CONCEPT CARE MAP

Implementation

Pathophysiology
Assessment
1. Observe for pain before
Kidneys filter
waste products
activity. If possible, treat
Subjective
Data:of pain of 6 when sedentary,
pain before activity and
metabolism
collect
pain of that
10 when
mobile
ensure that the client is
in theObjective
blood. TheData:
blood Respirations 20, O2 sat 93%,
not heavily sedated.
pulse
73,kidney
temp. by
98.1, BP 143/81, WBC 18,
reaches
each
2. Obtain any necessary
creatinine
1.9, albumin 2.8, protein 5.6,
a renal
artery that
assistive devices or
formation
of ileus from immobility, nausea,
branches
from the
equipment needed
vomiting,
diarrhea
abdominal
aorta.
before ambulating the
Pertinent20-25%
medical/surgical history: acute
Approximately
client (e.g., walkers,
failure,
type II diabetes
of therenal
cardiac
output
canes, crutches).
circulates
each
minute
3. Monitor and record the
through the kidneys. The
clients ability to tolerate
Diagnosis/Planning
nephron, the functional
activity: note pulse, bp,
unit of the kidney, forms
dyspnea, and skin color.
Nursing diagnosis: Activity intolerance
R/T the effects of anemia
References
the urine. When the
Teaching:
as evidenced by acute renal failure, pain of 10 when moving, and
4. Instruct client on
kidneys suddenly cant
formation of an ileus.
techniques to utilize for
filter the wastes from
Potter, P., & Perry, A. (2013). Urinary
avoiding activity
Patient Goal:
By the end ofInthe
clinical day, patient
will walk down
the blood, it results in
elimination.
Fundamentals
of nursing.
intolerance, such as
the
hallway
four
times
a
day.
acute renal failure
(Eighth ed., pp. 1042-1043). St. Louis,
controlled breathing
resulting in numerous
Missouri: Elsevier.
techniques.
complications such as
5. Teach the client the signs
decreased urinary
and symptoms of activity
output, nausea, fatigue,
intolerance such as chest
swelling due to fluid
pain, dyspnea,
retention, and shortness
palpitations,
of breath.
dysrhythmias,
lightheadedness, pallor,
cyanosis, nausea, and
Evaluation
increased heart rate.
Was goal met? How do you
6. Explain to the client how
know goal was or was not
to use assistive devices,
met? Was it partially met?
oxygen, and medication
Explain.
before or during activity.
No, goal was not met. Patient
was only able to walk the
hallway once.