Question

A client with prostate cancer and metastasis to multiple sites is admitted to a medical unit from a skilled nursing facility in significant respiratory distress. The client's advance directive states that the client does not want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which interventions would the nurse most likely note in the client's plan of care? Select all that apply.

checking on the client once per shift limiting client turning only when there is noticeable pain providing pillows for positioning to promote comfort providing mouth care based on family requests raising the head of the client's bed to ease breathing

Answer 1

Interventions likely noted in the plan of care would prioritize comfort, including pillow positioning, raising the bed's head, and mouth care per family requests, honoring the client's Do Not Resuscitate order and avoiding mechanical ventilation.

Step-by-step explanation:

Based on the client's advance directive, the interventions noted in the client's plan of care would focus on comfort measures rather than life-extending treatments like mechanical ventilation or resuscitation. The interventions that would likely be included in the plan of care are:

• Providing pillows for positioning to promote comfort
• Raising the head of the client's bed to ease breathing
• Providing mouth care based on family requests

Other interventions, such as checking on the client once per shift or limiting client turning only when there is noticeable pain, might not be consistent with the goals of a comfort-focused care plan. In this case, continuous assessment and frequent adjustments may be necessary to maintain the client's comfort according to the expressed wishes in the Do Not Resuscitate (DNR) order.