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Understanding limited DNR

Geriatric   (11,629 Views 16 Comments)
by me2shugar me2shugar (New Member) New Member

1,625 Visitors; 14 Posts

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This is my 1st month in LTC.

Today I saw a resident form marked for a limited DNR.

I cant wrap my mind around what I am suppose to be doing for a limited DNR while waiting for an ambulance in an emergency.

My orienter said I shouldnt resusitate but can do wink wink "sternal rub". I am not understanding the concept of limited DNR.

Does anyone have any experience with Limited DNR cases, what did you do?

thanks

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umcRN has 4 years experience.

1 Like; 21,451 Visitors; 867 Posts

hmm usually they have some specifics to them, but i work in an icu...things i might see on a limited dnr would include: no intubating, no chest compressions, no code meds, anything really, some kids have no intubating/chest compressions but we can suction/bag which often is enough, but there should be some clarificarion

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apocatastasis has 4 years experience and works as a APRN/ARNP, PMHNP.

11,431 Visitors; 207 Posts

Yeah. If you're talking about what I think you are... generally they're not called "limited DNRs" they're called something like chem code, or category IIs, or whatever your facility policy is. A DNR means DNR. If you doing ANY resuscitating, be it CPR, or pushing drugs, or bagging... in my book they're not a DNR. Essentially you need to look at the code status and advance directive form to see WHAT you are supposed to do if the patient goes downhill. Mucho important information to know.

Also: Um, a sternal rub is not resuscitation.

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Mandychelle79 has 2 years experience and works as a Psych Nurse.

1 Like; 9,102 Visitors; 771 Posts

Ours is called a limited code. It then describes later what the patient wants done. I usually see No Tubes as the qualifier.

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1,625 Visitors; 14 Posts

Thanks for the comments. I understood that sternal rub was not cpr that is part of what was confusing to me.

I am finding that the LTC facility has an under the table type work ethic because there are so many paitents to one nurse.

I didnt quite understand her "wink" at this though , if the heart is still beating should I compress to keep something engaged??? blood circulating??

wasnt sure what was being communicated; I didnt want to challange her right off since I had never heard of limited DNR.

Thought I would ask here to get other ops

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JulieCVICURN works as a Registered Nurse.

5,691 Visitors; 443 Posts

I find all of these very frustrating. I think they were created to make families feel better. Let's see, we can do a chemical code/no CPR - how exactly are those drugs going to circulate to help the patient? No intubation - what do you think you're going to have left if we do restart the heart? They're all just ways of avoiding making a real decision.

Sorry. Off my soapbox now.

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6,960 Visitors; 212 Posts

Thanks for the comments. I understood that sternal rub was not cpr that is part of what was confusing to me.

I am finding that the LTC facility has an under the table type work ethic because there are so many paitents to one nurse.

I didnt quite understand her "wink" at this though , if the heart is still beating should I compress to keep something engaged??? blood circulating??

wasnt sure what was being communicated; I didnt want to challange her right off since I had never heard of limited DNR.

Thought I would ask here to get other ops

if you feel a pulse you dont need to do CPR

if you dont feel a pulse start CPR..

unless they have DNR then dont..

"limited" DNRs can come in a bunch of different flavors: No Compressions, Drugs only, No ventilations, no intubation.. etc etc.. in order to find out which of the above it is your going to have to look at the paper..

also Sternal Rubs are a way to check if the patient is unconscious... i refuse to use it because of alot of providers doing it too hard and causing brusing.. abrasions.. especially in older patients

two ways i check if their conscious or not (other than yelling really loudly :lol2:) is put a pen between then fingers and squeeze and flick their eyelashes a few times

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merlee has 36 years experience and works as a nursing.

2 Likes; 13,258 Visitors; 1,246 Posts

Each patient in LTC has SIGNED forms stating what is to be done for end-of-life measures. You may actually need to read them. There is no 'wink-wink' here, there are written orders for each and every patient.

Sternal rub has no place here; nor should it.

Best wishes!

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blue heeler works as a RN.

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we call them modified codes. everyone has a right to their wishes for resuscitation but i find it difficult to remember, especially with three or four patients, all with different modifications.

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CoffeeRTC has 25 years experience and works as a RN LTC.

5 Likes; 21,279 Visitors; 3,719 Posts

I've been doing LTC for over 15 yrs and have never seen this. We have a facility form that is Yes, no or I don't want to make the decision now for CPR. Yes and no decision = start CPR.

In the advanced directives they indicate what type of life saving therapies they want..blood, abtx, intubation etc.

It is Yes or No cpr. Once we start CPR and the medics come, they continue...at the hospital then they can look at the advanced directives.

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wee_oneRN has 1 years experience.

2,673 Visitors; 120 Posts

The forms are usually more specifc, at least in CA. A pt can choose no CPR but still have limited treatment checked, which usually means no intubation but bagging and IV's for fluids, antibiotics are okay as well as any comfort measures. They may also choose whether or not they want to be transfered to a hospital.

I have seen many people choose no CPR (no compressions) but check the full treatment box, which makes no sense as was already pointed out. But, if it makes the family feel better, then give all the stagnant meds you want!

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arabstarRN works as a RN.

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My father-in-law suffered a massive stroke and ended up going from ICU to a rehab hospital within the hospital, more like a SNF within the hospital. Anyway, While he was in ICU he was a full code - and because of this, when he coded only days after being in ICU, he was intubated and placed on a temporary pacemaker because he had second degree heart block, his rates were down below 40 sometimes as low as mid 20's... His wife would not/could not sign a DNR as she felt he was going to recover (2/3 of his right brain was infarct... severe left sided weakness/borderline paralysis, doctors told her he would never come home if he did survive it - she was in denial and refused to believe it, as well as her oldest son, but the youngest son who is my husband, understood the situation perfectly and wanted a DNR in place for his dad's sake). He spent 3 weeks in ICU and then was transferred, where upon his admission I convinced her that a DNR was needed because if he coded again or anything caused him to lose more oxygen to his brain, it was only going to cause him more suffering (At this point, he had been trached, permanent pacemaker and on a ventilator... not really going to code, but stranger things have happened I guess....). He was in this facility 3 weeks and after several attempts to pull him off the ventilator, he couldn't handle it and the doctors decided he would have to stay on the vent the rest of his life. One doctor even told her that her options were to place him in a home where they take vents and he lay in bed until he finally passed from some other complication (he had pneumonia starting as well) or pull him of vent and make him comfortable and he didn't think he would last 24 hours. In this facility he was listed as a Category III - no compressions, no major treatments (but, he was already intubated via the trach, he already had the permanent pacemaker regulating his heart rate, so if his heart stopped beating he would have technically coded since it wasnt a pacemaker/defib combo unit, but still... he technically was already on life support...) This made her feel better but made no sense to me as he was already being supported. When the decision to pull him off the vent was made, he was swtiched to a Category IV which was to keep him comfortable with a morphine drip and do absolutely nothing to try to save his life, only comfort measures. He was pulled off the vent at 10 pm and took his last ragged breath at 4:01 pm the following day.

That was the hardest thing to sit and watch... I didn't sleep at all that night, I stayed by his bedside and held his hand so that his sons and my mother-in-law could sleep some. Hearing his lungs fill up was a horrible thing that I don't wish upon anyone... I learned so much from his unfortunate episode and I thank him dearly for that, although the sacrifice he made in order for me to learn was not something I wanted to happen, obviously. He taught me, without fully knowing, so much about trach care and ventilators and peg tubes and end of life care, I will be forever grateful to him for that.

Sorry, I got off topic there, my point originally was I don't fully understand the differences either as medically they seem to contradict each other at times, but it does help the family to deal with their decision and not feel like they are killing their loved one...

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