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The nurse is caring for a patient receiving a heparin infusion for the management of a pulmonary embolus (PE). The nurse observes bright red urine in the patient's catheter bag. What should be done first?

Explanation

•Bleeding, presenting as hematuria, could result from anticoagulation. This should be reported to the physician for further evaluation.

•Protamine is the antidote for heparin overdose. Since the heparin infusion is being used to treat a pulmonary embolism, protamine should not be given unless first confirmed by the physician.

•The aPTT should be checked, but only after the immediate threat of possible hemorrhage is addressed.

•The infusion should not be decreased, but may be put on hold (stopped) until receiving further orders from the physician.

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