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.
As a paramedic I would have had this pt before you and since I work for a very rural service 45 to 60 minutes transport times. I would establish iv draw labs and place in cooler give double dose of lasix rx iv place foley and possibly place on cpap to help with fluid in lungs and place on monitor and watch v/s.
I'm really confused why we've had 100 posts on a patient with CHF that needed lasix. Was there anything unique or interesting about this particular case that prompted you to start this thread?
As a paramedic I would have had this pt before you and since I work for a very rural service 45 to 60 minutes transport times. I would establish iv draw labs and place in cooler give double dose of lasix rx iv place foley and possibly place on cpap to help with fluid in lungs and place on monitor and watch v/s.
Chris, I was a PM years back. We used to give Lasix and morphine for CHF/PE. Is morphine no longer used?
In the ER I assume you are also placing her on monitor. Whenever I saw K's that were below 3 I the T's would be slightly inverted. Not an RN yet, but have worked the units long enough to know the initial dose of Lasix would be given first while the baseline is drawn. If the K comes back low, replacement is given. If what the woman says is true, that she hadn't taken her Lasix (for whatever reason), then her K is unlikely to be low. If she was still taking her K while she didn't take her Lasix, it may even be high....so the diureses may be a good thing all around. It's not like she isn't likely to be admitted so all will be monitored. I can't understand why her drug screen couldn't be drawn along with her other labs. they just don't have to be run STAT. Speaking of, what were her Sp02s? If they were below 80% (many long time COPD patients live long lives with Sats of 84% consistantly). Sp02 are good indicators of respiratory issues but they can be disguised due to circulation issues. ABG's are not a bad idea either especially in the case where you know that this is a chronic COPD. Use all your resources. I know how you feel about compliance issues. My own mother who lives with me can be pretty non compliant with her medications. She really does mean well, but she just doesn't understand how this all works and how her body is supposed to work with it. Hence, this is why she lives with me. If she didn't, instead of being admitted only once or twice a year for Exacerbations and CHF...she would probably not be here today. About the drug issue, I would not hesitate if my mother wanted something to "calm" her while she couldn't breath. She's 83, so I don't care if her addiction is a problem for someone else. I care if it helps her. This woman sounds like she needs a better home care evaluation... Just my 2 cents.
Administer Lasix. Monitor pt. labs were drawn during IV start. Wait for labs Obtain urine and hold for drug screen. ? Counseling pt depends on condition and ability to understand. Ie in resp. distress not going to comprehend or listen. Keep MD advised.
I'd give the Lasix. And if I had a question about it or the dose I would ask the doc. He's/She's right there to ask. That's the beauty of ER medicine. Collaboration at its finest.
Can you please share what drew you to share this case? This sounds like an everyday occurrence got ER nurses. Was there something unique about this situation?
CHRISTOPHERSDAD
27 Posts
As a paramedic I would have had this pt before you and since I work for a very rural service 45 to 60 minutes transport times. I would establish iv draw labs and place in cooler give double dose of lasix rx iv place foley and possibly place on cpap to help with fluid in lungs and place on monitor and watch v/s.