assessment-2.pptx

5/19/2023
By: Gedefaye Tesfahun and Fatuma Kedir
1

Nose
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2
 The nose is the first segment of the respiratory
system.
 It warms, moistens, and filters the inhaled air, and
it is the sensory organ for smell.
 It extends back over the roof of the mouth.
 The anterior edge of the cavity is lined with
numerous coarse nasal hairs, or vibrissae.
 The rest of the cavity is lined with a blanket of
ciliated mucous membrane.

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 The nasal hairs filter the coarsest matter from inhaled
air, whereas the mucous blanket filters out dust and
bacteria.
 Nasal mucosa appears redder than oral mucosa because
of the rich blood supply present to warm the inhaled air.
 The nasal cavity is divided medially by the septum into
two slitlike air passages.
 The anterior part of the septum holds a rich vascular
network, Kiesselbach plexus, the most common site of
nosebleeds.

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 In many people the nasal septum is not absolutely
straight and may deviate toward one passage.
 The lateral walls of each nasal cavity contain three
parallel bony projections—the superior, middle, and
inferior turbinates.
 They increase the surface area so more blood vessels
and mucous membranes are available to warm,
humidify, and filter the inhaled air.

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 The sinuses drain into the middle meatus, and tears from
the nasolacrimal duct drain into the inferior meatus.
 The olfactory receptors (hair cells) lie at the roof of the
nasal cavity and in the upper one-third of the septum.
 These receptors for smell merge into the olfactory nerve,
cranial nerve I, which transmits to the temporal lobe of
the brain.

paranasal sinuses
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 The paranasal sinuses are air-filled pockets within the
cranium .
 They communicate with the nasal cavity and are lined with
the same type of ciliated mucous membrane.
 They lighten the weight of the skull bones; serve as resonators
for sound production; and provide mucus, which drains into
the nasal cavity.
 The sinus openings are narrow and easily occluded, which
may cause inflammation or sinusitis.

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 Two pairs of sinuses are accessible to examination:
 the frontal sinuses in the frontal bone above and medial
to the orbits, and
 the maxillary sinuses in the maxilla (cheekbone) along
the side walls of the nasal cavity.
 The other two sets are smaller and deeper: the ethmoid
sinuses between the orbits, and the sphenoid sinuses
deep within the skull in the sphenoid bone.

Mouth
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 The mouth is the first segment of the digestive
system and an airway for the respiratory system.
 The oral cavity is a short passage bordered by the
lips, palate, cheeks, and tongue. It contains the teeth
and gums, tongue, and salivary glands
 The lips are the anterior border of the oral cavity

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 The arching roof of the mouth is the palate; it is divided into two parts.
 The anterior hard palate is made up of bone and is a whitish color.
 Posterior to this is the soft palate, an arch of muscle that is pinker in color
and mobile.
• The uvula is the free projection hanging down from the middle of the soft
palate The cheeks are the side walls of the oral cavity.
 The floor of the mouth consists of the horseshoe-shaped mandible bone,
the tongue, and underlying muscles.

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 The tongue is a mass of striated muscle arranged in a
crosswise pattern so it can change shape and position.
 The papillae are the rough, bumpy elevations on its dorsal
surface.
 Underneath, the ventral surface of the tongue is smooth
and shiny and has prominent veins.
 The frenulum is a midline fold of tissue that connects the
tongue to the floor of the mouth.
 The ability of the tongue to change shape and position
enhances its functions in mastication, swallowing, teeth
cleansing, and speech formation.

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 The glands secrete saliva, the clear fluid that moistens
and lubricates the food bolus, starts digestion, and cleans
and protects the mucosa.
 Adults have 32 permanent teeth—16 in each arch. Each
tooth has three parts: the crown, the neck, and the root.
 The gums (gingivae) collar the teeth. They are thick,
fibrous tissues covered with mucous membrane.
 They are different from the rest of the oral mucosa
because of their pale pink color and stippled surface.

Throat
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 The throat, or pharynx, is the area behind the
mouth and nose.
 The oropharynx is separated from the mouth by a
fold of tissue on each side, the anterior tonsillar
pillar
 Behind the folds are the tonsils, each a mass of
lymphoid tissue.

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 The posterior pharyngeal wall is seen behind these
structures. Some small blood vessels may show on it.
 The nasopharynx is continuous with the oropharynx,
although it is above the oropharynx and behind the nasal
cavity.
 The pharyngeal tonsils (adenoids) and eustachian tube
openings are located here
 The oral cavity and throat have a rich lymphatic network.

By: Gedefaye Tesfahun and Fatuma Kedir 5/19/2023
14
Nursing Assessment

Subjective Data
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Nose
1. Discharge- Any nasal discharge or runny nose? Continuous?
Is the discharge watery, purulent, mucoid, bloody?
 Rhinorrhea occurs with colds, allergies, sinus infection,
trauma.
2. Frequent colds- Any unusually frequent or severe colds
(upper respiratory infections [URIs])? How often do these
occur?
 Most people have occasional colds

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3. Sinus pain- Any sinus pain or sinusitis? How is this
treated? Do you have chronic postnasal drip?
 Up to 90% of patients with viral URI also have viral
sinusitis, which resolves without antibiotics.
4. Trauma-Ever had any trauma or a blow to the nose?
5. Patency-Can you breathe through your nose? Are both
sides obstructed or one?
 Trauma may cause deviated septum, which may cause
nares to be obstructed.

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5. Epistaxis (nosebleeds)- Any nosebleeds?
 How often?
 How much bleeding—a teaspoonful or does it pour out?
 Color of the blood—red or brown? Clots?
 From one nostril or both?
 Aggravated by nose-picking or scratching?
 How do you treat the nosebleeds? Are they difficult to
stop?

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 Epistaxis occurs with trauma, vigorous nose blowing,
foreign body.
 Person should sit with head tilted forward, pinch soft
part of nose above nostrils for 10 to 15 minutes.
6. Allergies-Any allergies or hay fever? To what are you
allergic (e.g., pollen, dust, pets)? How was this
determined? Which type of environment makes it worse?
Can you avoid exposure?
 “Seasonal” rhinitis if caused by pollen; “perennial” if
allergen is dust.

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 Use inhalers, nasal spray, nose drops? How often?
Which type? How long have you used them?
 Misuse of nasal medications irritates the mucosa,
causing rebound swelling, a common problem.
7. Altered smell-Experienced any change in sense of
smell?
 Sense of smell diminishes with cigarette smoking,
chronic allergies, aging.

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Mouth and Throat
1. Sores or lesions-Noticed any sores or lesions in the
mouth, tongue, or gums? How long have you had them?
Ever had this lesion before? Is it single or multiple? Does
it seem to be associated with stress, season change, food?
How have you treated the sore? Applied any local
medication?
 History helps determine whether oral lesions have
infectious, traumatic, immunologic, or malignant
etiology.

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2. Sore throat- How about sore throats? How frequently do
you get them? Have a sore throat now? When did it start?
 Is it associated with cough, fever, fatigue, decreased
appetite, headache, postnasal drip, or hoarseness?
 What is the humidity level in the room where you sleep?
Any dust or smoke inhaled at work?
 How have you treated this sore throat: medication,
gargling?
 How effective are these? Have your tonsils or adenoids
been removed?

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3. Bleeding gums-Any bleeding gums? How long have
you had them?
4. Toothache-Any toothache? Do your teeth seem
sensitive to hot, cold? Have you lost any teeth?
5. Hoarseness-Any hoarseness, voice change? For how
long? Feel like having to clear your throat? Or like a
“lump in your throat”? Use your voice a lot at work,
recreation?

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6. Dysphagia-Any difficulty swallowing? How long
have you had it? Feel as if food gets stopped at a
certain point? Any pain with this?
 Dysphagia occurs with pharyngitis, gastroesophageal
reflux disease, stroke and other neurologic diseases,
esophageal cancer.
7. Altered taste-Any change in sense of taste?

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8. Smoking, alcohol consumption-Do you smoke? Pipe
or cigarettes? How many packs per day? For how
many years? How much alcohol do you usually
drink?
 Chronic tobacco use leads to tooth loss, coronal and
root caries, and periodontal disease in older adults.
 Chronic use of tobacco, alcohol, and both together
highly increases risk for oral and pharyngeal cancers.

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9. Patient-centered care-How often do you use a
toothbrush and floss? Last dental examination? Do
dental problems affect which foods you eat? Do you
have a dental appliance, How do they fit?Any sores
or irritation on the palate or gums?
 Lesions may arise from ill-fitting dentures, or the
presence of dentures may mask the eruption of new
lesions.

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Additional History for Infants and Children
1. Does the child have any mouth infections or sores such as
thrush or canker sores? How frequently do these occur?
2. Does the child have frequent sore throat or tonsillitis? How
often? How are these treated?
 Children ages 5 to 15 years have a higher incidence of GAS
pharyngitis than adults do (37% vs. 10%).
 Did the child's teeth erupt about on time?
 Eruption is delayed with Down syndrome, cretinism, rickets.

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 Do the teeth seem straight to you?
 Malocclusion.
 Is the child using a bottle? Does the child go to sleep with a
bottle at night?
 Prolonged bottle use increases risk for tooth decay and middle
ear infections.
 Have you noticed any thumb sucking after the child's
secondary teeth came in?
 Prolonged thumb sucking (after ages 6 to 7 years) may affect
occlusion.

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 Have you noticed the child grinding his or her teeth?
Does this happen at night?
 Bruxism usually occurs in sleep or from dental problems
or nervous tension.
4. Patient-centered care. How are the child's dental habits?
Use a toothbrush regularly? How often does the child see
a dentist?
 Are the vaccinations up to date?
 Pertussis ixs on the rise because of lack of adherence to
recommended vaccination schedule.

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Additional History for the Aging Adult
1. Any dryness in the mouth? Are you taking any
medications? (Note prescribed and over-the-counter
medications.)
 Xerostomia (dry mouth) is a side effect of many
drugs: antidepressants, anticholinergics,
antispasmodics, antihypertensives, antipsychotics,
bronchodilators.

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2. Have you lost any teeth? Can you chew all types of
food?
 Note a decrease in eating meat, fresh vegetables, and
cleansing foods such as apples.
3. Are you able to care for your own teeth or dentures?
 Self-care may be decreased by physical disability
(arthritis), loss or access and/or income, vision loss,
confusion, or depression.

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4. Noticed a change in your sense of taste or smell?
 Some people add extra salt and sugar to enhance
food when taste begins to wane.
 Diminished smell also may decrease the person's
ability to detect food spoilage, natural gas leaks, or
smoke from a fire.

Objective data
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Preparation
 Position the person sitting up straight with his or her head at your
eye level.
 If the person wears dentures, offer a paper towel and ask the person
to remove them.
Equipments Needed
 Otoscope with short, wide-tipped nasal speculum attachment
 Penlight
 Two tongue blades
 Cotton gauze pad (4 × 4 inches)
 Gloves

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Inspect and Palpate the Nose External Nose
 Normally the nose is symmetric, in the midline, and
in proportion to other facial features .
 Inspect for any deformity, asymmetry, inflammation,
or skin lesions.
 If an injury is reported or suspected, palpate gently
for any pain or break in contour.

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 Test the patency of the nostrils by pushing each nasal
wing shut with your finger while asking the person to
sniff inward through the other naris.
 This reveals any obstruction, which later is explored
with the nasal speculum.
 The sense of smell, mediated by cranial nerve I,
Absence of sniff indicates obstruction (e.g., common
cold, nasal polyps, rhinitis).

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 Nasal Cavity
 Attach the short, wide-tipped speculum to the otoscope
head, and insert this combined apparatus into the nasal
vestibule, avoiding pressure on the nasal septum. Gently
lift up the tip of the nose with your finger before
inserting.
 View each nasal cavity with the person's head erect and
then with the head tilted back.
 Inspect the nasal mucosa, noting its normal red color and
smooth, moist surface.

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 Note any swelling, discharge, bleeding, or foreign body.
 Rhinitis—Nasal mucosa is swollen and bright red with
URI.
 Discharge is common with rhinitis and sinusitis, varying
from watery and copious to thick, purulent, and green-
yellow.
 With chronic allergy mucosa looks swollen, boggy, pale,
and gray

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 Observe the nasal septum for deviation.
 A deviated septum is common and is not significant
unless air flow is obstructed.
 Also note any perforation or bleeding in the septum.
 Perforation is seen as a spot of light from a penlight
shining in the other naris and occurs with cocaine
use.

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 Epistaxis commonly comes from the anterior septum
 Inspect the turbinates (the bony ridges curving down from the
lateral walls).
 The superior turbinate will not be in your view, but the middle and
inferior turbinates appear the same light red color as the nasal
mucosa.
 Note any swelling but do not try to push the speculum past it.
Turbinates are quite vascular and tender if touched.
 Note any polyps (benign growths that accompany chronic allergy),
and distinguish them from the normal turbinates.
 polyps are smooth, pale gray, avascular, mobile, nontender

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 Palpate the Sinus Areas Using your thumbs, press the
frontal sinuses by pressing firmly up and under the
eyebrows and over the maxillary sinuses below (not over)
the cheekbones
 Take care not to press directly on the eyeballs.
 The person should feel firm pressure but no pain.
 Sinus areas are tender to palpation in people with
chronic allergies and acute infection (sinusitis).

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 Another sign of sinusitis is to check for focal pain when the
person bends over (if able).
 Transillumination There is no evidence to support the practice
of transillumination of the frontal or maxillary sinuses when
you suspect sinus inflammation. The diagnosis requires
distinct differences in the illumination of one of the sinus pair.
 Thus the technique would not help in chronic sinusitis that
has diffuse swelling of all sinus mucosa. Although there is
more fluid collection with acute sinusitis, the asymmetry of
light illumination still is not valid because many healthy
sinuses normally do not transilluminate

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 Inspect the Mouth
 Begin with anterior structures and move posteriorly. Use a
tongue blade to retract structures and a bright light for
optimal visualization.
 Lips Inspect the lips for color, moisture, cracking, or lesions.
Retract the lips and note their inner surface as well
 All racial groups have lips that are deeper or pinker than facial
skin.
 However, some African Americans normally may have bluish
lips and a dark line on the gingival margin.

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 In light-skinned people: circumoral pallor occurs
with shock and anemia;
 cyanosis with hypoxemia and chilling; cherry red lips
with carbon monoxide poisoning, acidosis from
aspirin poisoning, or ketoacidosis.
 Cheilitis (perlèche) —Cracking at the corners.
 Herpes simplex, other lesions

Teeth and Gums
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 note any diseased, absent, loose, or abnormally
positioned teeth.
 The teeth normally look white, straight, evenly spaced,
and clean and free of debris or decay.
 Discolored teeth appear brown with excessive fluoride
use, yellow with tobacco use.
 Compare the number of teeth with the number expected
for the person's age.
 plaque—soft debris; caries— decay.

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 Ask the person to bite as if chewing something and note
alignment of upper and lower jaw.
 Normal occlusion in the back is the upper teeth resting
Grinding down of tooth surface;directly on the lower
teeth;
 in the front the upper incisors slightly override the lower
incisors.
 Malocclusion (poor biting relationship), protrusion of
upper or lower incisors.

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 Normally the gums look pink or coral with a stippled
(dotted) surface. The gum margins at the teeth are
tight and well defined (Fig. 17.12).
 Check for swelling; retraction of gingival margins;
and spongy, bleeding, or discolored gums.
 Some African Americans normally may have a dark
melanotic line along the gingival margin.

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 Gingival hyperplasia (see Table 17.3), crevices
between teeth and gums, pockets of debris.
 Gums bleed with slight pressure, indicating
gingivitis.
 Dark line on gingival margins occurs with lead and
bismuth poisoning.

Tongue
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 Check the tongue for color, surface characteristics, and
moisture.
 The color is pink and even. The dorsal surface is
normally roughened from the papillae. A thin white
coating may be present (Fig. 17.13, A). Ask the person to
touch the tongue to the roof of the mouth. Its ventral
surface looks smooth and glistening and shows veins
 Saliva is present.

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 Enlarged tongue occurs with hypothyroidism, acromegaly; a
small tongue accompanies malnutrition.
 Dry mouth occurs with dehydration, fever; tongue has deep
vertical fissures.
 Saliva is decreased when taking anti-cholinergic and other
medications.
 Excess saliva and drooling occur with gingivostomatitis and
Parkinson disease.
 With a glove,a hold the tongue with a cotton gauze pad for
traction and swing it out and to each side

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 Inspect for any white patches or lesions; normally
none are present. If any occur, palpate them for
induration.
 Oral precancerous and cancerous lesions. The lateral
and ventral tongue and the floor of the mouth are
high-risk sites for oral squamous cell cancer
 Inspect carefully the entire U-shaped area under the
tongue behind the teeth.

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 Note any white patches, nodules, or ulcerations.
 If lesions are present or for any person older than 50
years or with a positive history of smoking or alcohol use,
use your gloved hand to palpate the area and the rest of
the oral mucosa.
 Place your other hand under the jaw to stabilize the
tissue and to “capture” any abnormality, Note any
induration.
 Bimanual palpation.

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 Any lesion or ulcer persisting for more than 2 weeks
must be investigated.
 An indurated area may be a mass or
lymphadenopathy, and it must be investigated.

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 Buccal Mucosa
 Hold the cheek open with a wooden tongue blade
and check the buccal mucosa for color, nodules, or
lesions. It looks pink, smooth, and moist, although
patchy hyperpigmentation is common and normal in
dark-skinned people.

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 Dappled brown patches are present with Addison disease
(chronic adrenal insufficiency).
 Expect to find Stensen duct, the opening of the parotid
salivary gland. It looks like a small dimple opposite the upper
second molar. You also may see a raised occlusion line on the
buccal mucosa parallel with the level the teeth meet. This is
caused by the teeth closing against the cheek.
 Orifice of Stensen duct looks red with mumps.
 Koplik spots— Early prodromal (early warning) sign of
measles

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 A larger patch also may be present along the buccal
mucosa. This is leukoedema, a benign, milky, bluish-
white, opaque area, more common in blacks and East
Indians.
 When it is mild, the patch disappears as you stretch the
cheeks.
 It is always bilateral.
 With age it looks grayish-white and thickened. The cause
is unknown.

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 Do not mistake leukoedema for oral infections such as
candidiasis (thrush).
 Candida infection usually rubs off, leaving a clear or raw
denuded surface.
 Fordyce granules are small, isolated white or yellow
papules on the mucosa of cheek, tongue, and lips
 These little sebaceous cysts are painless and not
significant.
 The chalky white raised patch of leukoplakia is abnormal

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Palate
 Shine your light up to the roof of the mouth.
 The more anterior hard palate is white with irregular
transverse rugae.
 The posterior soft palate is pinker, smooth, and upwardly
movable.
 A normal variation is a nodular bony ridge down the
middle of the hard palate, a torus palatinus . This
benign growth arises after puberty;

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 It is more common in American Indians, Inuits, and
Asians; and is more common in females than in
males.
 The hard palate appears yellow with jaundice. In
blacks with jaundice it may look yellow, muddy
yellow, or green-brown.
 Oral Kaposi sarcoma is the most common early
lesion in people with AIDS.

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 Observe the uvula;
 it normally looks like a fleshy pendant hanging in the
midline. Ask the person to say “ahhh,” and note the
soft palate and uvula rise in the midline. This tests
one function of cranial nerve X, the vagus nerve.
 A bifid uvula looks as if it is split in two; more
common in American Indians.

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 Any deviation to the side or absent movement indicates nerve
damage, which also occurs with poliomyelitis and diphtheria.
 Inspect the Throat With your light observe the oval, rough-
surfaced tonsils behind the anterior tonsillar pillar
 Their color is the same pink as the oral mucosa, and their
surface is peppered with indentations, or crypts.
 In some people the crypts collect small plugs of whitish
cellular debris.
 This does not indicate infection. However, there should be no
exudate on the tonsils.

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 Tonsils are graded in size as follows:
 1+ Visible
 2+ Halfway between tonsillar pillars and uvula
 3+ Touching the uvula
 4+ Touching one another
 With an acute infection tonsils are bright red and swollen
and may have exudate or large white spots.
 A white membrane covering the tonsils may accompany
infectious mono-nucleosis, leukemia, and diphtheria.

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 You may normally see 1+ or 2+ tonsils in healthy
people, especially in children, because lymphoid
tissue is proportionately enlarged until puberty.
 Tonsils are enlarged to 2+, 3+, or 4+ with an acute
infection.
 Enlarge your view of the posterior pharyngeal wall by
depressing the tongue with a tongue blade

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 Push down halfway back on the tongue; if you push on its
tip, the tongue humps up in back.
 Press slightly off center to avoid eliciting the gag reflex.
 You can help the person whose gag reflex is easily
triggered by offering a tongue blade to depress his or her
own tongue.
 Scan the posterior wall for color, exudate, and lesions.
When finished, discard the tongue blade.

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 Viral pharyngitis shows erythematous tonsils with no
hypertrophy or exudates.
 Streptococcal pharyngitis shows with erythematous,
enlarged tonsils with exudates.
 Four features suggest streptococcal cause: absence of
cough; swollen, tender anterior cervical nodes; ever
>100.4° F (38° C); tonsillar exudate.

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 touching the posterior wall with the tongue blade elicits the gag
reflex.
 This tests cranial nerves IX and X, the glossopharyngeal and
vagus.
 Test cranial nerve XII, the hypoglossal nerve, by asking the
person to stick out the tongue. It should protrude in the midline.
Note any tremor, loss of movement, or deviation to the side.
 With CN XII damage, the tongue deviates toward the paralyzed
side.
 A fine tremor of the tongue occurs with hyperthyroidism;
 a coarse tremor occurs with cerebral palsy and alcoholism.

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 During the examination notice any breath odor, halitosis.
 This is common and usually has a local cause such as
poor oral hygiene and decaying food debris between the
teeth.
 Other common smells are caused by odoriferous foods,
alcohol consumption, heavy smoking, or dental infection.
 Diabetic ketoacidosis has a sweet, fruity breath odor; this
acetone smell also occurs in children with malnutrition
or dehydration.

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 an ammonia breath odor with uremia;
 a musty odor with liver disease;
 a foul, fetid odor with dental or respiratory
infections;
 an alcohol odor with alcohol ingestion;
 a mouselike smell of the breath with diphtheria.

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