간호사가 입원 기록을 검토합니다. 어떤 소견에 후속 조치가 필요한가요? 대상자의 의사결정 권리나 돌봄 계획과 충돌하는 소견을 강조하세요.

Nurses' Notes 1430: The client with metastatic pancreatic cancer is admitted for symptom management of a partial bowel obstruction. The client is awake, names the hospital and date, and explains the expected benefits and burdens of the available treatments. The record includes a signed directive declining cardiopulmonary resuscitation and endotracheal intubation. The client says, "I still want medicine for pain and a tube if it helps the nausea". The electronic admission banner lists the client as Full Code even though no later revocation is documented. The daughter asks the team to "do everything" because she believes the client will change their mind. The nurse asks the daughter to sign treatment consent while the client continues to answer questions coherently. The client requests nasogastric decompression for comfort and asks to discuss home hospice after symptoms improve. The medication record shows the client accepted the prescribed opioid after the nurse reviewed expected effects. A palliative care consultation has been requested for this afternoon. The blood pressure is 118/70 mm Hg, and the client speaks without respiratory distress. A clinician entry states that no capacity assessment is needed because metastatic cancer makes the client unable to decide. The social worker documents that the daughter is the named health-care representative if the client loses capacity. The nurse pauses the admission process to compare the client's current wishes, directive, and active orders.