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Discussion

Help with writing a care plan

I am currently working on Excelsior Colleges Health Safety exam. I am reading about the nursing process and under stand all the process entails ADPIE. I am getting a little confused as to how to write a care plan. You assess, You write a nursing Dx, I get caught up at plan and implement. I am confused on what they mean by outcomes interventions and goals and how to basically write this part. I have been a medic for 11 years and I have written SOAP format for years, I just want to understand this care planning so I have it locked down, Any help will be great. Thanks

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    example:

    Dx: potential for altered skin integrity r/t imobility as evidenced by pt inability to turn and transfer

    Goal: pt will not show develop any stage 1 pressure areas for the next month

    Goal: pt will not have any skin tears within the next month

    Interventions: apply moisture barrier to buttocks, and perineal area BID and with each episode of incontinence, pt will be repositioned every two hours, heels will be floated while in bed/ podus boots while in bed, transfers will be blah blah blah you get the picture

    Evaluation: skin integrity will be observed and documented by CNA/RN daily, full skin assessments will be completed by primary nurse weekly

    this is A ROUGH example. Haven't written a care plan in YEARS!!!! LOL

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    Thank you, now that I see the order I can understand it

    Thank you for answering me

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