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.
Not an ED nurse but I would want to give the lasix right away due to the symptomatic fluid overload. If she hasn't been taking her Lasix I wouldn't be as concerned about hypokalemia as I would be about beginning diuresis. Low K can be treated when labs come back. I doubt that a single dose of IV Lasix would affect her K that drastically.
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.
What would be the purpose of the drug screen at this point? Couldn't that be done as part of the admitting orders so withdrawal could be managed on the floor? Seems a bit early for it and certainly not the priority for this patient at this time.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Lasix as her oxygenation is compromised. Then a Foley, if she can tolerate lying flat for it. (Or "Flat enough."). Turnaround time for STAT labs is about 20-30 minutes in our hospital, so by the time I'd done that I should have her electrolytes back . . . I hope it was a large bore IV and not in the antecub. The CCU nurses hate those little tiny AC IVs.
Maybe we have a completely different population in my area, but the OP's description could easily describe a CHFr's condition when they're ready for discharge from the hospital, so I'm not really getting everyone's desire to jump to interventions without doing much assessment.
I don't work in the ER but I would feel more comfortable waiting for lab work (which shouldn't take long) and watch the patient. Even though she claims she ran out of her lasix I would want to see electrolytes and kidney function before proceeding with any diuretics as long as the patient isn't actively crashing.
I would go ahead and give the Lasix as just about one of the first things I did. The patient is short of breath, sats are borderline, she's tachypneic, and has crackles. It's not hard to picture this situation deteriorating into respiratory failure. The typical patient I see that looks like this is sitting bolt upright in the bed and using accessory muscles, so that's what I'm picturing right now.
If labs have already been sent down, I can always replace the potassium when it comes back if it's low, but making sure the patient doesn't drown is going to be a little higher on my priority list.
Since the patient does not appear (from what you said) to be in distress, I'd monitor while waiting for labs because they usually come back quickly. I'd get the Lasix ready and have it waiting.
Maybe we have a completely different population in my area, but the OP's description could easily describe a CHFr's condition when they're ready for discharge from the hospital, so I'm not really getting everyone's desire to jump to interventions without doing much assessment.
4+ pitting edema, crackles, RR 24, c/o SOB....and discharge ready? You must have a high readmission rate!
I don't get why anyone wants to hold the lasix for any reason. When the labs come back, is the doctor going to say, "Don't give the lasix?" Nope. The patient must be diuresed. It's a classic CHF exac presentation in a known CHFer who stated she ran out of her high dose of lasix! He/she might add to the orders (K replacement, maybe), but the lasix will still be given. Waiting will not change the lasix order; it will only delay the main treatment for her condition.
Only one person who wants to wait has given a diff diagnosis. (In my experience, a PE presents slightly differently, given the whole picture.) Why does everyone else want to wait?
Since the patient does not appear (from what you said) to be in distress, I'd monitor while waiting for labs because they usually come back quickly. I'd get the Lasix ready and have it waiting.
I disagree. Into the ER c/o sob with an RR of 24 will appear in distress, if even only mildly.
Not saying this is you, but I've run into more than a few nurses who couldn't spot respiratory distress even if they were experiencing it themselves.
Since the patient does not appear (from what you said) to be in distress, I'd monitor while waiting for labs because they usually come back quickly. I'd get the Lasix ready and have it waiting.
I'm with you and MunoRN. If she's not wigged out or looking like she's about to crash then I'm assessing her. None of her info is totally crazy. Is she peeing?
kiszi, RN
1 Article; 604 Posts
Not an ED nurse but I would want to give the lasix right away due to the symptomatic fluid overload. If she hasn't been taking her Lasix I wouldn't be as concerned about hypokalemia as I would be about beginning diuresis. Low K can be treated when labs come back. I doubt that a single dose of IV Lasix would affect her K that drastically.