Question

The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should:

A. ignore the patient's concern in evaluating goal attainment.
B. document the patient's unwillingness to continue the plan of care.
C. continue the plan of care as originally agreed upon.
D. modify the care plan in response to the patient's condition and wishes.

Answer 1

D, The nurse should modify the care plan in response to the patient's fear of falling, addressing the concern professionally and empathetically, and documenting any adjustments to support the patient's recovery.

Step-by-step explanation:

In response to the entry made by the nurse, the most appropriate action would be D. modify the care plan in response to the patient's condition and wishes. It is essential for healthcare providers to address patient fears and concerns instead of ignoring them. This not only respects patient autonomy but also encourages a collaborative approach between the patient and the healthcare team. The fear of falling is a legitimate concern, particularly for patients with mobility issues, and it can significantly impede recovery if not addressed properly.

The nurse should document the patient's concerns and work with them to identify strategies that could help mitigate the fear of falling. This may involve additional support measures, such as the use of assistive devices, more frequent supervision, or involving a physiotherapist to provide specific exercises aimed at building confidence and strength. The primary goal is to ensure the safety and comfort of the patient while encouraging progress towards mobility.