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Fitzgerald

Diagnosis #1
Acute pain related to physical agents (pancreatitis).
Outcome #1
Patient will rate pain as 2 or less out of 10
throughout the shift.

Evaluation #1:
Patient reports achieving pain relief with
analgesia and other measures and at numerous
points reported having pain less than 2/10.

Diagnosis #2
Social isolation related to altered state of wellness.
Outcome #2
Patient will interact with caregivers and develop plan for
increasing social activity by end of day.
Evaluation #2:
Patient interacted with caregivers and increased
social activity by talking with friends on the phone,
playing games with dad, and talking to staff.
Developmental:
Erickson: Industry vs. inferiority
Star soccer player; athletic; likes to be active
Straight A student
Avid reader

Diagnosis #3
Nausea related to irritation of GI system.
Outcome #3
Patient will report no feelings of nausea by end of shift.
Evaluation #3:
Patients nausea subsided by end of shift.

6W Concept Map

Samantha Hasenzahl

Patient has had abd pain for 2 weeks. Went to PCP twice; first given Nexium and had no relief,
second time prescribed Carafate and scheduled abd US. Pain persisted and patient went to Dr.
Roundtree who drew labs lipase was 435 and diagnosed with pancreatitis; prescribed Nexium
and low fat diet. Patient continued to have pain so returned and was directly admitted from
GIclinic.
Assessment Data #1:
Verbalizes pain; it ranged from 4-6/10; crying;
laying in fetal position; facial grimaces.

Rationale #1:
1. Pain medication helps alleviate pain and
promote comfort/rest.
2. Helps patient take mind off of pain.
3. Repositioning helps reduce muscle tension
and redistribute pressure on body parts.

Assessment Data #2:


Patient stated that she was home sick and sad about
missing the soccer tournament this weekend.
Rationale #2:
1. Listening communicates concern, interest, and
acceptance, allows time for patient to collect thoughts
and express feelings.
2. Allowing time for family bonding demonstrates
respect for patient and her relationship with others.
3. This provides pleasure, increases feelings of selfworth, and decreases negative self-absorption.

Assessment Data #3:


Patient expressed feelings of nausea and lightheaded ness;
patient was warm to touch with light perspiration.
Rationale #3:
1. Provides relief from nausea
2. Helps cool patient down and provide comfort.
3. Helps patient relax and rest.

Weight: 54.6kg
(120.12 lbs)

Interventions #1:
1. Assess signs and symptoms of pain and administer pain
medication as prescribed.
2. Plan activities to provide distraction such as reading,
playing games, social interaction.
3. Help position patient into comfortable positions.
Medications for Diagnosis #1
Morphine- opioid analgesic; CNS depressant that inhibits pain
impulses; dose = 0.05mg/kg (IV q2h PRN for severe pain).
[admin 2.72mg]
Ketorolac (Toradol)- NSAID analgesic; inhibits prostaglandin
synthesis; dose = 0.5mg/kg(IV q6h PRN for mild to moderate
pain). [admin 27.3mg]

Key:
Care Concept
Diagnoses
Outcomes
Assessment
Weight
Developmental
Interventions
Rationales
Evaluation
Medications

Interventions #2:
1. Spend at least 15 minutes with patient and listening
to her.
2. Allow ample private time for patient to spend time
with family and friends.
3. Arrange with patient for specific periods of
appropriate planned divisional activities.

Interventions #3:
1. Administer anti-nausea medication as prescribed.
2. Apply cool wash cloth to patients neck.
3. Teach relaxation techniques like deep breathing to
comfort patient.
Medications for Diagnosis #3
Ondansetron (Zofran)- antiemetic; selective antagonist of
serotonin receptors; dose = 6mg q6h PRN for
nausea/vomiting