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.
I would definitely give Lasix first! Clearly they are fluid overloaded. Labs are important as well, but I believe the patient needs the fluid off first. BSC is also needed :) I'd say counseling patient would come last..
Draw the labs and then give the Lasix without waiting for the result. You will have the information you need and chances are, since Lasix strips potassium, that your order for an IV will have K+ in it. If it doesn't, you should ask for one that does. If the K+ is too high and you have overshot (which happens sometimes), you can always give K-exelate. But if the patient is in acute CHF, they need diuresis without waiting.
I'd want to know her temp first (is she septic from pneumonia or ??) as well as her BP (will I bottom her out with the Lasix if she's in cardiogenic shock?) and while we're at it, what's her cardiac rhythm? But out of these choices, I'd go with giving the Lasix and getting stat lab results. (This is a cool question - let's do more!)
I am going to take a bit of a different approach because Emergent, RN said later that they did what everyone is pretty much agreeing is the right course of action and I am assuming that something happened.
This is is a drug abuser with poor coping skills. These types of individuals are prone to lying. That is one classic of their "poor coping." What are we talking about though? Pot? Cocaine? PCP? Meth? Crack? So we're first of all assuming the patient did in fact run out of Lasix. Is that true? What goes through the mind of a drug addict can be totally out of touch with reality. I am not an ER nurse but I would like to know if and what he/she's using and a BMP result to ensure he/she's telling the truth.
I was thinking later about cocaine and the effects on the lungs and circulation especially if there is already an underlying condition. I am not that knowledgable on this topic but I am wondering what the effect would be if the patient had something involving drug abuse going on and was lying about home Lasix med because they wanted a quick fix to the side effects of what they were doing. I think a complete metabolic panel would be better than just a basic metabolic panel to see if something is happening in the liver. A lot of those drugs are laced with fillers that can harm again especially if there is an underlying condition. Then add a whopping dose of Lasix and what would that be? Could that throw such an individual in a state of ODing because the fluids in the body are needed to process the drugs? With cocaine too, I have a family member that used to be an addict. When these folks are on a high, it is not like, for example, being drunk. They seem like they are normal as rain when they're not. They have those same characteristics of any drug abuser though such as irresponsibility and lying. Pot causes the bloodshot eyes. I am totally ignorant on other types of drug abuse and what it looks like. Pot is something one would have to smoke and again, some of it has fillers. Could this effect the lungs in an already compromised patient? Another thought I had was whether the pitting edema was due to malnutrition versus the CHF? Cocaine addicts will go a long time without eating.
There are too many variables and not enough information. HCG test? Are we assuming that ER nurses write orders and the doctor signs off later? Do we need O2, I mean is respiratory distress imminent? If she's a drug abuser, is she withdrawing and needing a detox protocol that will not depress respiratory drive? So many options on what to do next...
That she is on "high doses" of Lasix at home tells me she most likely has severe CHF, that she is out of her home Lasix tells me she didn't go to the pharmacy for her refill, that she is "well known" to this ER tells me that she probably does this kind of thing on a fairly regular basis, which means that where her labs tend to run, what her VS typically look like, and what her EKG typically looks like are well known also.
From the sounds of it, she probably could have simply been given her regular PO dose of Lasix, except it would take longer. IV administration is fast, it's going to get her feeling better much quicker, and get her out of your ER and free up a bed that much sooner.
Although, on the down side, this also just enables her to continue to make poor choices because she knows the ER is there to save her behind. Is she at least polite? If you're going to abuse the ER in this fashion, you might as well be nice about it.
Since all lab work in the ER is STAT, the results will be back soon, and any abnormalities of concern can be addressed promptly.
And, I might be a "know-it-all", but I certainly do not know it all!
Michele9589
3 Posts
All that can be do e after the patient is stabilized!