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Case Study: At 7:30am a 60 year old client who had a new tracheostomy placed yesterday complains of pain. The client states "I have not had any pain medicine since last night before bed." The client would like to start the day with a dose of pain medication to help control the pain. The client appears alert and demonstrates behaviors consistent with acute pain. When you review the Pyxis you note that the narcotic pain medication was signed out at 8pm, midnight and 4am for the client. According to the Pyxis, the client can have the next dose of narcotic pain medication at 8am.
You wonder why the client does not remember the medication. When you review the chart, you see no mention of medications or pain assessments. During report, the off going nightshift nurse did not mention administering pain medication, was drowsy in report and expressed a desire to go home right away.
Questions:
How would a nurserespond?
What are the actual and potential legal issues?
What are the actual and potential impacts on ethically?
What could or should a nurse do, considering this information?
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