alan Whitcombe, 68, day 1 after an open right hemicolectomy. He has a morphine PCA, an IV infusion of compound sodium lactate at 83 mL/hr, and a urinary catheter. The recovery nurse says: “He’s a bit sleepy but rousable. BP 92/54, pulse 112, temp 36.9, resp 22, SpO2 95% on 2 L. Pain score 2 at rest. Urine output 15 mL in the last hour. The surgical registrar reviewed him at 18:00 and said ‘keep an eye on him.’ His daughter is at the bedside asking when he can go home.” The ward has one healthcare assistant and the registrar is in theatre until 21:00.
1. Which three findings in the handover require immediate clarification or escalation, and why?
Read the worked answer
Priority findings
- Urine output 15 mL/hour - below 0.5 mL/kg/hour for most adults; after hemicolectomy this suggests hypovolaemia, bleeding, or poor renal perfusion. I would clarify his weight, total fluid balance, drain output, and whether the catheter is patent.
- BP 92/54 with pulse 112 - compensated shock until proven otherwise. I would not accept ‘keep an eye on him’ without parameters. I would ask for the last haemoglobin, whether there was intraoperative blood loss, and the registrar’s escalation plan.
- Drowsiness with a morphine PCA - could be opioid accumulation, but also hypoperfusion or sepsis. I would check respiratory rate, sedation score, last bolus, and pain score before giving more opioid.
Why this matters: the combination of tachycardia, hypotension, oliguria, and drowsiness is a cluster, not three isolated numbers. The handover lacks a clear trigger for medical review.
2. Prioritise your first four actions in the first 15 minutes.
Read the worked answer
First 15 minutes
- Do a full ABCDE assessment at the bedside: airway, respiratory rate, SpO2, heart rate, blood pressure, conscious state, pain, and temperature. Attach continuous monitoring.
- Check the surgical site, drain, catheter, and fluid balance. Confirm urine output and catheter patency; perform a bladder scan if unsure.
- Escalate to the on-call surgical registrar or anaesthetist now, not at 21:00. State the observations and the trend. Ask for a review and for a fluid order; do not give a bolus independently unless a protocol or order authorises it.
- Prepare for bloods (FBC, U&E, coagulation, group and save), keep the patient nil by mouth until reviewed, and document the handover, actions, and response.
I would not give additional morphine before assessing sedation and perfusion.
3. What would you say to the daughter at this point?
Read the worked answer
To the daughter
“I can see you are worried about when your father can go home. Right now his blood pressure is low, his pulse is fast, and he is passing less urine than we would expect. That can happen after surgery, but we need to check it properly. The surgical team is coming to review him, and I will update you as soon as I have spoken to them. I do not want to give you a discharge date until his observations are stable.”
Reasoning: acknowledge emotion, give honest information without guessing, avoid false reassurance, and commit to a concrete update. Do not discuss details the patient has not consented to share beyond what is necessary for the daughter’s concern.