Our Lady of the Pillar College-Cauayan

Cauayan City, Isabela

College of Nursing and Midwifery

HEALTH ASSESSMENT

PHYSICAL ASSESSMENT
ACTIVITY 5
MOUTH, NOSE, THROAT AND SINUSES

Name of Patient: Patient A Age: 5 years old Gender: Female Birthday: May 10, 2018
Address: Macanao, Luna, Isabela Occupation: N/A
Chief Complaints: Coughing frequently at night due to change of weather

Assessment Technique Actual Findings Analysis/ Interpretation

GENERAL APPEARANCE
 Skin appearance
 Dress and Grooming
 Hygiene
Inspection  Pinkish and smooth  Abnormal, with lesion or
 Presence of red patches wheal due to mosquito
bites
Inspection  Neat and Casual  Normal
 Patient’s hair is properly fixed
 Normal
Inspection  Patient uses handkerchief
 Baths everyday

 Patient is in sitting position

 Posture Inspection  Normal
 Patient has no problem standing up
independently
  Body build Inspection  Height: 110 cm  Normal
 Weight: 18.9 kg
 BMI: Normal
 Normal
 Level of Consciousness Inspection  Patient is conscious
 Maintains eye contact
 Responds immediately
 Normal
 Level of Comfort Inspection
 Patient is comfortable
 Normal
 Facial Expression Inspection
 No signs of grimace
 Patient maintains a straight face
 Speech Inspection  Normal
 No signs of stuttering
 Normal speaking
VITAL SIGNS
 Body Temperature Inspection  36.5 °C  Normal

 Pulse Rate Palpation/  76 bpm  Normal

Inspection
 Respiratory Rate  Normal
Palpation and  24 breaths per minute
Inspection
 Blood Pressure
Auscultation  90/60 mmHg  Normal

MOUTH
 Lips Inspection  Lips are smooth and moist without  Normal
lesions or swelling.

 Teeth and gums Inspection  20 pearly whitish teeth, presence of

tooth cavities in the hard surface of  Abnormal due to
teeth presence of tooth cavities

 Buccal mucosa Inspection &  No presence of lesion  Normal

palpation
 Stensen ducts Inspection &  Stensen ducts visible with flow of  Normal
palpation saliva

 Tongue Inspection &  Normal

palpation  Tongue is pink, moist, moderate size
with papillae present
 No presence lesions

 Ventral surface of the Inspection &  Normal

tongue palpation  Smooth, shiny, pink, or slightly pale,
with visible veins, no lesions
 Wharton ducts Inspection &  Normal
palpation  Wharton ducts are visible, with
salivary flow or moistness in the area.
 Sides of the tongue Inspection &  Normal
palpation  no swelling, redness or pain

 Strength of the tongue Inspection &

 Normal
palpation
 tongue offers strong resistance
 Normal
Inspection &
 Anterior tongue’s ability
palpation
to taste  can distinguish taste
Inspection &
 Anterior and posterior  Normal
palpation
palate  Anterior hard palate white with
irregular transverse rugae  Normal
 Posterior soft palate is pinker, smooth,
Inspection and upwardly movable
 Odor  Normal
Inspection  no presence of distinctive odor
 Uvula  Normal
Inspection  no presence of abnormalities
 Tonsils  Normal
 1+ Visible
  Posterior pharyngeal wall Inspection  Normal
 no presence of abnormalities

NOSE
 External nose Inspection &  no presence of abnormalities  Normal
palpation

 Patency of airflow Inspection &  no presence of abnormalities  Normal

palpation

 Internal nose Inspection &  no presence of abnormalities  Normal

palpation

SINUSES
 Frontal sinuses Percussion  no tenderness and no presence of  Normal
abnormalities
 Normal
 Maxillary sinuses Percussion  no tenderness and no presence of
abnormalities
DOCUMENTATION