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.
My first action is #3. We know she was on high doses of lasix and that she stopped so we already know the cause of the CHF exacerbation. O2 sats and RR dont concern me at all. They're typical symptoms of uncontrolled CHF. If sats were in the 80's and/or RR greater than 35, I'd be worried. C/O SOB is very vague and doesnt tell you much. Her lungs are filling with fluid so SOB is expected. Also, SOB causes anxiety which raises RR. She doesnt seem to be in any acute distress and her body is compensating fine. She just needs her lasix.
Labs will come back in no time. In the event of low k, that can be treated. Since she's tolerated high doses of lasix before, why would I hold the lasix on the off chance its critical?
I wouldn't order a drug screen. There is no indication she is drug seeking in this scenario. Even if she was, she presented with a real condition that needs attention first.
BSC is perfectly acceptable. There is no mention of her having incontinence, impaired mobility, or altered mental status. Foleys should never be the first choice unless there is ample reason.
I just wonder why she went to the ER without contacting her Dr. or the pharmacy first. I'm sure there's a story behind it but I dont understand why someone would wait til they cant breath to act.
This was a great topic. I know we had someone who posted these sort of things awhile ago. These are not only a great way to learn from each other, but to get us thinking about patients we do not always encounter daily. I enjoy them a lot more than the bickering posts.
Specializes in Med/surg, Telemetry/PCU, Bone & Joint.
#3, give the Lasix. Patient is almost certain to be in fluid overload based on the symtoms presented, as well as patient admitting to having run out of her Lasix. We can also add that no data in the given scenareo mentions how long she has gone without her Lasix, and considering it is mentioned that she is on "high" doses of Lasix at home, even just a few days skipped can severely distrupt her fluid balance and send her into fluid overload.
Give the lasix!!! Based on the clinical presentation the patient is likely in full blown CHF. If you worked in ER for any amount of time this kind of thing happens very frequently. Whether she's a drug user or not whether she's really out of her medicines are not does it matter. labs, tox screne in counseling I'll come later
Once she's stabilised, I'd counsel her regarding management of her CCF; the UDS may not be a priority at present - I'd be worried more about her obs, unless of course you're worried about possible interactions or contraindications with the Tx prescribed and illicit drugs. I'd then refer to HARP-DMT (Hospital Admissions Risk Program - Diseas Management Team) so they can provide ongoin education, monitoring and management. Maybe a referral to mental health if you observe a possible depression.
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 would monitor the patient while awaiting the lab results. The patient already has 4 + pitting edema, heaven knows when she last took her Lasix. and I would hook her up to a monitor so that her HR, BP Svo2 and ekg tracing could be monitored. I would also ask the doctor to order a 12 Lead EKG looking for signs of hypokalemia.
For once in my life, I feel like this question has a very straightforward answer.
It would be #3.
The pt. is showing significant signs of fluid overload (aeb SOB, crackles in lungs, 4+ pitting edema is a lot (!), and RR of 24), and has said that she has run out of her lasix. While it makes sense to be concerned about K+ levels after the lasix administration, with CHF, she's at high risk for an immediate cardiac and pulmonary event from the excess fluid - what's most important is to get rid of that fluid first and foremost before her body is no longer to maintain compensatory mechanisms and a life threatening event occurs.
I'd do this: administer the lasix, then check to see if labs are back immediately afterwards. Communicate with the doctor and tell her/him the lasix has been given and the lab results and X, Y, and Z, and let them know if you are concerned about X, Y, or Z and why. If K+ is normal in the results, it can be deduced that a high dose of lasix might cause it to dip too low, however, the doc ordering K+ via IV requires a 1000mg NS hanging bag at the very least to be administered, I believe, and your patient does not need more fluid..
Edit: I changed my mind. The pt's body is currently compensating appropriately for the time being. I'd hold the lasix and wait for the lab results and continue to monitor.
Was always told to insert foley immediatley after IV lasix administration. Lasix first to deal with the emergent problem of fluid overload due to hx of CHF.
Hey y'all, I've enjoyed seeing everyone's thinking on this question. I answered 3 earlier based on experiences in ER (a patient in respiratory distress tends to stay in respiratory distress unless you do something to fix it), but I think I want to take a trip to NCLEX world and give you guys my NCLEXy type answers.
I was taught to answer the question like your answer is the one and only thing you can do for the patient, and that the patient is always trying to die.
1)Order a urine drug screen --- Nope. This will do nothing for the problem.
4) Counsel pt on better adherence to home medication routine. --- Nope. Also does nothing for the problem. Also sounds very silly. Definitely not a priority right now.
2)Monitor pt while awaiting lab results --- Now this is appealing because you're suppose to check kidney function before giving a diuretic, but I was taught to never pick the "assess later" type of answer. This means that you will see the patient in distress, and do nothing.
3)Give Lasix and bring BSC. --- This is the only answer that fixes the problem stated in the question, so I'd still pick this one based on an NCLEXy process of elimination.
Sorry to those who have no interest in NCLEX world. I just took it, and it's still painfully raw.
Obvious had fluid overload, so you would treat the most critical first: oxygen sat, labs, lasix, monitoring, urine, teaching.
Labs to see if she had a wbc count immediately: also check the potassium, bun creat see if it's also causing kidney failure. Give lasix, slow at first. Get them started on the drop and wait for labs. When they come back, get it set on proper dose. Urine later, alert patient: who really cares right now if they like drugs? Known drug user, assume it's Positive. Lastly teaching. You can lead a horse to water, but not make it drink. Get a home health referral.
emtb2rn, BSN, RN, EMT-B
2,942 Posts
Give the lasix. Labs will be back before she starts peeing. Correct k as needed.