How do you write a care plan?

[FutureSuccessStory19]

I am trying to write my first care plan, and am having a bit of trouble. I am just a student, so please bear with me! I've started it but have no idea if I am putting the correction information in the right spots or if I am correctly wording it. I have a template, and a power point explaining the steps that was given to me in class but I struggle with learning & understanding just by reading how-to instructions. Plus, there are no pictures or examples. I'm the type of learner that needs someone to walk me through it, but because that cannot happen through a screen, my main question(s) is this... So, I must go through and assess each of Gordon's 11 Functional Health Problems, which I did of course. For EACH of those, I must include a nursing diagnosis (what is/are NANDA btw...? Many I have seen speak about a NANDA list but I do not have one, I believe) with supporting subjective & objective data. (what if the patient didn't give much subjective data, or any for one of these?) I then need to create a short term goal that would occur during the clinical shift and next, include 3 interventions for this goal with a rationale for each and making sure to identify the source for each rationale! Next is where I am getting confused... we are to evaluate the effectiveness of our short-term goal. If I had my assigned patient for one day, and am not going to have that patient again next clinical shift, how do I know if my goal was met? Our care plan doesn't actually go into use & effect I know... so do we just make up whether or not our goal was met? (sorry if that is a dumb question, plz no rude comments) Anyways, how do I come up with these diagnosis's and how do I word them? Online I read that the nursing diagnosis will be written, and include "r/t or relative to" as well as "AEB or as evidenced by" but is it true that you do not include AEB for a "risk for" diagnosis? Such as risk for falls? I have to turn in my assessment data, and on the top it reads "medical diagnosis" but I have no idea what it would be for this patient if it's asking for only one. I will refrain from posting info regarding my patient for now, as I am certainly not asking for my care plan to be written for me. I am just asking for some tips on how to write/word what I say and looking for answers to the few questions I have. Please, even if you only have one thing to say, any comment is welcomed & appreciated! Thanks ahead of time!

[Girlafraid13]

There's a nanda book I recommend you purchase. And you are correct about the "risk for" not having aeb. Example risk for falls r/t left sided weakness.

Definitely get the NANDA book which you can find on amazon.

[Purple_roses]

What I'm going to tell you is something that I have continually told myself this semester: You are going to mess up, and that's actually a really good thing. Your teacher is going to mark up those care plans. It might hurt a little at first to see all of the corrections, but it will just make your next care plan that much better. You will improve with each one. So do your very best on this one. Follow the template as best you can. And then review those corrections when you get it back. The care plans are simply a tool to make us think like nurses, which is hard to do at first.