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.
ANS: D
Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. Evaluation is not a record of the care that was implemented. Evaluation must clearly identify the effectiveness of implemented interventions with the patient as its focus. During the evaluation step of the nursing process, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and desired outcomes were achieved. Monitoring whether the patient's goals were attained is a collaborative process involving the patient. Nurses need to ask some questions when evaluating the effectiveness of provided nursing interventions: Did the patient meet the goals and outcome criteria established during the planning phase? Since care began, have new assessment data been identified that should be taken into consideration? Does the care plan need to be modified in response to patient changes? Based on the patient's response to the implemented interventions, should the plan of care be continued, revised, or discontinued?
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