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.
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.
Good point. It may not do anything, but you would still give it in the ER environment, then eval response. Remember, this is a frequent flyer based on the OPs description, so I would hope CKD would be known. Nephro would be put on consult for admitting orders and conversations concerning dialysis would happen then.
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.
Well, 1 and 4 can be ruled out, as they are silly. What is going to come up on a u-tox that is going to change anything? Counseling at this point? Well that's just goofy.
2 can pretty well be ruled out, as labs can take an hour, and the pt needs diuresis. So- the labs come back with a K of 2.7 after I gave the lasix. As luck would have it, we happen to have potassium,
So, gonna go with actually doing my job and following dr orders on this one.
As far as all the folks who were going to wait for something or order something: Do you not trust your docs? How about you ask them if you have concerns about the orders?
Not sure why people are scared to give the lasix- people call there pcp during an exacerbation and get their lasix doubled over the phone.
And- I am not putting a foley in. I am perfectly capable of measuring from a hat or a commode, and don't care if it's off by 67 ml.
This seems pretty straigh forward here. Maybe I missed something. Can somebody give some good rationale for not following these orders?
I would go with monitor and wait for labs based on the information given. Can I get a STAT portable chest if lab turn around is excessive?
I REALLY want to know the rest of the patient's vital signs to know if she is febrile or hypertensive to help guide me. Ever seen a case that looked like CHF and then turned out to be pneumonia?
Also what drugs has she abused in the past?
Come back and play Emergent- you can't just leave us hanging like this.
Yes...I really want to know missing info. In reality, I would ask the ER doc if he wanted the lasix given before the labs came back or should we wait for them. The doc is right there and easy to ask. Labs in the ER do not take an hour to come back...add - at least ER's I've been in.
Without going into potentially revealing detail, care was assumed, pt was heartily diuresed as per physician intent, and released from ER with script and attempts at pt education.
On the surface this patient is presenting like someone in right sided heart failure (4+ pitting edema, pulmonary edema, tachypnea). Is there any JVD? Why are there no VS? If the patient is not hypotensive, give the lasix. I'd also want cultures to rule out PNA as PNA can present as tachypnea with crackles (so perhaps the 4+ pitting edema is the patient's baseline). Obviously stat labs are in order and at the very least a VBG to check pH, CO2, and HCO3. If the patient's SCr is wildly elevated, you can give all the lasix you want but nothing is going to come out. I'd give the lasix while waiting for labs to come back. I agree with the CXR, too.
I guess the question is why is the OP questioning the treatment ordered? A RR of 24 doesn't scream respiratory distress to me, but the patient can quickly decompensate. If the patient was breathing 35-40 times a minute I'd be getting an ICU consult while preparing to intubate.
Does this person have a history of DVTs and what other medications has she run out of?
This patient could possibly have pneumonia, endocarditis ( or a dozen other things that trigger CHF) and sepsis, or be having a RVMI. It is possible that the volume overload is all that's keeping her going.
It is safer to have a good history and some baseline tests than it is to risk shock, intubation, pressors, line placement, a pneumo, chest tubes....
Does this person have a history of DVTs and what other medications has she run out of?
This patient could possibly have pneumonia, endocarditis ( or a dozen other things that trigger CHF) and sepsis, or be having a RVMI. It is possible that the volume overload is all that's keeping her going.
It is safer to have a good history and some baseline tests than it is to risk shock, intubation, pressors, line placement, a pneumo, chest tubes....
i will posit that your line of thinking and Emergent's line of thinking is the basic difference between ER and ICU nursing.
I'm a floor nurse, but the difference between the two specialties is evident just in receiving report.
Specializes in Cath/EP lab, CCU, Cardiac stepdown.
Slap on tele, monitor and assess patient, wait for lab results, give lasix if lab indicates and do an echo. Patient is in low 90s to mid 90s in saturation, that's not too bad, give 2 L O2 via nc if needed. See what the lab shows and check ejection fraction. And I wouldn't put in a foley just for I&O because of cauti, I mean if she's mobile, she can use the commode with a hat. Bladder scan her too if she's showing signs of retention.
Without going into potentially revealing detail, care was assumed, pt was heartily diuresed as per physician intent, and released from ER with script and attempts at pt education.
I'm kind of bummed it wasn't a trick question... I was hoping it was going to be a tropical illness, or three different things happening all at once (CHF exac, CKD, and PNA at the same time!).
In practice I do the "when you hear hoof beats, think horses not zebras" thing. Online I'm totally looking for zebras.
dudette10, MSN, RN
3,530 Posts
I love these threads, btw. Forget the arguing over netiquette and NETY and crap like that. This is what nurses need to talk about!