Documenting MS04

Hey quick question ,

How do you document MSO4 use on the dying pt? To clarify if you have a pt who cannot verbalize pain but who maybe moans when turned or something along those lines , how do document reason for giving morphine? Thanks for the help . I always turn to my expert friends on allnurses!

Maxie:rolleyes:

I document just what I see. I would state that the pt is non verbal but is exhibiting non verbal signs of pain, such as moaning or grimacing on movement, etc...Much of the time we are using morphine for respiratory distress so I will document that the med was given for "labored breathing" or "increased respirations." Is that what you were asking?

At our facility, if we premedicate before doing ADLs but the pt is comfortable when not being moved, we feel more comfortable getting an order that in addition to "PRN pain/dyspnea" also says "premedicate with ___mg 20 minutes before repositioning/ADLs". The straight PRN technically wouldn't cover premedicating because you would be giving the med before the symptom appears, and there is too much room for the needed med NOT to be given. However, if that's all you've got, you could say, "Attempted positioning pt on L side @1910, pt grimaced and groaned, attempt halted. Admisistered Roxanol 5mg @1915. Pt tolerated T&P@ 1940 without s/s of discomfort", or something like that.

Good for you for recognizing the value of assessing carefully for discomfort in the non-verbal patient!