Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences
COLLEGE OF NURSING

ASSESSING THE MOUTH, OROPHARYNX,

NOSE AND SINUSES
A. LEARNING OBJECTIVES:
The students will be able to:
• Evaluate the client’s current physical condition
• Detect early sign of developing health problem
• Establish a baseline for future comparisons
• Evaluate the client’s responses to medical and nursing interventions

B. EQUIPMENT NEEDED:
• Clean gloves
• Tongue depressor
• Gauze pad
• Flashlight or penlight
• Nasal speculum

EVIDENCE TO BE PRODUCED RATIONALE

1. Prior to performing the procedure, greet and To build rapport between the nurse
introduce self to the client. and the patient

2. Verify the clients identity using two (2) patient To recognize the correct patient
identifiers

3. Explain to client what you are going to do, why it To enhance patient’s cooperation
is necessary, and how he or she can participate.
Discuss how the result will be used in planning
further care or treatment

4. Perform hand hygiene and observe appropriate To prevent transfer of

infection control procedures microorganism

5. Provide for client privacy To provide comfort and safety

6. Position the client comfortably, seated if

possible.

ASSESSING THE MOUTH AND OROPHARYNX

7. Inspect the outer lips for symmetry of contour,
color and texture:
• Ask the client to purse the lips as if
attempting to whistle
To identify deviations from normal:
pallor or cyanosis of lips; blisters,
generalized or localized swelling,
fissures, crust, or scales (may result
from excessive moisture, nutritional

8. Inspect and palpate the inner lips and buccal
mucosa for color, texture, moisture and presence
of lesions
• Apply clean gloves
• Ask the client to relax the mouth
• Pull the lip outward and away from the
teeth
• Grasp the lip on each side between the
thumb and the index finger
9. Inspect the teeth and gums while examining the
inner lips and buccal mucosa
• Ask the client to open mouth
• Using a tongue depressor, retract the
cheek
• View the surface buccal mucosa from top
to bottom and back to front
• A penlight will help illuminate the surface
• Repeat procedure on the other side
10. Inspect the gums around the molars. Observe
for bleeding, color, retraction, edema and lesions:
• Assess the texture of the gums by gently
pressing the gum tissue with a tongue
depressor
11. Inspect the dentures if any. Ask the client to
remove complete or partial dentures. Inspect their
condition, noting for broken or worn out areas
ASSESSING THE TONGUE
12. Inspect the surface of the tongue for position, To check for: tongue deviation from
color, and texture. Ask the client to protrude the the center (may indicate damage to
tongue
13. Inspect tongue movement. Ask the client to roll
the tongue upward and move it from side to side
deficiency, or fluid deficit); inability to
purse the lips may indicate facial
nerve damage
To check for: pallor, leukoplakia
(white patches), and bleeding;
excessive dryness; mucosal cyst,
irritations from dentures; abrasions,
ulceration; nodules
The condition of the teeth and gums
is an index of a person’s general
health. This step will help to check
for: missing teeth; ill-fitting dentures;
brown or black discoloration of the
enamel (may indicate staining or
presence of caries); excessively red
gums; receding and atrophied gums.
The condition of the teeth and gums
is an index of a person’s general
health. This step will help to check
for: missing teeth; ill-fitting dentures;
brown or black discoloration of the
enamel (may indicate staining or
presence of caries); excessively red
gums; receding and atrophied gums.
To check for: ill-fitting dentures;
irritated and excoriated areas under
dentures.
hypoglossal nerve); excessively
trembling tongue; smooth red
tongue (may indicate iron, vitamin
B12 or B3 deficiency); dry furry
tongue (associated with fluid deficit);
white coating (may indicate oral
yeast infection); nodes, ulceration,
discoloration; areas of tenderness.
To check for restricted mobility of
the tongue (may indicate damage to
hypoglossal nerve).
14. Inspect the base of the tongue, the mouth floor
and the frenulum. Ask the client to place the tip of
the tongue against the roof of the mouth.
15. Palpate the tongue and the floor of the mouth
for any nodules or lumps:
• To palpate the tongue, use a piece of gauze
to grasp its tip, and with the index finger of
the other hand, palpate the back of the
tongue, its borders and its base

ASSESSING THE OROPHARYNX AND TONSILS

16. Inspect the oropharynx for color and texture: To check for the presence of lesions,
• Inspect one side at a time to avoid eliciting plaques, or drainage.
the gag reflex
• To expose one side of the oropharynx,
press a tongue depressor against the
tongue of the same side about halfway back
while the client tilts the head back and
opens the mouth wide.
• Use penlight if needed.

17. Inspect the tonsils for color, discharge and size To check for discharges,
inflammation or swelling:

• Grade 1 (normal): The tonsils

are behind the tonsillar pillars.
• Grade 2: The tonsils are
between the pillars and uvula.
• Grade 3: The tonsils touch the
uvula.
• Grade 4: One or both tonsils
extend to the midline of the
oropharynx.

18. Elicit the gag reflex by pressing the posterior

tongue with a tongue depressor

ASSESSING THE NOSE AND SINUSES

EVIDENCE TO BE PRODUCED RATIONALE

19. Inspect the external nose for any deviations in
shape, size, or color and flaring or discharge from
the nose.
20. Lightly palpate the external nose to determine
any areas of tenderness, masses and displacement
of bone and cartilages.
21. Determine patency of both nasal cavities: This will reveal any obstruction
• Ask patient to close the mouth which is later explored using the
• Exert pressure to one nares and breath nasal speculum.
through the opposite nares
• Repeat the procedure to assess patency of
the opposite nares.
22. Inspect the nasal cavities using flashlight or
nasal speculum:
• Hold the speculum in your right hand to
inspect the client’s left nostril and your left
hand to inspect the client’s right nostril
• Tip client’s head back
• Facing the client, insert the tip of the closed
speculum (blades together) about 1
centimeter up to the point at which the
blade widens
• Stabilize the speculum with your index
finger against the side of the nose. Use the
other hand to position the head and then to
hold the light
• Open pressure as much as possible and
inspect the floor of the nose (vestibule), the
anterior portion of the septum, the middle
meatus and the middle turbinate
• Inspect the lining of the nares and the
integrity and the position of the nasal
septum
• Observe for the presence of redness,
swelling, growths and discharges
• Inspect the nasal septum between the nasal
chambers
23. Palpate the maxillary and frontal sinuses for
tenderness :
• Begin by pressing your thumbs over the
frontal sinuses below the superior orbital
ridge.
• Palpate the maxillary sinuses below the
zygomatic arches of cheekbones.
• Observe the client for signs and symptoms
of discomfort
24. Percuss the maxillary and frontal sinuses for
tenderness
25. Perform handwashing
26. Document findings in the client’s record