Nurse's Pocket Guide

Nailbeds: pink
Conjunctiva and sclera: white
Ego Integrity
SUBJECTIVE (REPORTS)
Report of stress factors: “Normal farmer’s problems: weather,
pests, bankers, etc.”
Ways of handling stress: “I get busy with the chores and talk
things over with my livestock. They listen pretty good.”
Financial concerns: medicare only needs to hire someone to do
chores while here
Relationship status: married
Cultural factors: rural/agrarian, eastern European descent,
“American,” no ethnic ties
Religion: Protestant/practicing
Lifestyle: middle class/self-sufficient farmer
Recent changes: no
Feelings: “I’m in control of most things, except the weather and
this diabetes now.”
Concerned re possible therapy change “from pills to shots.”
OBJECTIVE (EXHIBITS)
Emotional status: generally calm, appears frustrated at times
Observed physiological response(s): occasionally sighs deeply/
frowns, fidgeting with coin, shoulders tense/shrugs shoulders,
throws up hands
Elimination
SUBJECTIVE (REPORTS)
Usual bowel pattern: almost every PM
Last BM: last night Character of stool: firm/brown
Bleeding: 0 Hemorrhoids: 0 Constipation: occ.
Laxative used: hot prune juice on occ.
Urinary: no problems Character of urine: pale yellow
OBJECTIVE (EXHIBITS)
Abdomen tender: no Soft/firm: soft Palpable mass: 0
Bowel sounds: active all 4 quads
Food/Fluid
SUBJECTIVE (REPORTS)
Usual diet (type): 2400 calorie (occ. “cheats” with dessert; “My
wife watches it pretty closely.”)
No. of meals daily: 3/1 snack
PUTTING THEORY INTO PRACTICE 49
Plan of Care