Nursing Care Plan HELP!

[MLSruns800]

Hello everyone. I am working on my first practice nursing care plan and I am stuck. I was wondering if anyone can give me a little insight. I obviously am not expecting anyone to do the work for me. I am just asking for any advice and opinions if I am heading in the right direction when completing my first nursing care plan for practice.

So I was given a case scenario where the primary admitting diagnosis was generalized weakness.

Some of my assessment findings were:

Pt. reported having a hard time getting up from toilet and chairs twice this morning.

Pt. reported having no strength to get dressed, eat, or take morning meds.

Pt. reported feeling very weak and fatigued while trying to get out of bed so wife called EMS.

Pt. reported feeling congested, having a sore throat and having cough.

Dry cough present.

Temperature on admission 100.1.

Blood sugar was 254.

Patient reports having a fall in June of 2016 resulting in sprained ankle.

Patient has some right side deficit from previous stroke.

I chose my nursing diagnosis to be:

Activity intolerance related to generalized weakness as evidenced by inability to perform ADLs, impaired mobility, and fatigue.

My (2-3) expected outcomes for my patient were:

Patient will demonstrate ability to perform basic ADLs without signs of exhaustion or fatigue by discharge.

Patient will ambulate 100 feet (or more if tolerated) with staff twice daily.

Patient will remain free from falls during length of hospital stay (or until discharge.)

My nursing interventions for my patient were:

Reduce intensity level or discontinue activities if patient shows signs of overexertion.

Plan cares to balance rest periods with other activities.

Evaluate if patient might need additional help (PT/OT) in home after discharge.

Maintain safe environment and follow fall prevention measures.

My nursing evaluation:

Patient demonstrated ability to dress upper and lower body, bath self, perform self oral care without showing signs of fatigue or exhaustion. (Goal/outcome met)

Patient ambulated 3 times daily with staff in room and hallway to exceed 100 feet. (Goal/outcome met)

Patient had no falls during hospital stay. (Goal/outcome met)

[Kuriin, BSN, RN]

Excellent care plan. Don't forget about the history -- previous stroke. :]