PHYSICAL ASSESSMENT GUIDE
Questions
Current symptoms
1. Gather equipment
 Gloves
 Cotton gauze pad
 Penlight
 Speculum
 Tongue depressor
2. Explain the procedure to
client
Mouth
1. Notice any distinctive odor
2. Inspect and palpate lips,
buccal mucosa, gums, and
tongue for color variations.
 Pallor
 Redness
 White patches
 Bluish hue
Inspect also if there is
moisture, tissue consistency
or lesions
Stensen and Wharton duct.
Procedure Findings
Breath
1. Stand facing the patient and about 30
cm away.
2. Smell the breath
Normal Findings:
The breath should smell fresh.
Abnormal Findings:
- The breath smells foul.
- The breath smells of acetone.
- The breath smells musty.
- The breath smells of ammonia.
lips Inspection
- Instruct the patient to open the mouth.
- Use a tongue blade to inspect the
membranes that connect the upper and
lower lips to the gums
Normal Findings:
The lips and membranes should be pink
and moist with no evidence of lesions or
inflammation.
Abnormal Findings:
- The lips are pale or cyanotic
- The lips are dry and cracked.
- Swelling of the lips is noted.
- The skin at the outer corners of the
mouth is atrophic, irritated and cracked.
Lips Palpation

3. Inspect gums for
hyperplasia, blue-back line
4. Inspect teeth for number
and shape, color and
occlusion
5. Inspect and palpate tongue
color texture and consistency,
moisture and size.
1. Don nonsterile gloves.
2. Gently pull down the patient's lower
lip with the thumb and index finger of
one hand and pull up the patient's upper
lip with the thumb and index finger of the
other hand.
Normal Findings: Lips should not be
flaccid and lesions should not present
1. Ask the patient to open the
mouth as wide as possible
2. Use a tongue depressor and a
penlight to assess the inner
cheeks and the openings of
Stensen's ducts
3. Observe for color,
inflammation, hydration and
lesions
1. Instruct the patient to open the mouth
2. Count the upper and lower teeth.
3. Observe the teeth for discoloration,
loose or
missing teeth, caries, malocclusion and
malformation
Normal: The adult normally has 32 teeth,
which should be white with smooth
edges, in proper alignment, and without
caries.
1. Ask the patient to stick out the tongue
(CN XII assesses tongue
movement).
2.Ask the patient to move the tongue
from side to side and up and down.
3. With the patient's tongue back in the
mouth, ask the patient to press it
against the cheek. Provide resistance with
your finger pads held on the
outside of the cheek.
4. Ask the patient to touch the tip of the
tongue to the roof of the mouth. You may
also grasp the tip of the tongue with a
gauze square held between the thumb and
the index finger of the gloved hand
Palate

Throat
1. Inspect the throat for color,
consistency, torus, palatinus
uvula
2. Inspect the tonsils for color
and consistency; grading
scale 1+, 2+, 3+, 4+
Nose
1. inspect and palpate the
external nose for color, shape, -Color is the same as the rest of the face
consistency, tenderness, and
1. Ask the patient to tilt the head
back and open the mouth as
wide as possible. 2. Shine the penlight in
the
patient's mouth. 3. Observe both the hard
and the
soft palates. 4. Note their shape and
color,
and the presence of any
lesions or malformations
1. Ask the patient to tilt the head back
and to open the
mouth widely. The patient can either
stick out the tongue
or leave it resting on the floor of the
mouth.
2. With the right hand, place the tongue
blade on the middle
third of the tongue.
3. With the left hand, shine a light at the
back of the
patient's throat.
4. Ask the patient to say 'ah'.
5. Observe the position, size, color and
general appearance of
the tonsils and uvula.
6. Touch the posterior third of the tongue
with the tongue
blade.
7. Note movement of the palate and the
presence of the
gag reflex.
8. Assess the color of the oropharynx
Normal Findings:
- Nasal structure is smooth and
symmetric
- without swelling, bleeding, lesions and
masses
Abnormal Findings:
- Nose is misshapen, broken or swollen
patency of airflow
2. Inspect the internal nose,
for color, swelling, exudate,
bleeding, ulcers, perforated
septum or polyps.
Sinuses
1. Palpate the sinuses for
tenderness
a. have the patient occlude one nostril
with a finger
b. ask the patient to breathe in and out
through the nose
c. repeat on the other side
Normal Findings:
- Each nostril is patent.
Abnormal Findings:
- You observe or the patient states that air
cannot be moved through the nostril(s)
that is not occluded
1. Position the patient with the
head in an extended position.
2. Place the nondominant hand
firmly on top of the patient's
head.
3. Using the thumb of the same
hand, lift the tip of the patient's
nose.
4. Gently insert a nasal speculum
or an otoscope with a short, wide
nasal speculum
If using a nasal speculum, use a penlight
to view the nostrils
5. Assess each nostril separately.
6. Inspect the: - mucous membranes
- nasal septum
- inferior and middle turbinate’s
- nasal pass
Observe the patient’s face for swelling
around the nose and eyes
Normal Findings:
The is no evidence of swelling around the
nose and eyes
Abnormal Findings:
Swelling is noted
To palpate and percuss the
frontal sinuses:
1. Stand facing the patient
2. Gently press up on the brow
on each side of nose using
the thumbs
3. Observe the presence of
pain.
 4. Percuss the areas using the
middle or index finger of
the dominant (direct
percussion
5. Note of sound
Maxillary Sinuses:
1. Stand in front of the patient.
2. Apply gentle pressure in the
area under the infraorbital
ridge using the thumb or
middle finger
3. Observe for the presence of
pain
4. Percuss the area using the
dominant middle or index
finger
5. Note the sound
2. Percuss and transilluminate To evaluate the frontal sinuses:
the sinuses for air versus fluid 1. Place the patient in a sitting
or pus position facing you in a dark room.
2. Place a strong light source such as
a transilluminator, penlight, or tip of
an otoscope
with the speculum under the bony
ridge of the upper orbits.
3. Observe the red glow over the
sinuses and compare the symmetry of
the two side.

To evaluate the maxillary sinuses:

1. Place the patient in a sitting
position facing you in a dark room.
2. Place the light source firmly under
each eye and just above the
infraorbital ridge
3. Ask the patient to open the mouth.
observe the red glow on the hard
palate.
4. Compare the two side
Analysis of data
1. formulate nursing
diagnosis
2. formulate collaborative
problems
3. make necessary referrals.
Nursing Interview guide to collect subjective data from the client
Questions Findings
Current symptoms
Tongue and mouth
1. Mouth problems (tongue or mouth sores of
lesions, gum or mouth redness, swelling
bleeding or pain)
Do you experience tongue or mouth sores or lesions?
Do you experience redness, swelling, bleeding or pain
of the gums or mouth?
2. Sinus problems (pain over sinuses, postnasal
drip)?
Do you have pain over your sinuses? (cavities around
nasal passages)
Do you experience nosebleed? Describe the amount of
bleeding you have and how often it occurs. What color
is the blood?
Do you experience frequent clear or mucous drainage
from your nose?
Can you breathe through both of your nose?
Do you have stuffy nose at time during the day and
night?
Have you experience a change in your ability to smell?

Throat
3. Do you have difficulty swallowing or painful
swallowing? How long have you had this?
4. Do you have sore throat?

5. Do you experience hoarseness?

Past history

1. Previous problems with mouth, throat, nose, or

sinuses. Surgeries or treatment, how much and
how often?
2. Do you have history of sinus infection?
3. Use of nasal sprays?
4. Do your regularly use any treatment or
medications for conditions that affect the
mouth, nose or throat, to control pain in the
mouth nose throat or sinuses
5. History of tooth grinding
 6. Last dental exam? Fit dentures?

Family history

1. Family history or oral, nasal, or sinuses cancer

or chronic problems
Lifestyle and health practices

1. Daily practices of oral, tooth care or denture

care
2. Usual diet

3. History of smoking, use of how much and how

often
4. Use of alcohol (how much and how often?)

5. How do you care for your braces?