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  1. Nguyen, Tram N. RN, BScN

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RESPONDING TO the patient call bell, you find Ervin Marz, 62, complaining of dizziness and shortness of breath. He's alert and oriented to time, place, and person, but he's pale and diaphoretic. You quickly assess his airway, breathing, and circulation and obtain vital signs: BP, 90/60 mm Hg; pulse, 120; respirations, 24; SpO2, 90% on room air; and temperature 98.2[degrees] F (36.8[degrees] C). You note bright red bloody urine in his urinary drainage bag. You administer supplemental oxygen by nasal cannula, and call the healthcare provider.


What's the situation?

Two days ago, Mr. Marz had a transurethral resection of a bladder tumor. He's receiving continuous bladder irrigation (CBI) through an indwelling urinary catheter.


Mr. Marz has a history of type 2 diabetes, hypertension, and bladder cancer. His daily medications include hydrochlorothiazide, irbesartan, glyburide, atenolol, low-dose aspirin, and vitamin E. He didn't stop the aspirin and vitamin E preoperatively; however, it hasn't been given to him in the hospital.


His most recent lab results are all within normal limits except for a hemoglobin of 7.5 g/dL (normal range for men, 13.3 to 16.2 g/dL); platelet count of 120 x 103/mm3 (normal range, 165 to 415 x 103/mm3); prothrombin time of 13 seconds (normal, 12.7 to 15.4 seconds), and activated partial thromboplastin time of 30 seconds (normal, 26.3 to 39.4 seconds).


What's your assessment?

Based on Mr. Marz's clinical status, lab results, and medication history, you suspect that his postoperative bleeding is caused by the aspirin and vitamin E he was taking to prevent myocardial infarction and ischemic stroke. Vitamin E interferes with platelet adhesion and helps prevent thrombosis. Aspirin is a potent antiplatelet drug. Although the combination reduces the risk of cardiovascular events, it also increases the patient's tendency to bleed.


What must you do immediately?

Your primary goal is to stop the bleeding and restore hemodynamic stability. Increase the flow rate of his 0.9% sodium chloride I.V. solution and prepare to transfuse packed red blood cells (PRBCs) as prescribed. Closely monitor Mr. Marz's level of consciousness, vital signs, and urine output.


After administration of 2 units of PRBCs and 1 liter of 0.9% sodium chloride solution, Mr. Marz's hypotension, tachycardia, shortness of breath, and oxygen desaturation resolve. His urine is now pink rather than bloody red, and his vital signs are: BP, 110/70 mm Hg; pulse, 80; respirations, 20; and SpO2, 98%.


What should be done later?

Continue I.V. hydration as ordered. Mr. Marz's CBI also will be continued; closely monitor his urine output and watch for signs of bleeding. Monitor his vital signs and lab results. When Mr. Marz's vital signs are stable, his hemoglobin is above 10 g/dL, and his urine is clear, his CBI, urinary catheter, and I.V. fluids will be discontinued.


Before discharge, review Mr. Marz's medications with him. He'll restart his antihypertensive medication, low-dose aspirin, and vitamin E at home. He's discharged home a week later and recovers completely.