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Difficulty: MediumAdvance Directives and Informed Consent

A practical nurse (PN) is providing care for an older adult resident in a skilled nursing facility. The resident, who currently has a "Do Not Resuscitate" (DNR) order in their medical record, states, "I have changed my mind. If my heart stops, I want you to do everything possible to save me." In what order should the PN perform the following actions? Arrange the actions from first to last.

  1. 1Ask the resident to elaborate on their decision to change their resuscitation preferences.
  2. 2Report the resident's verbalized request to the charge nurse and the primary healthcare provider.
  3. 3Document the conversation and the notification of the healthcare team in the medical record.
  4. 4Confirm that the healthcare provider has canceled the previous advance directive order.
  5. 5Change the resident's code status identifiers and update the daily care plan.

Answer

The correct sequence is to first ask the resident to elaborate on their decision, then report the request to the charge nurse and provider, document the conversation in the medical record, confirm the provider has canceled the order, and finally change the resident's code status identifiers.
When a client requests a change to their advance directive, the practical nurse must first assess the client's understanding and intent. Because the practical nurse cannot independently alter medical orders, the request must be escalated to the registered nurse and provider. Documentation follows immediately to create a legal record of the client's verbal revocation. The practical nurse must then wait for the provider to officially cancel the order in the chart before physically changing the client's care plan and identification tools to reflect a 'Full Code'.

Step-by-Step Solution

1
Collect data by exploring the resident's request.
The practical nurse understands the resident's intent and ensures the request is voluntary.
Data collection is the necessary first step of the nursing process before taking any further action.
2
Notify the charge nurse and healthcare provider.
The individuals with the authority to legally alter the medical order are informed.
A practical nurse cannot independently cancel a legal advance directive such as a DNR order.
3
Document the interaction and notifications.
A formal legal record of the resident's wishes and the nurse's actions is established.
Timely documentation is required to protect client rights and maintain accurate medical records.
4
Verify the new medical prescription.
The practical nurse confirms the DNR order has been legally discontinued by the provider.
Nursing interventions regarding code status must be based on a valid, updated provider prescription.
5
Update the care plan and client identifiers.
The interdisciplinary team is made aware of the resident's new 'Full Code' status.
Updating physical identifiers and the care plan ensures that all staff will perform life-saving measures if a cardiac event occurs.

Key Concept

A competent client has the right to revoke an advance directive, such as a DNR order, at any time. The practical nurse's role is to gather information, escalate the request to the provider for a legal order change, document the event, and update care identifiers only after the new order is verified.
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Topics

Advance Directives and Informed Consent

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