Reason for nursing care?

[MadilouN]

Hi. I have to write up a concept map for my Advanced Med/Surg clinical but I've become stuck. The directions say to place the "Reason for Nursing care" in the center and not the actual medical diagnosis. The following is my patient profile:

GS is a 92-year-old male admitted to Saint Joes from home with systemic inflammatory response syndrome (SIRS). The patient was admitted on 1-26-2016 to the floor for treatment.

Mr. S lives at home and is visited by home health daily. He has a caregiver that stays with him in between visits. He weighs 99kg and reports allergies to Hydroxyurea and Iodine. He has no history of smoking or substance use and has a history of MRSA. He is able to walk using a walker and with assistance. He is eats a regular diet but his I&O's are monitored. On 1-28, the patient's AV Fistula malfunctioned requiring an angioplasty. Mr. S's concurrent medical diagnoses include the following:

Renal Disease – receives dialysis 3xWeek (Tuesday, Thursdays, Saturday)

Heart Failure – treated with furosemide (Lasix) and clopidogrel bisulfate (Plavix)

BPH – treated with tamsulosin (Flomax) and finasteride (Proscar)

HTN – treated with furosemide (Lasix)

Current Status:

Mr. S has been undergoing treatment with maxipime to treat the infection. He has been placed on contact isolation due to having a history of MRSA. He has a left wrist 22 gauge IV. Upon questioning, he reported pain of 2 out 10 on the right anterior side, just below his shoulder. He has been provided a Lidoderm patch to decrease his pain. Upon Mr. S's neurological assessment, he presented with acute confusion. He is oriented to person and place but not to date or time. He mixes up days and shows short-term memory problems. His long-term memory remains intact (remembers children, caregivers). He consistently expresses confusion towards own abilities, requiring frequent watching and reminders. He often pulls at his IV and takes off his heart monitor. Mr. S is stable when getting up from bed with his walker to the chair or bathroom. However, due to his confusion, he does not wait to be helped or use his walker. When taken for an echocardiogram, he consistently tried to stand up from the bed to go home. This is a change in status from the previous day, where he had presented with no confusion. His neurovascular assessment revealed color WNL in both of his upper extremities and lower extremities. Capillary refill 3 seconds in both feet due to the present edema. His left lower extremity presented with 2+ pitting edema and his right lower extremity with 1+ pitting edema. Both lower extremities displayed weakness. Mr. S's anterior lobes were clear and posterior lobes diminished. His abdomen is soft, non-tender and normoactive bowel sounds. His last bowel movement on 1-29 was brown and formed. Vital signs at 0800: T 36.7 C, P 83, R 18, BP 115/68, O2 91% on RA. Vital signs at 1200: T 36.5 C, P 84, R 18, BP 113/59, O2 95% on RA. PT visited Mr. S at 1330 to get him moving about before the physician could clear him for discharge. He was cleared for discharge to home by his physician after receiving teaching and a booklet on heart failure.

What I'm confused on is that the day in which I cared for Mr. S, he was not receiving many treatments due to being discharged. I spent the day monitoring him due to his confusion so would my reason for nursing care be his confusion or would I need to focus more on his infection even though he was discharged home?

[NurseGirl525, ASN, RN]

You need a nursing diagnosis. Nursing Dx do not use medical diagnosis. They are different things. Do you have a Nursing Dx book? An updated Nanda book? The newest one is the 2015-2017 edition.