assessment of the mouth, nose

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how to assess the mouth and nose.

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assessment of the mouth, nose

  1. 1. Maria Carmela L. Domocmat, RN, MSN
  2. 2. Maria Carmela L. Domocmat, RN, MSN
  3. 3. Maria Carmela L. Domocmat, RN, MSN
  4. 4. Inspection and PalpitationInspect the lips Maria Carmela L. Domocmat, RN, MSN
  5. 5. Lips are smooth and moist w/out lesionsor swelling. Pink lips are normal in ligth-skinned clients are bluish or freckled lipsin some dark-skinned clients, especiallythose of Mediterranean descent. Maria Carmela L. Domocmat, RN, MSN
  6. 6. Maria Carmela L. Domocmat, RN, MSN
  7. 7. Pallor around the lips( circumoral pallor)is seen in anemia and shock.Bluish(cyanotic) lips may result from cold orhypoxia. Reddish lips are seen in clientsw/ ketoacidosis, carbon monoxidepoisoning, and COPD w/ polycythemia.Swelling of the lips(edema) is common inlocal or systemic allergic or anaphylacticreactions. Maria Carmela L. Domocmat, RN, MSN
  8. 8. SWELLING LIPS Maria Carmela L. Domocmat, RN, MSN
  9. 9. Inspection and PalpitationInspect the teeth and gums. Maria Carmela L. Domocmat, RN, MSN
  10. 10. Thirty-two pearly whitish teeth w/ smooth surfaces and edges. Upper molar should rest directly on the lower molars and the front upper incisors should slightly override the lower incisors. Some clients normally have only 28 teeth if the 4 wisdom teeth do not erupt.No repaired or decayed areas ; no missing teeth or appliances. Maria Carmela L. Domocmat, RN, MSN
  11. 11. Maria Carmela L. Domocmat, RN, MSN
  12. 12. Clients who smoke, drink large quantitiesof coffee or tea or have an excessiveintake of fluoride may have yellow orbrownish teeth.Receding gums are abnormal in youngerclients;in elderly clients, the teeth mayappear longer because of age-relatedgingival recession, w/c is common.Red, swollen gums that bleed easily areseen in gingivitis, scurvy(vitamin Cdeficiency), and leukemia. Maria Carmela L. Domocmat, RN, MSN
  13. 13. Maria Carmela L. Domocmat, RN, MSN
  14. 14. BROWNISH YELLOWISH Maria Carmela L. Domocmat, RN, MSN
  15. 15. Inspection and PalpitationInspect the buccal mucosa Maria Carmela L. Domocmat, RN, MSN
  16. 16. Maria Carmela L. Domocmat, RN, MSN
  17. 17. It should appear pink in light-skinnedclients;tissue pigmentation typicallyincreases in dark-skinned clients.In both,tissue is smooth and moist w/out lesions Maria Carmela L. Domocmat, RN, MSN
  18. 18. Leukoplakia may be seen in chronicirritation and smoking. Maria Carmela L. Domocmat, RN, MSN
  19. 19. Maria Carmela L. Domocmat, RN, MSN
  20. 20. Inspection and PalpitationInspect and palpate the tongue Maria Carmela L. Domocmat, RN, MSN
  21. 21. Tongue should be pink, moist, amoderate size w/ papillae(littleprotuberances) present. A commonvariation is a fissured, topographic-map-like tongue, w/c is not unusual in olderclients. No lesions are present. Maria Carmela L. Domocmat, RN, MSN
  22. 22. Among possible abnormalities are deeplongitudinal fissures seen in dehydration;a black tongue indicative of bismuth(PeptoBismol)toxicity: black, hairytongue; a smooth ,reddish, shiny tonguew/out papillae indicative of niacin orvitamin B12 deficiencies, certainanemias, and antineoplastic therapy. Maria Carmela L. Domocmat, RN, MSN
  23. 23. Inspection and PalpitationAssess the ventral surface of the tongue Maria Carmela L. Domocmat, RN, MSN
  24. 24. The tongue’s ventral surface is smooth,shiny, pink or slightly pale w/ visibleveins and no lesions. Maria Carmela L. Domocmat, RN, MSN
  25. 25. Leukoplakia, persistent lesions, ulcers, ornodules may indicate cancer and shouldbe referred. Induration increases thelikelihood of cancer. Maria Carmela L. Domocmat, RN, MSN
  26. 26. Inspection and PalpitationInspect for Wharton’s ducts Maria Carmela L. Domocmat, RN, MSN
  27. 27. The frenulum is midline; Wharton’s ductsare visible w/ salivary flow or moistnessin the area. The client has no swelling,redness, or pain. Maria Carmela L. Domocmat, RN, MSN
  28. 28. Abnormal findings include lesions,ulcers, nodules, or hypertrophied ductopenings on either side of frenulum. Maria Carmela L. Domocmat, RN, MSN
  29. 29. Inspection and Palpitation.Observe the sides of the tongue Maria Carmela L. Domocmat, RN, MSN
  30. 30. No lesions,ulcers,or nodules areapparent. Maria Carmela L. Domocmat, RN, MSN
  31. 31. Cancer sores may be seen on the sides ofthe tongue in clients receiving certainkinds of chemotherapy. Leukoplakia ,persistent lesions, ulcers, or nodules mayindicate cancer and should be furtherevaluated medically. Maria Carmela L. Domocmat, RN, MSN
  32. 32. Inspection and Palpitation.Check the strength of the tongue Maria Carmela L. Domocmat, RN, MSN
  33. 33. The tongue offers strong resistance Maria Carmela L. Domocmat, RN, MSN
  34. 34. Decreased tongue strength may occur w/a defect of the twelfth cranial nerve-hypoglossal-or w/ a short-ened frenulumthat limits motion. Maria Carmela L. Domocmat, RN, MSN
  35. 35. Inspection and PalpitationCheck the anterior tongue’s ability to taste Maria Carmela L. Domocmat, RN, MSN
  36. 36. The client can distinguish between sweetand salty. Maria Carmela L. Domocmat, RN, MSN
  37. 37. Loss of taste discrimination occurs w/zinc deficiency. A seventh cranialnerve(facial)defect, and certainmedication use. Maria Carmela L. Domocmat, RN, MSN
  38. 38. Inspection and PalpitationInspect the hard(anterior)andsoft(posterio)palates and uvula. Maria Carmela L. Domocmat, RN, MSN
  39. 39. The hard palate is pale or whitish w/ firm,trasverse rugae(wrinklelike folds). Maria Carmela L. Domocmat, RN, MSN
  40. 40. A candidal infection may appear as thickwhite plaques on the hard palate.Deeppurple, raised, or flat lesions mayindicate a Kaposi’s sarcoma.A yellow tint to the hard palate mayindicate jaundice because bilirubinadheres to elastic tissue(collagen). Anopening in the hard palate is known as acleft palate. Maria Carmela L. Domocmat, RN, MSN
  41. 41. Inspection and PalpitationNote odor Maria Carmela L. Domocmat, RN, MSN
  42. 42. No unusual or foul odor is noted. Maria Carmela L. Domocmat, RN, MSN
  43. 43. Fruity or acetone breath is associated w/ diabetic ketoacidosis.An ammonia odor is often associated w/ kidney disease.Foul odor may indicate an oral or respiratory infection, or tooth decay.Alcohol or tobacco use may be identified by breath odor.Fecal breath odor occurs in bowel obstruction;sulfur odor(fetor hepaticus) occurs in end- stage liver disease. Maria Carmela L. Domocmat, RN, MSN
  44. 44. Inspection and PalpitationAssess the uvula Maria Carmela L. Domocmat, RN, MSN
  45. 45. The uvula is a fleshy, solid structure thathangs freely in the midline. No redness ofor exudate from uvula or soft palate.Midline elevation of the soft palate. Maria Carmela L. Domocmat, RN, MSN
  46. 46. A bifit uvula looks like it is split in two orpartially severed.Clients w/ a bifit uvulamay have a submucous cleft palate. Maria Carmela L. Domocmat, RN, MSN
  47. 47. Inspection and PalpitationInspect the tonsils Maria Carmela L. Domocmat, RN, MSN
  48. 48. Tonsils may be present or absent.Theyare normally pink and symmetric andmay be enlarge to 1+ in healthyclients.No exudate, swelling, or lesionsshould be present. Maria Carmela L. Domocmat, RN, MSN
  49. 49. Tonsils are red,enlarge(to 2+, 3+, or4+),and covered w/ exudate intonsilitis.Abnormal findings 15-2 depictsgrading of tonsils.They also may beindurated w/ patches of white or yellowexudate. Maria Carmela L. Domocmat, RN, MSN
  50. 50. Maria Carmela L. Domocmat, RN, MSN
  51. 51. Inspection and PalpitationInspect the posterior pharyngeal wall. Maria Carmela L. Domocmat, RN, MSN
  52. 52. Throat is normally pink w/out excudateor lesions. Maria Carmela L. Domocmat, RN, MSN
  53. 53. A bright red throat w/ white or yellowexudate indicates pharyngitis. Yellowishmucus on throat may be seen w/postnasal sinus drainage. Maria Carmela L. Domocmat, RN, MSN
  54. 54. Maria Carmela L. Domocmat, RN, MSN

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