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.
The national average for CHF 30-day readmissions is around 24%, ours is around 7%, which is mainly due to intensive outpatient management, but reading through this thread it might also be partly due to not admitting patients that don't need to be admitted.
4+ pitting edema does not directly represent intravascular volume overload and is often chronic and certainly does not require emergent intervention. A RR of 24 in a patient prone to anxiety (drug abuser with poor coping skills) is pretty darn good, I'd be more worried if it was 16. "SOB" is not particularly useful as an objective assessment, it's just a trigger to do an objective assessment. And requiring no supplemental O2 to boot, it's certainly not something I would see as requiring an override of our basic process due to an impending crash, and not even likely requiring admission; check the CXR, check the labs, catch 'em up with some IV lasix, give them a script or enough PO lasix to tide them over and their on their way (with an outpatient follow up in the next day or two).
I still haven't figured out what BSC stands for. Anyone want to clue me in? I am reading this for education for me not because I have anything meaningful to contribute at this point.
Specializes in Acute Care - Adult, Med Surg, Neuro.
More threads like these, please! As a new-ish nurse I love to see the critical thinking process of more experienced nurses, and nurses in other specialties.
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.
?
I would drop a Foley more for energy conservation than I&O accuracy. Once she starts to diurese, she's going to be peeing like a racehorse-you ever try to get out of bed to a commode every 15-20 minutes when you can't breathe?
In the ED, I would place a Foley for accurate I&Os and given her edema, it must not be easy to move quickly to the commode.
I wouldn't hold the Lasix. So #3.
As a side note, I would not order a drug screen unless the patient agreed to it. I'd never do one without patient consent unless we're talking about an OD for example and we don't know what they took.
Sent from my iPhone -- blame all errors on spellcheck
I love reading the different outlooks and views into the critical thinking process of nurses from different specialties. Very interesting and insightful!!
There are times though that I may council someone like this when they are still unstable but not dying of course, because I want them to remember how bad they felt due to their lack of control of their own meds and habits.
And I wouldn't counsel the patient until stabilized, who listens under ER conditions?
May be giving 80 or 100mg on the first dose depending on what they are supposed to be taking at home, I would expect this much if they were on a "high" dose at home.
Re chance of acute on CKD, she went into acute CHF because she missed her Lasix, not because of the Lasix, right?
Just how much would this first dose be before labs were back?
But an automatic foley isn't called for any longer. Foley's cause UTI's which lengthen hospital stays and make the bean counters angry. If they are able to get on the bedside commode then they need to do this unless they are too medically fragile to do so.
Fun!
In the ED, I would place a Foley for accurate I&Os and given her edema, it must not be easy to move quickly to the commode.
I wouldn't hold the Lasix. So #3.
As a side note, I would not order a drug screen unless the patient agreed to it. I'd never do one without patient consent unless we're talking about an OD for example and we don't know what they took.
Sent from my iPhone -- blame all errors on spellcheck
PP's are right this is a fun thread! Ok here it goes...
1. Assess (doesn't take long). Monitor, 2L O2 NC, may need bipap
2. IV and labs drawn (CBC, CMP, BNP, Coags, Troponin, UA and UDS), sent off, but not waiting for these to come back.
3. EKG done and shown to provider
4. Give Lasix, then make sure this patient has a BSC before leaving her. If unstable someone else can do this but it doesn't say she is that unstable. Call light should be in reach with TP.
NursesRmofun, ASN, RN
1,239 Posts
Agreed.