Rationale/Pathophysiology

You can't just pick Nursing Dx out of the air. Each has a set of defining characteristics... that should coincide with your assessment findings.

just getting started espically the pathosphysiology part I guess I don't really understand its meaning.

I'm not exactly sure what you mean, but first with the assessment. What is it telling you? Why might this be happening? (Patho), then you formulate your nursing diagnosis based on that assessment. You use the "related to" next to your nursing diagnosis to connect the assessment.

Come up with a plan now? What do you want to see in the patient? What is the goal? It has to be measurable and realistic.

Now what is the nursing intervention? Why are you doing it? (rationale)

Now evaluate, did the patient meet the goals? Why? Anything you could've done differently?

There you have your care plan

This is an example for you, why is the patient at risk for infection? You can't just put that down, where is your assessment that led you to believe so? Some examples are: impaired skin integrity, diabetes, immunosupressed, invasive procedures, etc.

So Let's go with a stage 3 decubitus ulcer is seen on your patient. This is your assessment, there is a pressure ulcer, it is stage 3, and of course the skin is not intact.

So what is this? Risk for infection bc of portal of entry (patho) as seen from the nonintact skin from the pressure ulcer.

Plan? Prevent infection, and facilitate wound healing. So patient will be free of symptoms of an infection, like no fever, no swelling, lab tests norm, etc.

Intervention: what do you do to prevent infection? Hand hygiene, aseptic technique, assess for sign of infection, change the dressing as ordered, facilitate healing, administer things like vit c as ordered. Educate the patient on proper care, aseptic technique, hand hygiene, signs of infection etc.

Evaluate: did the patient get an infection or exhibit signs during your shift? Where the precautions taken?