Sample Nursing Care Plan
face. No erythema, lesions.
Head: Head is normocephalic, atraumatic
Eyes: PERRLA, sclera anicteric, no erythema, injection, discharge. VA 20/20 individually and bilaterally
Ears: EAC clear bilaterally, TMs shiny grey, hearing is grossly intact bilaterally.
Nose: Patent nares bilaterally, no discharge or sinus tenderness.
Throat: Mucous membranes are moist and without signs of ulceration.
Respiratory: CTA bilaterally throughout without adventitious sounds. No W/R/R.
Cardiovascular: Normal S1 and S2. No M/R/G.
Abdomen: Appears slightly obese. Normal active bowel sounds. Abdomen NTTP throughout. No HSM.
Musculoskeletal: Knee – bilateral knee without swelling, tenderness, full ROM, 5/5 strength, normal muscle tone. Right hip – 5 degree of flexion in right hip. Tenderness over hip capsule. Pain with internal rotation, abduction, and flexion that prevent assessment of the ROM. Current passive ROM and abduction is 15 degrees, adduction is 20 degrees, internal rotation is 5 degrees, external rotation is 45 degrees, flexion is 60 degrees, extension is 0 degrees. Left hip – nontender passive ROM and abduction is 45 degrees, adduction is 30 degrees, internal rotation is 30 degrees, external rotation is 45 degrees, flexion is 110 degrees, extension is 30 degrees. Back – spine is without tenderness. Full ROM in all planes however difficult to assess curvature due to patient being unable to bear weight on the right leg.
Neurological: Sensation to…