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 say order the drug screen before you administer the lasix which may in some alter the results. Everything clinically points to her edema and she has CHF, but there is always the possibility that some of her symptoms are because of drug use and not just the CHF. The second intervention would be to draw the blood, the third to administer the lasix the fourth, although you have been doing this all along would be to monitor the patient. In the event that the patient is just not adhering to her medication regime, then once she is stable, I would counsel her on her self-care.
I would do 2,3, and 4 all at the same time! Bring the BSC, give the Lasix while counseling on better medication adherence, and monitor while waiting on labs.
Once the BSC has been used, I'd then obtain a urine sample and advocate for a drug screen.
Since she's on Lasix at home anyway, but has missed doses, I wouldn't be too worried of her K+ level. She needs to be diuresed because she's symptomatic. If the labs did show a decreased level it could be corrected anyhow.
You will already have a BP before meds are ever ordered. The first thing done when a pt. comes back to the room is hooking them up to the monitors. As far as a BMP, labs take up to an hour to result even when they are stat, so we usually don't wait unless ordered by the Dr.
Specializes in Emergency, Trauma, Critical Care, Flight.
I still keep my old paramedic priorities close to heart, and that is your ABC's. Airway open, check. Breathing? Well, if she's in respiratory distress, I would give the Lasix, and additionally, get some nitro ready, both SL and IV. The K+ level can wait. If she's fluid overloaded because of not taking her Lasix, she is probably not hypokalemic, and in all honesty, watching someone slowly drown in pulmonary edema because I didn't want to give her a potentially life saving medication because I'm waiting for a lab test to come back doesn't seem the right thing to do. I'd rather have a breathing patient with messed up lytes than a cyanotic patient headed towards an severely hypoxic state with text book labs. In this case, treat the patient, not the labs.
Garden,RN, ASN, RN
144 Posts
I would say order the drug screen before you administer the lasix which may in some alter the results. Everything clinically points to her edema and she has CHF, but there is always the possibility that some of her symptoms are because of drug use and not just the CHF. The second intervention would be to draw the blood, the third to administer the lasix the fourth, although you have been doing this all along would be to monitor the patient. In the event that the patient is just not adhering to her medication regime, then once she is stable, I would counsel her on her self-care.