short term goal for High priority NANDA diagnosis Risk for Traumatic Brain Injury
The Correct Answer and Explanation is:
Correct Answer:
Short-Term Goal:
The client will remain free from head injury during the hospital stay, as evidenced by the absence of falls or trauma within 48 hours.
Explanation
The NANDA nursing diagnosis “Risk for Traumatic Brain Injury” refers to a vulnerable state in which a person has an increased likelihood of suffering a brain injury due to internal or external factors. It is classified as a risk diagnosis, meaning that no current evidence of injury exists, but there are known risk factors that must be addressed proactively.
In nursing care planning, setting short-term goals helps the healthcare team focus on preventing harm within a manageable time frame. A suitable short-term goal for this high-priority diagnosis is ensuring that the patient remains free from trauma, especially head injuries, within the first 48 hours of observation or care. This is critical because most inpatient accidents, such as falls, are likely to happen shortly after admission when patients are still unfamiliar with their environment or when their health condition is most unstable.
This goal is measurable, specific, attainable, realistic, and time-bound. It focuses on a 48-hour period, allowing the nurse to assess whether interventions such as safety measures, monitoring, and patient education are effective in preventing injury.
For example, if a patient is disoriented, has seizures, or takes medications that impair coordination or alertness, they are at elevated risk. Nursing actions like raising bed rails, using non-slip footwear, and supervising mobility directly support the goal.
By achieving this short-term goal, nurses can protect the client from harm and reduce the likelihood of a more serious complication. It also provides a foundation for planning longer-term goals, such as preparing the patient for self-care safety at home or educating caregivers about fall prevention.
