Can anyone help me?

ok, this is what you need to be doing. first of all, you should be following the nursing process when you do a care plan. step #1 assessment is probably the most important thing you have to do. you need to glean as much information about the patient as you can from their medical record and from doing your own physical assessment and talking with the patient. from that you need to develop a list of everything that is not normal. this list of abnormal assessment data becomes your patient's list of symptoms which you will see as their problems. that list/problems is what you use to determine your patient's nursing diagnoses. that is step #2 of the nursing process. once you have done that you move on to step #3 which is writing goals and nursing interventions. these are based almost solely on those symptoms the patient has (see the list you created from the patient's initial assessment and that you used to diagnose them). in essence, goals are pretty much the reversal of the symptoms. now, figuring out the time element that it will take to achieve that is a bit of a problem sometimes. that is information that comes with experience. something you will need to remember to do when you are in clinicals is to ask questions of the nurses. ask how long they have seen that certain things start to reverse when nurses start instituting some procedures. in some cases a pathophysiology book may be helpful, especially when it comes to things like healing. see post #157 on https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html for a discussion on what goes into a goal/outcome statement.

as for references, your instructors are looking for you to reference where you are getting your information regarding how long goals are going to take and where you getting your information regarding which nursing interventions to use. we also did this when i was going through my bsn program. every goal and nursing intervention had to be referenced. we used nursing textbooks, anatomy and physiology and pathophysiology books primarily for this. in some cases we even used a fundamentals of nursing textbook for basic nursing procedures. keep in mind that what we do is also based in the sciences so don't be afraid to go to other science resources (chemistry or biology) to support any claim that you are making. also, the time element on some goals will just be based on common sense. however, you cannot be afraid to ask other healthcare providers in the hospital setting about these things and ask if they have books or other resources in their department that you can look at to verify what they are saying. then get page numbers and book titles to quote in your references. you have to get over this fear of approaching and asking questions of others. your instructor is also a colleague.

you should also keep copies of all your care plans since many of the interventions, particularly with med/surg patients tend to come up again and again so you won't be wasting time re-looking up things. use your care plan books to help you with the rationales and goals, but use your textbooks to verify and use to reference these rationales since you are not allowed to use care plan books. some books, particularly nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig name and list the references for the interventions in their book. saunders comprehensive review for the nclex-rn examination, 3rd edition, by linda anne silvestri has a lot of the rationales for nursing interventions as well as some of the goals listed in it (use the index to find things). it is not a care plan book and i imagine could be used as a reference in lieu of a textbook or a care plan book for your care plans. other potential references would be medical dictionaries, lab and medication reference books and even internet websites. be creative. use anything that is going to support what you are using to rationalize statements you are making. i even referenced instructors statements from lectures when i was desperate.

For pathophysiology try one of the books in the "Incredibly Easy" series, or I have a copy of

Pathophysiology: A 2-in-1 Reference for Nurses by Springhouse, Springhouse Publishing Company Staff which I think is very good. I will sometimes quote from it when answering questions for students on the forums. It includes nursing interventions as well as signs and symptoms for most of the major diseases and is organized by body systems. It costs 44.95.