A 62-year-old male patient on the unit complains of sudden onset chest pain. His nurse performs an assessment and gives a dose of nitroglycerin per standing order. Which of the following examples represents correct documentation of the situation?

0.3 mg nitroglycerin sublingual given PRN at 1700 hrs for 9/10 chest pain described as throbbing and radiating to the left arm and jaw. MD informed. VS WNL. Pain rated at 3/10 after 5 minutes.

Explanation

•This is the correct answer: 0.3 mg nitroglycerin sublingual given PRN at 1700 hrs for 9/10 chest pain described as throbbing and radiating to the left arm and jaw. MD informed. VS WNL. Pain rated at 3/10 after 5 minutes.

•When documenting an abnormal finding or a report of pain, the nurse must always document the intervention or further assessment initiated. What was done to address it? 

•When administering medication for pain, always document an objective measurement of the pain with the patient's description as well as the efficacy of the treatment after the drug has had time to work (usually 30-45 minutes for the oral route).

Incorrect options: 

•The other options are all missing a complete description and rating of the pain as well as an evaluation of the efficacy of the treatment.

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