Health Assessment

(NUR 241)

Mouth, & Nose

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 Objectives
After completion of this presentation, the nurse will be able to:
Conduct a basic adult mouth, and nose assessment.
Distinguish normal from abnormal findings
 Nose – Inspection/Palpation
Inspection
Size, shape
Symmetry
Lesions/signs of infection
Patency test
Septum (by use nasal speculum)-deviation, inflammation or
perforation

Palpate for tenderness, swelling

Assess Nose for Symmetry, Edema, and Air
Passage
Mouth / Tongue/ Teeth / Throat
Mucous membranes

Sores / Lesion

Tonsils

Sore throat

Gums

Teeth
Mouth and Pharynx - Inspection
Lips Tongue and floor of mouth
Note color, moisture, Note color and texture,
lumps, ulcers, cracking ulcers
Gums and teeth
Note color, presence and uvula, tonsils, pharynx
position of teeth Note color, symmetry,
presence of exudate,
Roof of mouth
Note color
swelling, ulceration or
tonsillar enlargement
Gingivitis
Glossitis
The Mouth and Gums
Under the Tongue
Above and behind the tongue
 Say “AAHHH”

Abnormal

Normal CN X
Tonsillitis Peritonsilar Abscess
Is the tongue moist and pink?

Assess both top and….

….underneath
Oral Herpes Simplex
Assess Outside of Mouth and Lips for
Color, Moisture, and Abnormalities
Place your hands on both sides of the lower jaw and ask the
patient to clench his teeth. Should be able to feel same
muscle tension bilaterally

CN V
Ask the patient to stick
his tongue straight out of
his mouth.

CN XII
 Summary
Abnormalities
Nose Drainage (rhinorrhea), congestion, sneezing,
nose bleeds (epistaxis)
Mouth Swelling, ulceration or tonsillar enlargement
Question?

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