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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 67

KEY POINTS FOR REPORTING AND RECORDING

● Abnormal findings in assessment, including the use of a hear-
ing aid.
● Symmetry of external ears; redness, scaling, discharge, masses,
or tenderness noted on examination of the external ear and
canals.
● Characteristics of the tympanic membrane, such as color, abil-
ity to see landmarks, integrity of the membrane.
● Whispered words repeated correctly or incorrectly.
● Results of Weber test—normally tone heard midline without
lateralization
● Results of Rinne test—normally AC (air conduction) ⬎ BC
(bone conduction) 2:1.
● Results of Romberg test—normally negative (no swaying).
● Use of hearing-aid device.
● Any consultations recommended.

PROCEDURE 4.3
Assessing the Nose and Sinuses
OVERVIEW
● The nose is the first segment of the respiratory system and is multi-
functional.
• As inspired air passes through the nasal mucosa, nasal turbinates,
and nasal hairs, it is heated, humidified, and filtered.
• The nose is also the sensory organ for smell.
● The sinuses lighten the skull, serve as resonators for sound, and pro-

vide mucus, which drains into the nasal cavity.

● Assessment of these areas offers insight to respiratory complaints as

well as problems involving the ears, throat, and even headaches.

P R E PA R AT I O N
● Review related history that would give the examiner information
(past and present) regarding patient’s sense of smell and general
information regarding the nose and sinuses, including allergies,
epistaxis, nasal discharge, frequent colds, trauma or surgery, and
sinus pain.
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68 C h a p t e r 4 Physical Assessment

● Ask about the use of nasal sprays and intranasal use of cocaine or
amphetamines.
● Cranial nerve I is usually not tested in a routine examination. If the

sense of smell is tested, it can be performed while assessing the nose

or while assessing the neurologic system.

Special Considerations
Pediatric Patient
• Most newborns are obligate nose breathers, and, therefore, special
attention must be given to the patency of the nares. Often, nasal flar-
ing is a sign of respiratory distress.
• Avoid the nasal speculum in infants and young children; simply push
the tip of the nose up and shine the light into the nares.
• Only palpate the sinuses in children 8 and older; in younger children
the sinuses are too small for palpation.
• In toddlers, pay special attention to the possibility of foreign bodies
lodged in the nasal cavity.
Pregnant Patient
• Nasal stuffiness and epistaxis may occur during pregnancy because
of the increased vascularity in the upper respiratory tract.
Elderly Patient
• In older patients, the nose may appear larger, with the growth of
especially coarse nasal hairs. The sense of smell may be diminished,
and the nasal mucosa may become drier, making these patients
more prone to nosebleeds.

R E L E VA N T N U R S I N G D I A G N O S E S
● Possible disturbed sensory perception: olfactory
● Possible ineffective airway clearance

EXPECTED OUTCOMES
● Completion of the examination while maintaining the patient’s
comfort
● Examination performed appropriately for age, and developmental

and educational level

EQUIPMENT/SUPPLIES
Otoscope with short, wide nasal tip or nasal speculum and penlight
Small samples of familiar odors
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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 69

I M P L E M E N TAT I O N
➧ Inspect the external aspect of the nose.
Exposes any asymmetry, deformity, inflammation, or skin lesions.
➧ Palpate the nose gently.
Uncovers pain, any breaks in the contour of the nose, or minute masses.
➧ Test the patency of each nostril by having the patient close the
mouth, then occlude one nostril and sniff inward through the
other naris.
Reveals any obstruction of the nares, such as nasal polyps or rhinitis.
➧ Inspect the nasal cavity using
either the otoscope with the
nasal tip or a nasal speculum
and penlight.
This allows a more thorough
examination of the nasal cavity.
● Tilt the patient’s head back,
stabilize the instrument, and
gently insert the speculum
approximately 1 cm while
FIGURE 4.3A Inspect nasal cavity.
avoiding the nasal septum.
Provides maximum exposure while maintaining patient safety and
comfort; the nasal septum is highly vascular and may bleed if irritated
by the speculum.
● Note the color and characteristics of the mucosa.
Exposes any swelling, discharge, or bogginess, which are indicative
of rhinitis, sinusitis, or chronic allergies.
● Note the inferior and middle turbinates (the superior will not be in
your view).
Exposes nasal polyps or foreign bodies.
● Note any deviation of the nasal septum.
A deviated septum is common and does not present a problem unless airflow
is obstructed (if found in a hospitalized patient, document the findings in
case the person requires a nasogastric tube or nasal suctioning).
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70 C h a p t e r 4 Physical Assessment

➧ Palpate the sinuses.

Tenderness is elicited by palpation
of sinuses in persons with chronic
allergies and sinusitis.
● Frontal sinuses by pressing
with your thumbs up from
under the medial aspect of
the eyebrows.
Pressure but not pain should be
felt; be careful not to press on
the eyeballs.
● Maxillary sinuses by pressing
up and in from under the
cheekbones.
Pressure but not pain should
be felt.

FIGURE 4.3B Palpate sinuses.

➧ Test cranial nerve I: olfactory.

Evaluates the patient’s sense of smell; abnormalities can indicate a neuro-
logic or a local problem.
● Direct the patient to close eyes and occlude one naris.
Ensures that the patient is not identifying the substance by sight and that he
or she is not compensating by using the other naris.
● Hold a substance with a familiar odor under the other naris and
have the patient identify the odor.
Allows easy detection if the sense of smell is intact.
● Repeat for the other side.
Tests the sense of smell in each naris.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Inspect and ensure that if any bleeding occurred during the exami-
nation, it has stopped
● Compare assessment findings to normal

● Refer patient to an ear, nose, and throat specialist for further testing

and evaluation of abnormal findings, if necessary

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P r o c e d u r e 4 . 4 Assessing the Mouth and Pharynx 71

KEY POINTS FOR REPORTING AND RECORDING

● Abnormal findings noted in the assessment.
● Deformities or tenderness noted as well as location and
description.
● Patency of nares.
● Color, character of mucosa, including any lesions and their
location.
● Position of septum (midline or side of deviation).
● Results of palpation of sinuses (note tenderness/no tender-
ness and which sinus).
● Sinus tenderness.

PROCEDURE 4.4
Assessing the Mouth and Pharynx
OVERVIEW
● The mouth and pharynx are the first segments of the respiratory
and digestive systems.
● The structures included in this region are important for speech

formation and the sense of taste, and contain a large amount of

lymphatic tissue.
● Assessment of this area provides clues to local and systemic

problems, such as nutritional status, hydration, and infection.

P R E PA R AT I O N
● Review related history that would give the examiner information
(past and present) regarding the general state of the patient’s mouth
and pharynx, including sore throat, lesions, toothache, voice changes,
difficulty swallowing, and self-care behaviors.
● Observe the patient with dentures to inspect the fit, but have the

patient remove the dentures during the examination.

● Note the use and type of tobacco products (how much, how often,

how long).
● Cranial nerve X and XII are usually tested during the assessment

of the neurologic system, but such testing can be performed while

assessing the mouth and pharynx as well.