University:
University of Alberta
Course:
NURS 125 | Nursing Practice - Health Assessment
Academic year:

2024
Views:

443

Pages:

3
Author:

Ali O

Chapter 17: Nose, Sinuses, Mouth, Throat Assessment Focused Health History · Assessment of risk factors ↳ smoking ↳ occupational exposures ↳ environment (air quality) · Personal History · medications · dental health · surgical history · psychosocial history · family history Physical Assessment · equipment needed: penlight, tongue depressor, nasal speculum/otoscope, appropriate "liquid" for swallowing study · preparation: patient comfort, dignity, and safety · physical examination: nose, sinuses, mouth, throat, swallowing evaluation ↳ water is the hardest to swallow in those with dysphagia . techniques: ↳ inspection ↳ palpation ↳ percussion Common Mouth & Upper Respiratory symptoms · facial pressure, pain, headache · dental pain · snoring and sleep apnea · obstructive breathing · nasal congestion · epitaxis (nose bleeds) · halitosis (bad breath) · anosmia (inability to smell) · cough · pharyngitis/sore throat · dysphagia (trouble swallowing) · hoarseness/voice changes · oral lesions Inspection & Palpation: Nose ① Inspection · observe external structures ↳ symmetry ↳ patency (breathing in each nostril) ↳ note discharge · inspect internal canal bilaterally (otoscope) ↳ note: congestion, bleeds, polyps, allergy etc. · test smell (not peppermint! ) ② Palpation · paired nasal bones ↳ alignment, symmetry, tenderness · nasal cartilages ↳ alignment, symmetry, tenderness Inspection & Palpation: Sinuses ① Inspection · redness · swelling · discharge from eyes, ears, nose ② Palpation · frontal, ethmoid & maxillary sinuses · "fullness" ③ Percussion · direct over sinuses for pain/tenderness Inspection & Palpation: Mouth, Tongue, and Throat ① Extraoral Assessment · inspect: symmetry, swelling, moisture and colour of lips ·palpate: Masseter muscle, parotid gland/lymph nodes ② Intraoral Assessment · inspect: colour, size, lesions, dentition, tongue, salivary glands · palpate: texture, masses, tenderness (palpate as needed) - - - Tonsillar Size Swallowing Study · impaired swallowing (dysphagia) · delayed (pocketing) · gurgly voice · coughing · choking, gagging (or not?) · can't clear · drooling/food falling out Expected Findings: · nose: symmetrical, midline and proportionately shaped to facial features. Skin is smooth without lesions, coloration is consistent. No drainage. There is no pain or tenderness on palpation. Internal mucosa is pink and moist. Airflow unimpeded · sinuses: symmetrical, no redness or swelling, non tender · mouth: lips are pink and moist with no lesions. Buccal mucosa, soft and hard palates pink with no lesions. Gingiva is pink and moist without inflammation. Breath has no foul odour. Tongue is smooth and midline. Teeth are well aligned with no evidence of decay. Uvula rises symmetrically with “ah”. No swelling, pain, or tenderness. · throat: tissue is pink and moist with symmetrical margins. No enlargement or lesions are noted. Tonsils are present with no obstruction of midline evident (0-25%). · swallowing: <1 second, no signs of aspiration