Listen, teaching someone how to write a care plan is, for me anyway, way too much typing for a post or an e-mail. Go to your school's library or call your local hospitals and ask the medical librarian if they have a copy of Carpenito's Nursing Diagnosis book
. The first 12 pages or so gives a really good explanation of what to do.
The nursing diagnosis is the tricky part. Here is a BRIEF example
Problem: Alteration in skin integrity
Etiology: related to bedbound status
Symptom: as evidenced by stage ii breakdown on sacrum
(Nsg dx must have these 3 components prob, etiol, & Sympt, ...usually)
Goal: Wound will be decreased in size by three weeks and healed in nine weeks (goals need time limits, must be measureable)
Outcome: Client's wound will be healed and wound will remain free of infection. No new breakdowns.(What you want the end result to be)
Nursing orders: (how you plan to reach your goals and outcomes)
1. Assess nutrition, ie 3 day diary, skin turgor, quantities of fruits veg's PROTIEN, milk etc, instruct in balancing diet and ways to inc prot in diet if not contraindicated (liver disease)
2. Turn pt q 2 hours, teach caregivers to avoid prolonged pressure on bony prominences
3. Measure wound weekly. If no improvement in wound after 3 weeks of present wound care, consult physician or wound care consultant.
4. Observe for and report signs of infection.
blah blah blah etc etc etc yada yada yada
Also, the student nurse forum is pretty active here, so check it out, they are recent pros at writing care plans