I am working on my first care plan, and I am having trouble coming up with my nursing diagnosis and short term goal. My patient suffered multiple open and closed fractures of BLE and is NWB due to an MVA.
Here is what I have for diagnosis:
Nursing Diagnosis: Impaired Physical Mobility r/t limited WB/BLE, pain/discomfort and fear of ambulation a.e.b. (some may know this area as the as manifested by section, we have to use as evidenced by) muscle weakness in BLE, limited ROM in BLE, dependence of wheelchair for ambulation, and statement "I want to get up and walk, but I am afraid I'm going to fall and make things worse."
Short term goal: Will transfer to/from bed and wheelchair independently with the assistance of a slider plate and remain free of falls or further injury for entire 12 hour shift.
Any thoughts or suggestions on how to improve the diagnosis and/or short term goal? We have to use NANDA and we have to be able to achieve the goal by the end of our next shift.
Moved to Nursing Student Assistance for more response.
Good luck with your care plan!