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Home  arrow PART 1: MEDICAL-SURGICAL NURSING PRACTICE  arrow Chapter 1: Medical-Surgical Nursing  arrow Case Studies  arrow The Client with an Advance Directive

The Client with an Advance Directive

Client's Name: Mary Smith

Abstract: Mary Smith, age 78, has been on the medical-surgical nursing unit for 10 days. She was admitted with advanced breast cancer, dementia, anorexia, dehydration and electrolyte imbalance. Prior to being diagnosed with dementia, she established an advance directive, which her son, at this time feels unable to honor. The nurse must deal with this dilemma.

Objectives:
Demonstrate critical thinking when using the nursing process to provide knowledgeable, safe client care.
Explain the importance of nursing codes and standards as guidelines for clinical nursing practice.


Mrs. Smith has been treated for the past 10 days for the acute symptoms that necessitated her admission. She is no longer dehydrated nor in electrolyte imbalance. However, there is no treatment recommended for her advanced cancer and she is currently refusing to eat, despite attempts to feed her by the nursing staff and her son. She becomes angry and combative when someone attempts to help her eat. She is malnourished and has lost 5 pounds during her hospital stay. Her advance directives state the client’s wishes to not be resuscitated or placed on life support in event of cardiopulmonary arrest. The client also indicates in the directive that she does not want the placement of a gastric or nasal feeding tube, nor does she want any other type of nutritional support in the event she does not eat. The client’s son, who has legal power of attorney, is insisting that his mother have a feeding tube inserted and nutrition administered. The physician complies with the son’s request and orders the placement of a nasogastric feeding tube and Ensure feedings to begin at 40ml. per hour. The nurse caring for Mrs. Smith is a new graduate, who recently passed her NCLEX-RN licensing examination. The nurse becomes upset when she is informed about the order to insert a feeding tube in her client despite the client’s advance directive.

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