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Nr 302 Weekly Lab Documentation

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NR 302 WEEKLY LAB DOCUMENTATION

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NR 302 WEEKLY LAB DOCUMENTATION
Each week in lab, you will practice specific skills that are important in the assessment of a
particular system/region of the body. You will also do vital signs. In your weekly lab
documentation, you will share what you saw, felt and heard during your assessment of your lab
partner along with the vital signs. Use the lab handout as your guide for what to do during the
lab time as well as what to include in this report when answering these questions. This lab
report should be uploaded to Canvas within 48 hours of the end of your lab session.

Vital signs (Temperature, pulse, respirations, oxygen saturation and pain)
The vitals of my partner are as followed; Temperature 98.9F, Pulse 70 beats per minute,
Respiration 15 breaths per minute, SpO2 99, Pain 0

What did you see?
This week we examined eyes, ears, nose mouth and throat. I administered a distant vision test
using Snellen eye chart and my partners vision was OU 20/13, OS 20/20, OD 20/13. I also
performed the peripheral vision with confrontation test and her peripheral vision was intact. In
general, with the eyes and external structures everything looked intact, with no noticeable
trauma, red reflex was observed, corneal light reflex was intact, direct and consensual light
reflex was also intact with the pupils starting at 5mm and constricting to 2mm. The ears looked
intact and symmetrical, the tympanic membrane was observed and grey, but my partner did
struggle with the whisper voice test. The environment was not ideal and may have affected her
ability to hear what was said. The only abnormal finding in my partner was the absence of any
tonsils. She than informed me that she had her tonsils removed at 12 years old

What did you feel?
As I inspected and palpate the nose and sinuses, no edema, pressure or pain was noticed or
reported by my partner. Her nose was proportionate, had no lumps or any noticeable
deformities.

What did you hear?
We did not use our stethoscope in lab, but we did ask a few questions about health history.
While talking to my partner she informed me she had Lasik eye surgery to correct her vision and
only experiences eye redness, swelling and watering with allergies. Also, she wears head gear
when going to the shooting range every weeks, gets sinus pain when congested, gums bleed
when she bushes to hard, and has exposed nerves from overbrushing which gives her
temperature sensitivity. My partner also stated she brushes her teeth one a day at night, flosses
once in a while and had a dental exam in October 2017




/NR-302-WEEKLY-LAB-DOCUMENTATIONdocx/

Información del documento

Subido en
9 de febrero de 2022
Número de páginas
1
Escrito en
2021/2022
Tipo
Examen
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Preguntas y respuestas
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