WEEK 4- NOSE, THROAT, MOUTH Flashcards
Identify & landmark major structures & features of the nose, mouth, & throat.
nose
- nasal cavity
- septum
- superior, middle, inferior turbinates’
- meatus
- paranasal sinuses (4)
mouth
- tongue
- uvula
- teeth
- salivary glands- parotid gland
-frenulumn
- papialle
- vallate papilale
- oral cavity
- lips
- hard palate and soft palate
- cheeks
throat
- pharynx
- oropharynx
- nasopharynx
- tonsils
Identify health promotion strategies.
- no more vaping, smoking, tobacco chewing= oral cancer
Identify equipment needed for physical examination & safe infection prevention & control practices.
Otoscope Penlight
Two tongue blades
Cotton gauze pad (10 × 10 cm)
Gloves
∗
Abnormal Findings: Abnormalities of nose: epistaxis, foreign body, sinusitis.
epistaxis- nose bleeds
foreign body- lodged in nose, prevent proper breathing/in airway
sinusitis- inflammation or infection of sinuses
Lip/Mouth: cleft lip, herpes simplex 1, dental caries, gingivitis, candidiasis infection, aphthous ulcers, fissured or scrotal tongue, bifid uvula.
cleft lip- split or opening in the upper lip, could extent to nose, tissues in lip don’t fully fuse during fetal development
herpes simplex 1; infectious, affects mucous membranes and skin, infected persons salvia- you can get it from kissing, sharing any type of salvia with an infected person.
dental caries- tooth decay or cavities, too much sugar, poor oral hygiene, no brushing/flossing.
gingivitis- common mild form of peridontal, gum disease, gums are inflamed and bleeding.
candidiasis- fungal infection, white creamy on tongue- oral thrush
aphthous ulcers- canker sores, inner round sores, inside of mouth, inner lips, throat,
fissured tongue- pysoriss- usually benign, sometimes not
bifid uvula- split or cleft lip in uvula- congenital
Throat: acute tonsilitis
inflammation and infection of tonsils
- viral or bacterial infection
Epistaxis is common in which population?
pregnant women
A client has purulent nasal discharge and a temperature of 38.6. What should the nurse’s priority action be?
tell clients family they need to thoroughly and frequently wash and clean hands
The nurse that assessing the back of the throat of a client requires
tongue depressor and penlight
When assessing the gums of pregnant woman the nurse noted swelling of the gums. What is the nurse’s response to this finding
document swelling of gums as a result of pregnancy
The nurse knows that assessment of the tongue may reveal which findings that are within normal range: (Select all that Apply)
- fissures on surface
- raised taste buds
- small brown macules
The nurse assess the teeth of a client. Findings within normal range include: (Select all that Apply)
- teeth are not movable
- gums are in close contact with teeth
- teeth has varying shades of white
the nose
Sensory organ
First segment of respiratory system
Warms, humidifies & filters
Nasal cavity
Nares & nasal mucosa
Septum -Kiesselbach’s plexus
Three bony turbinates
Lateral walls
Increase surface area
Sinuses and nasolacrimal ducts drain into turbinates
paranasal sinuses
Frontal
Maxillary
Ethmoid
Sphenoid
(4)
mouth and pharynx
Gums, buccal mucosa and 32 teeth
Hard and soft palates
Uvula
Tongue (papillae)
Tonsils
Anterior & posterior pillars
Salivary glands
health history questions- nose
Discharge
Colds
Sinus pain
Trauma
Epistaxis
Allergies
Altered smell
health history questions- throat
Sores or lesions
Sore throat
Bleeding gums
Toothache
Hoarseness
Dysphagia
Altered taste
Smoking
Alcohol consumption
Self-care behavious
objective data- inspect and palpate nose
External nose
Symmetry, midline, in proportion, deformity, lesions and inflammation
If injury suspected, palpate
Patency of nostrils
inspection of nose
- objective data
Nasal cavity/mucosa
Lift tip of nose
Positioning of head
Erect, and then head tilted
Inspect
Colour, smooth moist surface, discharge, bleeding, swelling, foreign bodies
Nasal septum
Perforation, bleeding, and deviation
Deviation not significant unless air flow is obstructed
Turbinates
Colour, swelling, and polyps
mouth
- objective data
inspect and palpate
*Tongue blade, penlight and gloves
Lips, teeth and gums
Tongue
Buccal mucosa
Hard and soft palate
Test CNIX (glossopharyngeal) and CNX (vagus nerve)
“ahhh”
- Soft palate and uvula rise
- Tonsillar pillars move medially
DO NOT TEST GAG REFLEX
Tongue- what is normal vs abnormal
normal
- fissures
- painless bumps
- raised taste buds
- small brown macules
- sores- from biting something, etc, normal
abnormal
- white layers
- abnormal smoothness
- abnormal redness
- black and hairy
- thick yellow coating
- sores- consist
objective data- throat
Throat—Inspect
Tonsils
Oval, rough surfaced with indentations
Colour and presence of exudate
Grade tonsils
Posterior pharyngeal wall
Colour, exudate, lesions
Note halitosis
Test cranial nerve XII (hypoglossal nerve)
“stick your tongue out”
social/cultural considerations-
cleft lip and uvula and palate- most common in aboriginal and Asian descent
leukoedema- may be most common in African descent
periodontal disease and tooth decay- most common in aboriginal people in Canada
born with teeth- 1/2 in 100 Canadian inuit
1 in 3000, European descent
developmental considerations
Some Developmental Considerations
Infants/children
Salivation starts at 3 months
Deciduous, temporary teeth replaced by permanent teet
Pregnancy
Epistaxis and gum bleeding
- as a result of increased vascularity in the upper
respiratory tract. - The gums may be hyperemic and softened and
may bleed with normal tooth brushing. - Contrary to folklore, no
evidence shows that pregnancy causes tooth decay or loss.
Older adults
Nose becomes more prominent
Loss of taste buds and decreased salivary secretion and sense of smell
teeth history
Both sets of teeth begin development in utero. Children have 20
temporary deciduous teeth. These erupt between 6 and 24
months of age. All 20 teeth should appear by 2½ years of age. The
deciduous teeth are lost between ages 6 to 12 years.
nose development
the nose develops during adolescence, along with secondary sex
characteristics. This growth starts at age 12 or 13 years, reaching full
growth at age 16 years in girls and 18 years in boys
subjective data
Nose
1. Discharge
2. Frequent colds (upper respiratory infections)
3. Sinus pain
4. Trauma
5. Epistaxis (nosebleeds)
6. Allergies
7. Altered smell
Mouth and Throat
1. Sores or lesions
2. Sore throat
3. Bleeding gums
4. Toothache
5. Sugar consumption
6. Bruxism (teeth grinding)
7. Hoarseness
8. Dysphagia
9. Altered taste
10. Tobacco consumption
11. Alcohol consumption
12. Sleep apnea
13. Self-care behaviours
Oral care pattern
Mouthwash
health promotion
- no vaping
- no cigarettes
- no tobacco
