Looking fof examples and input APIE/Labs

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Specializes in Medical/Surgical, Cardiac/Telemetry.

I was wondering where I could find completed "mock" examples of written diagnosis? I read a few of the sticky's listed here and most seem to have how to put it together but not the whole picture (unless I missed it)

In essence, I'd like to see the assessment too to see how the diagnosis is determined, if that makes sense.

Reason being, I am working on "mock" lab reports (posted about them previously) and they are hard to do especially without much of a history to go on. I asked my instructor for a few extra to work on this week and they don't' seem to be getting much easier.

This is the one I'm working on currently:

Hx - Glomerulonephritis

Sodium 126

Potassium 6.9

Chloride 92

Bun 28

Creatinine 1.2

So far I'm thinking Renal calculi /Renal failure/ dehydration

Something like: Fluid volume deficit RT failure of regulatory mechanisms (secondary to decreased renal perfusion. (AEB Lab results?)

It's theory, so we can put a medical diagnosis. It's hard without any other information for me. But, am I on the right track? Is this person dehydrated even tho the creatinine is within normal limits?

Btw, this is not for a grade, I just wanted to practice for a better understanding of labs.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

do you have a care plan book? most care plan books explain the care plan writing process in the very first pages of the book. if you are going to be required to write care plans then you really should be getting yourself one. they run anywhere from $30-$50.

you could say fluid volume deficit r/t failure of regulatory mechanisms secondary to glomerulonephritis [not renal perfusion because that is another nursing diagnosis--it is ok to use a medical diagnosis as a "secondary to"] aeb bun of 28, creatinine of 1.2 and [you should include other signs and symptoms of dehydration as well].

you need a care plan or nursing diagnosis book in order to check that you are classifying these diagnoses correctly. that's what these books are for. that's why i gave you information and links for acute pain in your last post. how do you think a medical student learns to diagnose medical diseases correctly? they use similar reference books, many times a pocket book that they carry around with them. why should nurses be any different when learning to nurse diagnose? i don't care what your nursing instructor is telling you.

no one hardly ever posts their entire care plan on allnurses or the internet. and, i have yet to see any examples of a complete patient assessment that goes on to take you through the steps of the nursing process except partially as in some of the questions that have been asked on the forums here and in some case studies that i am giving you links to below. one of the major problems i find is that most students don't "get it" that their assessment information is crucial to the foundation of their care plan and formulation of their nursing diagnoses. most students start right at picking a nursing diagnosis without seeming to give any thought at all to their assessment information which is why you are finding so little assessment information. you will find me time and time again asking students to list their patients symptoms when they are asking for help with figuring out a nursing diagnosis to use for a patient with xyz medical diagnosis. that tells me right off the bat that they do not know what they are doing with regard to the nursing process.

you can look at completed care plans and case studies that have nursing diagnostic statements (not saying they are all correct) on these web sites. these links, by the way, are all posted on the care plan sticky threads i list for students to read over all the time. i suspect, however, that most do not read all the posts.

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Specializes in Medical/Surgical, Cardiac/Telemetry.

Thanks Daytonite,

I've read many of your posts and how much you emphasize that the diagnosis is directly related to the assessment. You've planted that seed and I'm very grateful for that.

Eventually I want to get a diagnosis book, and I will, however we are not allowed to use them per our instructor. I just asked her this morning. It really does not make sense to me but we're supposed to go only by our labs, assessments and all other pertinent data we can gather.

I will check out your links, I've been sifting through the plethora listed in the stickies as time permits and have more bookmarks than memory of them all ;) This is a learning process and I think I'm getting there, you do spell it out time and time again so I look forward to reading your posts.

We're not in the exact phase of writing care plans just yet, the exercise I posted was mainly lab related and recognizing abnormal values and where they can lead to. I just wanted to start practicing the proper technique in documentation. Without the assessment to go by I felt like pulling my hair out.

I'll get to the links, I promise not to just glance and not delve deeper for my answers.

Thanks so much!

(oh, and I don't think I'm the one you referred to about the acute pain, I only posted about lab values r/t dehydration. But, now I know about that too! ;))

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Specializes in med/surg, telemetry, IV therapy, mgmt.

sorry about the acute pain. i've answered a number of care plan questions lately and i forget who i'm writing to.

there is lots of information on various kinds of assessment and guidelines on how to do an assessment on this sticky thread:

vickyrn, who is the moderator of this forum and also a nursing instructor, has done a lot of work to get many of the links posted and some of them are absolutely excellent. i've found many of the medical school links. if you have a copy of taber's cyclopedic medical dictionary you will find a 6-page nursing assessment in the middle of the book under the listing "nursing". i will also copy and send that to you if you like. i also have a copy of the daily nursing assessment used by the nurses at the local hospital in the town where i live. if you can open the link at the bottom of all my posts called student clinical report sheet for one patient" you will find a review of systems and a simple systems assessment in the lower 2/3rds of it. if you can't open the link i can send you the word document as an e-mail attachment if you send me your e-mail address in a pm message (don't post it publicly on the forums as it is a violation of the terms of service).

i don't understand why your instructor wouldn't want any of you to be using a care plan or nursing diagnosis book. knowledge is power. i'd get one anyway and not tell her or anyone else that i had one, but that's just me. one of the better explanations on how to write a care plan is in the first pages of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig. it costs $39. i would try to find someone who has the book and ask them if they would copy section i for you, it's only 15 pages. that's the part that has the information on how to write a care plan and explains adpie. i would be happy to copy it and mail it to you if you send me your address in a pm (don't post it publicly on the forums as it is a violation of the terms of service). let me know as i am going to be starting my next round of chemotherapy on wednesday, thursday and friday and won't be feeling like doing much of anything on those days and for 5 days or so afterward--the chemo pretty much knocks me on my butt. i believe the 8th edition of this book is in the process of being prepared for publication. there is a shorter and cheaper version of this book published under the name of mosby's handbook of nursing diagnoses.

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