Ch. 18 Mouth, Throat, Nose, Sinuses Flashcards
The nurse percussing an adult client’s sinuses will understand which assessment finding suggests sinusitis?
A. Dullness
B.Tympany
C.Tenderness
D.Resonance
c
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+”
d
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
d
Mouth
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.
Saliva…
helps break down food/lubricates it. enzyme amylase in saliva digests carbs
Salivary glands
parotid - below/in front of ear. submandibular - lower jaw. sublingual - under tongue
Throat (pharynx)
behind mouth/nose. nasopharynx - upper, oropharynx - middle, laryngopharynx - bottom. arches formed behind tongue by soft palate, anterior/posterior pillars, uvula
Tonsils
masses of lymphoid tissues that help protect against infection. three types/locations in the throat - palatine, lingual, pharyngeal/adenoids
Palatine tonsils
both sides of oropharynx at end of soft palate between anterior/posterior pillars
Lingual tonsils
at base of tongue
Pharyngeal or adenoid tonsils
found high in nasopharynx
Nose
external portion, nasal cavity, nasal septum, conchae, hairs, ciliated mucosal cells, paranasal sinuses/nasolacrimal duct, first cranial nerve
External portion of nose
bone/cartilage, lined w/ mucous membrane. bridge, tip, two oval openings - nares
Nasal cavity
between roof of mouth and cranium. from anterior nares to posterior nares and into nasopharynx
Nasal septum
separates cavities into two halves, rich blood supply area called Keisselbach = common site for nosebleeds. warms air entering nose
Conchae (nasal)
superior, middle, inferior turbinates, bony lobes, project from lateral walls of nasal cavity. increase surface area exposed to incoming air
Nasal hairs
filter large particles
Ciliated mucosal cells
capture debris/propel down throat. destroyed in stomach
Paranasal sinuses and nasolacrimal duct receive
drainage. risk of infection when blocked
First cranial nerve
upper part of nasal cavity/septum. olfactory - smell
List paranasal sinuses
frontal, maxillary, ethmoidal, sphenoidal
Paranasal sinuses
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.
Frontal sinuses
above eyes
Maxillary sinuses
upper jaw
Which sinuses are accessible for examination?
frontal, maxillary
Ethmoid and sphenoidal sinuses
smaller, deeper. not accessible for examination
History of present concern
tongue swollen or sores (painful?)? sinus pain or frequent nosebleeds? frequent nasal drainage/what color? difficulty swallowing? sore throat? hoarseness?
Health history
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
Assessment supplies
gloves, 4x4 gauze pad, penlight, short/wide tipped speculum attached to otoscope, tongue depressor, nasal speculum
What to know for assessment
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
Assessing the mouth (inspection)
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
Teeth
open mouth - number, color/condition, dental work, bite down to check alignment
Reddened opening in stensen ducts
mumps
Inspect/palpate tongue
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)
Assess ventral surface of tongue
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
Tongue
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
Uvula
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
Assess tonsils
use tongue depressor, mouth open wide, inspect for color/size/presence of exudate. grade tonsils - 0 absent, 1+ normal, 2+ 3+ 4+ abnormal
1+ tonsils
normal, visible
2+ tonsils
halfway between pillars/uvula
3+ tonsils
touching uvula
4+ tonsils
touching each other
How to prevent gagging when using tongue depressor
off center
Posterior pharyngeal wall
tongue depressor in place/mouth open, shine penlight to back of throat, observe color - normally pink, exudate or lesions
Inspect/palpate nose
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)
What is a deviated septum?
may appear overgrowth of tissue, normal finding if doesn’t obstruct breathing. can be due to trauma or genetic
Assess sinuses
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
General routine screening
inspect lips, odor of mouth, teeth, gums, tongue, buccal mucosa, internal nose, patency of air flow through nostrils, inspect throat
Focused specialty assessment
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
Mouth/throat abnormalities
herpes simplex, vitamin b12 deficiency, leukoplakia, acute tonsillitis, streptococcal pharyngitis
Herpes simplex
clear vesicles surrounded by red indurated base
Vitamin b12 deficiency
smooth reddish shiny tongue w/o papillae
Leukoplakia
thick raised patch does not scrape off, seen w/ heavy tobacco/alcohol use
Acute tonsillitis
secondary infection to mononucleosis, marked tonsillar enlargement w/ erythema/large white/gray patches
Streptococcal pharyngitis
erythematous posterior pharynx, palatal petechia, white strawberry tongue, strep throat
