What would you do in this situation? (If you know it all ;) )

[Emergent, RN]

Multiple choice here, and, hopefully a discussion. If you are a know it all, please let us all know (so we can try to set you straight, and you can tell us why you are right )

A pt comes into the ER C/O SOB, well known to you as a drug abusing CHF pt with very poor coping skills, on very high doses of home Lasix. States she is out of Lasix. Lower extremities with 4 plus pitting edema, crackles in lungs, sats in low to mid 90s, RR 24. You've established IV access and have obtained blood, and Dr has ordered IV lasix and labs.

What should be your first action?

1)Order a urine drug screen

2)Monitor pt while awaiting lab results

3)Give Lasix and bring BSC

4) Counsel pt on better adherence to home medication routine.

[Libby1987]

I don't know jack about ER but wouldn't you want to draw the labs before starting the Lasix to get a baseline?

[bugya90, ASN, BSN, LVN, RN]

5: close door to patients room and hope next shift comes in soon to take care of the train wreck 😜

(Just to clarify I'm only joking)

[Emergent, RN]

The labs were drawn with the IV start. I'll clarify in my opening post

[Libby1987]

You have to start the lasix before labs come back if it was ordered that way.

Monitoring is a given.

Should the urine be collected before diuresis begins?

[Libby1987]

And I wouldn't counsel the patient until stabilized, who listens under ER conditions?

[bugya90, ASN, BSN, LVN, RN]

Wouldn't you start the Lasix first and then get the urine for the drug screen? Once you start the Lasix they should be able to produce a sample for drug screening. Teaching and counseling about medication adherence can wait until the patient is stabilized.

[brownbook]

Number 3, but worry about her getting to the BSC without assistance?

[Emergent, RN]

The doctor has not ordered any urine test. Sometimes ER nurses add an order when Dr is busy, hence one of my choices. The doctor signs off orders later.

[Libby1987]

You don't have to have an order to collect it and hold it, do you?

Does the lasix have an effect on the drug screen? Lower urine concentration with interstitial fluid? Or doesn't really matter that much?

[blondy2061h, MSN, RN]

Wait for labs and monitor. Normally I'd go ahead and give the lasix given the scenario you describe with crackles, edema, patient stating they're out of lasix at home, etc. But I have a feeling this is a trick. Hopefully those labs were stat and you get a decent turn around so we can at least see a creat, na, & k before diuresising.

[Libby1987]

Does the nurse get to decide when to admin lasix if the orders aren't written with parameters or at least to hold lasix until labs reviewed?