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

[Emergent]

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.

[NursesRmofun, ASN, RN]

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?

Yeah. What are her vitals, is she peeing?...I think "we" have 10-15 mins to wait for labs while we assess.

[dudette10, MSN, RN]

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?

I have to go back to the basic question then: what are you waiting for that would change the order to diurese her, given her presentation and brief history? Do you think the diagnosis is wrong?

[blondenurse12, MSN, NP]

Well, based on the info provided, the physician has already ordered the Lasix so why not give it? You're going to have to give it one way or the other because this patient is fluid overloaded. If the provider was so concerned about hypokalemia, they could have ordered a blood gas with a critical care panel to be run stat. As for the BNP, who cares? It's not going to change your plan of care. It's just going to give a baseline. Personally, I think additional testing such as CXR, EKG, and a blood gas would be appropriate in this situation. Who knows how long her respiratory rate has been that high and when she'll begin to decompensate.

[Been there,done that, ASN, RN]

All of the above.. why is this a question?

[Dogen]

I have to go back to the basic question then: what are you waiting for that would change the order to diurese her, given her presentation and brief history? Do you think the diagnosis is wrong?

Well, I'm not an ER nurse, so everyone should take this with a grain of salt (like I need to tell anyone here that)... but CHFers have an increased risk of CKD, and if she's not peeing the Lasix isn't going to do anything. So, I'd probably ask when the last time she peed was.

ETA: Like a PP, I also assume this is a trick.

[klone, MSN, RN]

I have to go back to the basic question then: what are you waiting for that would change the order to diurese her, given her presentation and brief history? Do you think the diagnosis is wrong?

Ooh, this is fun! It's like an M&M!

[Kyrshamarks, BSN, RN]

Wait the 10-15 minutes for labs to come back and assess the patient? The assessment should already have been done by the time the doc wrote the orders for lasix. GIVE THE LASIX. In those few minutes of distress she could go from mild exacerbation to full blown CHF exacerbation with heart failure and intubation. Don't wait. A low K+ can be treated easily enough.

[klone, MSN, RN]

Well, I'm not an ER nurse, so everyone should take this with a grain of salt (like I need to tell anyone here that)... but CHFers have an increased risk of CKD, and if she's not peeing the Lasix isn't going to do anything. So, I'd probably ask when the last time she peed was.

What is CKD? (students, this is why a year of Med/Surg before you specialize is probably a good idea!)

[Twinmom06, ASN, APN]

4+ pitting edema, crackles, RR 24, c/o SOB....and discharge ready? You must have a high readmission rate!

the majority of my patients (with the exception of the crackles) live this way. I work on Stepdown (mainly respiratory) and most of our CHF'ers and COPD'ers live their lives like this...They come in every few months for a good diuresing and a few days on BiPAP and then go back on about their lives...

[dudette10, MSN, RN]

the majority of my patients (with the exception of the crackles) live this way. I work on Stepdown (mainly respiratory) and most of our CHF'ers and COPD'ers live their lives like this...They come in every few months for a good diuresing and a few days on BiPAP and then go back on about their lives...

But this patient does not because she came into the ER. It is clearly not her baseline.

[Dogen]

What is CKD? (students, this is why a year of Med/Surg before you specialize is probably a good idea!)

The snazzy new name for renal failure. Apparently having kidneys that are failures at their one job is a bummer, so they call it a disease to make people feel better.*

* This is probably not why they changed the name.

[dudette10, MSN, RN]

What is CKD? (students, this is why a year of Med/Surg before you specialize is probably a good idea!)

Chronic kidney disease.