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 have to say go with your gut feeling. She is high risk and could have pneumonia or a PE. Consider her BP and check for JVD and an S3. Get a temp ask about fever and chills and immobility. Did she run out of lasix because of money or because she was too ill to go out? I would request an EKG and CXR. The labs should be resulted after those are done. I would put her on 2lpm nc 02.
If that's all the information I get to have then we would usually just monitor and wait for labs (need to ensure reasonable K+ level prior to giving lasix in a reasonably stable patient, you're balancing the potential harm of potentially acutely worsening hypokalemia, which isn't unusual in drug abusing patients, compared to the potential harm in a short delay to getting lasix). That assumes there was no ABG (which could include lytes). Does she take home K+ replacement and has she been taking that but not the lasix or did she stop taking both? Are the crackles fine crackles in the bases or coorifice throughout? Vitals? Just how labored are those 24 resps/min? What did the CXR look like? Was this SOB an acute change for the patient or gradual in onset?
I would need a BP and BMP before giving the Lasix but I'm a floor nurse, not an ER nurse and the thought of giving Lasix (unless its their normal at home PO dose) terrifies me.
Not to sound like NoADL's for a second here, but tell me RN's aren't off fetching commodes when there are unstable and potentially unstable patients to be had.
Pretending that there is nothing more to the story than what has been given, she's presenting as CHF exacerbation. Give the lasix. She's on high doses at home, but she ran out. If she was still taking her K replacement, the lasix will do some good there too.
Although the BP is important, it would have to be pretty low for me to hold it because diuresis is absolutely necessary here.
brownbook
3,413 Posts
What are her vital signs?