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.
護理紀錄
1430:
罹患轉移性胰臟癌的個案因部分腸阻塞的症狀處理而入院。個案清醒，能說出醫院名稱與日期，並解釋可用治療的預期效益與負擔。紀錄中包括一份拒絕心肺復甦術與氣管插管的簽署指示。個案說，「我仍然想要止痛藥，如果管子能幫助噁心感，我也願意」。電子入院橫幅將個案列為全力急救，但沒有後續撤銷的紀錄。女兒要求團隊「盡一切努力」，因為她相信個案會改變心意。護理師在個案仍能連貫回答問題時，要求女兒簽署治療同意書。個案要求鼻胃管減壓以舒適，並希望在症狀改善後討論居家安寧。給藥紀錄顯示個案在護理師說明預期效果後，接受了處方的鴉片類藥物。今天下午已要求安寧緩和會診。血壓為 118/70 mm Hg，個案說話時沒有呼吸窘迫。一則臨床紀錄指出不需要能力評估，因為轉移性癌症使個案無法決定。社工記錄女兒是指定的醫療代理人，在個案失去能力時代理。護理師暫停入院流程，以比較個案目前的意願、指示與現行醫囑。