Nurse's Pocket Guide

Extended family: 1 daughter lives in town (30 miles away); 1
daughter married/grandson, living out of state
Other: several couples, he and wife play cards/socialize with 2 to
3 times/mo
Role: works farm alone; husband/father/grandfather
Report of problems related to illness/condition: none until now
Coping behaviors: “My wife and I have always talked things out.
You know the 11 th commandment is ‘Thou shalt not go to
bed angry.’”
OBJECTIVE (EXHIBITS)
Speech: clear, intelligible
Verbal/nonverbal communication with family/SO(s): speaks
quietly with wife, looking her in the eye; relaxed posture
Family interaction patterns: wife sitting at bedside, relaxed, both
reading paper, making occasional comments to each other
Teaching/Learning
SUBJECTIVE (REPORTS)
Dominant language: English Second language: 0 Literate: yes
Education level: 2-yr college
Health and illness/beliefs/practices/customs: “I take care of the
minor problems and see the doctor only when something’s
broken.”
Presence of Advance Directives: yes—wife to bring in
Durable Medical Power of Attorney: wife
Familial risk factors/relationship:
Diabetes: maternal uncle
Tuberculosis: brother died, age 27
Heart disease: father died, age 78, heart attack
Strokes: mother died, age 81
High BP: mother
Prescribed medications:
Drug: Diabeta Dose: 10 mg bid
Schedule: 8 AM/6 PM, last dose 6 PM today
Purpose: control diabetes
Takes medications regularly? yes
Home urine/glucose monitoring: “Only using TesTape,
stopped some months ago when I ran out. It was always
negative, anyway.”
Nonprescription (OTC) drugs: occ. ASA
Use of alcohol (amount/frequency): socially, occ. beer
Tobacco: 1/2 pk/day
Admitting diagnosis (physician): hyperglycemia with nonhealing
lesion L foot
PUTTING THEORY INTO PRACTICE 53
Plan of Care