Final answer:
Documentation of a client being medicated for pain would be found on the progress notes and the Medication Administration Record (MAR). These documents ensure accountability and accurate record of treatments provided, facilitating a collaborative approach to patient care and management.
Step-by-step explanation:
The student asked where the documentation of medicating a client for pain would be found. The correct answer is on the progress notes and MAR, which stands for Medication Administration Record. When nurses administer medications, they must thoroughly document the process to assure accountability, accuracy, and compliance with the prescribed treatment.
The nurse communicates and reviews various key items with the healthcare team, such as the name of the procedure recorded, counts of needles, sponges, and instruments, labeling of specimens (if any) including the patient's name, and any equipment issues that need to be addressed. Additionally, post-procedure, the surgeon, nurse, and anesthesia professional will discuss the key concerns for the recovery and care of the patient, ensuring a collaborative and informed approach to patient management.
A tool like the Mosby pain rating scale may aid healthcare providers in assessing the level of pain a patient is experiencing. The scale's effectiveness also provides a quantitative method to record in the MAR, correlating with the progress notes that will include the nurse's assessment, interventions, rationale, and the patient's response to the given medication.
Referring to clinical situations, such as the case of Barbara who has metastatic inflammatory breast cancer, underscores the importance of accurate and comprehensive documentation. The physician's steps to address Barbara's potential catheter site infection - including the treatment with a topical antiseptic, changing the dressing, and the prescription of antibiotics - must all be documented appropriately in the patient's healthcare records, allowing for continuous and consistent care.