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Health Assessment > Ch. 18 Mouth, Throat, Nose, Sinuses > Flashcards

Ch. 18 Mouth, Throat, Nose, Sinuses Flashcards

1
Q

The nurse percussing an adult client’s sinuses will understand which assessment finding suggests sinusitis?
A. Dullness
B.Tympany
C.Tenderness
D.Resonance

A

c

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2
Q

A nurse is assessing a client who came to the clinic because of a sore throat. The nurse notes that the client’s tonsils are touching the uvula. How would the nurse document this finding?
a. “Patient’s tonsil area is reddened with a grading scale of 1+”
b. “Patient’s tonsils are within normal limits”
c. “Patient’s tonsils area is reddened and graded as 2+”
d. “Patient’s tonsils area is reddened and graded as 3+”

A

d

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3
Q

A client comes to the clinic concerned about a chronic nosebleed. Which area in the nose would the nurse assess?
a. inferior and middle turbinates
b. Nasal septum
c. Conchae
d. Keisselbach

A

d

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4
Q

Mouth

A

formed by lips/cheeks, hard/soft palates, uvula, tongue and its muscles. start of digestion/airway tracts. three pairs of salivary glands, thirty two teeth in adult.

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5
Q

Saliva…

A

helps break down food/lubricates it. enzyme amylase in saliva digests carbs

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6
Q

Salivary glands

A

parotid - below/in front of ear. submandibular - lower jaw. sublingual - under tongue

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7
Q

Throat (pharynx)

A

behind mouth/nose. nasopharynx - upper, oropharynx - middle, laryngopharynx - bottom. arches formed behind tongue by soft palate, anterior/posterior pillars, uvula

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8
Q

Tonsils

A

masses of lymphoid tissues that help protect against infection. three types/locations in the throat - palatine, lingual, pharyngeal/adenoids

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9
Q

Palatine tonsils

A

both sides of oropharynx at end of soft palate between anterior/posterior pillars

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10
Q

Lingual tonsils

A

at base of tongue

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11
Q

Pharyngeal or adenoid tonsils

A

found high in nasopharynx

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12
Q

Nose

A

external portion, nasal cavity, nasal septum, conchae, hairs, ciliated mucosal cells, paranasal sinuses/nasolacrimal duct, first cranial nerve

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13
Q

External portion of nose

A

bone/cartilage, lined w/ mucous membrane. bridge, tip, two oval openings - nares

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14
Q

Nasal cavity

A

between roof of mouth and cranium. from anterior nares to posterior nares and into nasopharynx

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15
Q

Nasal septum

A

separates cavities into two halves, rich blood supply area called Keisselbach = common site for nosebleeds. warms air entering nose

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16
Q

Conchae (nasal)

A

superior, middle, inferior turbinates, bony lobes, project from lateral walls of nasal cavity. increase surface area exposed to incoming air

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17
Q

Nasal hairs

A

filter large particles

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18
Q

Ciliated mucosal cells

A

capture debris/propel down throat. destroyed in stomach

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19
Q

Paranasal sinuses and nasolacrimal duct receive

A

drainage. risk of infection when blocked

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20
Q

First cranial nerve

A

upper part of nasal cavity/septum. olfactory - smell

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21
Q

List paranasal sinuses

A

frontal, maxillary, ethmoidal, sphenoidal

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22
Q

Paranasal sinuses

A

located in skull - air filled chambers, decrease weight of skull, resonance chambers during speech, lined w/ ciliated mucous membrane that traps debris/moves toward outside. primary site for infection b/c potential blockage.

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23
Q

Frontal sinuses

A

above eyes

24
Q

Maxillary sinuses

A

upper jaw

25
Q

Which sinuses are accessible for examination?

A

frontal, maxillary

26
Q

Ethmoid and sphenoidal sinuses

A

smaller, deeper. not accessible for examination

27
Q

History of present concern

A

tongue swollen or sores (painful?)? sinus pain or frequent nosebleeds? frequent nasal drainage/what color? difficulty swallowing? sore throat? hoarseness?

28
Q

Health history

A

surgeries, frequent sinus infections, seasonal allergies, OTC meds, smoker/chewing tobacco, excessive alcohol (oral cancer risk), teeth grinding, last dental exam, braces (avoid certain foods?). wear dentures, brush tongue (prevent bad breath), lip sunscreen in sun, dietary intake poor nutrition (increase risk of oral cancer), cancer in family

29
Q

Assessment supplies

A

gloves, 4x4 gauze pad, penlight, short/wide tipped speculum attached to otoscope, tongue depressor, nasal speculum

30
Q

What to know for assessment

A

able to ID/understand relationship among structures of mouth throat nose/sinuses. know age related changes. aware of ethnocultural phenomena related to oral/nasal health

31
Q

Assessing the mouth (inspection)

A

use gloves, retract lips/cheeks to check gums for color/consistency. inspect buccal mucosa for color/consistency- penlight/tongue depressor to detract lips/cheeks. stensen ducts (parotid ducts) - show visible flow of saliva, no pain/swelling, area moist

32
Q

Teeth

A

open mouth - number, color/condition, dental work, bite down to check alignment

33
Q

Reddened opening in stensen ducts

A

mumps

34
Q

Inspect/palpate tongue

A

have pt stick out tongue, inspect for color/moisture/size/texture, check for midline protrusion (not midline may be stroke), observe for fasciculations (fine tremors), palpate for lesions/induration (hardness). older adults might have fissured tongue (map like tongue surface)

35
Q

Assess ventral surface of tongue

A

touch roof of mouth w/ tongue, use penlight to inspect ventral surface, frenulum, check for short frenulum that limits tongue motion, area under tongue. palpate if see lesions, over 50, use tobacco/alcohol. assess Wharton ducts (opening of submandibular salivary glands) - midline, visible, either side of frenulum on floor of mouth, moisture present, no swelling/redness/pain

36
Q

Tongue

A

observe side of tongue using square gauze pad to hold pt’s tongue to each side/inspect, palpate any lesions ulcers/nodules for induration (hardness). check tongue strength/resistance. check anterior tongue ability to taste (sweet/salty). inspect hard/soft palates/uvula - pt open mouth wide, use penlight to look at roof, observe color/integrity

37
Q

Uvula

A

apply tongue depressor to tongue, shine penlight, open mouth wide, note position, say ahh to watch for uvula/soft palate rise midline. cultural considerations - native americans/asians may have split uvula

38
Q

Assess tonsils

A

use tongue depressor, mouth open wide, inspect for color/size/presence of exudate. grade tonsils - 0 absent, 1+ normal, 2+ 3+ 4+ abnormal

39
Q

1+ tonsils

A

normal, visible

40
Q

2+ tonsils

A

halfway between pillars/uvula

41
Q

3+ tonsils

A

touching uvula

42
Q

4+ tonsils

A

touching each other

43
Q

How to prevent gagging when using tongue depressor

A

off center

44
Q

Posterior pharyngeal wall

A

tongue depressor in place/mouth open, shine penlight to back of throat, observe color - normally pink, exudate or lesions

45
Q

Inspect/palpate nose

A

external nose - note color, shape, consistency, tenderness. check patency by occluding one nostril at a time/sniffing. inspect internal nose - use otoscope short wide tip attachment (or nasal speculum and penlight), tilt head back, insert tip of otoscope into nose, slowly move otoscope to view - nasal mucosa dark pink moist and free of exudate, nasal septum intact and free of ulcers or perforations, inferior/middle turbinates dark pink moist free of lesions, nasal passage. (can’t see superior turbinate)

46
Q

What is a deviated septum?

A

may appear overgrowth of tissue, normal finding if doesn’t obstruct breathing. can be due to trauma or genetic

47
Q

Assess sinuses

A

palpate frontal/maxillary. could be tender from allergies, bacterial infection, viral upper respiratory infection. may feel crepitus, large amounts of exudate. percuss sinuses - lightly tap looking for tenderness

48
Q

General routine screening

A

inspect lips, odor of mouth, teeth, gums, tongue, buccal mucosa, internal nose, patency of air flow through nostrils, inspect throat

49
Q

Focused specialty assessment

A

palpate buccal mucosa/tongue, assess ventral surfaces/side of tongue, inspect wharton/stensen ducts, check strength of tongue, check anterior tongue ability to taste, inspect hard/soft palate/uvula, assess uvula/tonsils/posterior pharyngeal wall, inspect internal nose w/ otoscope/nasal speculum, palpate/percuss/transilluminate sinuses

50
Q

Mouth/throat abnormalities

A

herpes simplex, vitamin b12 deficiency, leukoplakia, acute tonsillitis, streptococcal pharyngitis

51
Q

Herpes simplex

A

clear vesicles surrounded by red indurated base

52
Q

Vitamin b12 deficiency

A

smooth reddish shiny tongue w/o papillae

53
Q

Leukoplakia

A

thick raised patch does not scrape off, seen w/ heavy tobacco/alcohol use

54
Q

Acute tonsillitis

A

secondary infection to mononucleosis, marked tonsillar enlargement w/ erythema/large white/gray patches

55
Q

Streptococcal pharyngitis

A

erythematous posterior pharynx, palatal petechia, white strawberry tongue, strep throat

Health Assessment (32 decks)

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