Republic of the Philippines

President Ramon Magsaysay State University

(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
Name:________________________________Section/Group:_______________Date:____________
Rating
5 Correctly and independently performs procedure and states complete rationale
4 Performs procedure and states rationale with minimal guidance
3 Satisfactorily performs procedure with moderate guidance
2 Procedure incorrectly done without rationale
1 Procedure not performed

Assessing the Mouth and Oropharynx

PROCEDURE 5 4 3 2 1
Assemble the equipment and supplies:
 Clean gloves
 Tongue depressor
 2 x 2 gauze pads
 Penlight
1. Introduce yourself and verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, and how she
can cooperate.
2. Perform hand hygiene and observe other appropriate infection
control procedure
3. Provide client privacy
4. Inquire if client has any history of the following:
 Routine pattern of dental care
 Last visit to dentist
 Length of time ulcers or other lesions have been present
 Any denture discomforts
 Any medications the client is receiving
5. Position the client comfortably-seated, if possible.
6. Inspect the outer lips for symmetry of contour, color, and
texture.
 Ask the client to purse lips as if to whistle.
7. Inspect and palpate the inner lips and buccal mucosa for color,
moisture, texture, and the presence of lesions.
8. Inspect the teeth and gums while examining the inner lips and
buccal mucosa.
9. Inspect the dentures.
 Ask the client to remove complete or partial dentures. Inspect their
condition, noting in particular broken or worsen areas.
10. Inspect the surface of the tongue for position, color and texture.
 Ask the client to protrude the tongue and move it from side to side.
11. Inspect the tongue movement.
 Ask the client to roll the tongue upward and move it from side to
side.
12. Inspect the base of the tongue, the mouth floor, and the
frenulum.
 Ask the client to place the tip of his tongue against the roof of the
mouth.
13. Palpate the tongue and the floor of the mouth for any nodules,
lumps, or excoriated areas.
 Use a piece of gauze to grasp the tip of the tongue and, with the
index finger of your other hand, palpate the back of the tongue, its
borders, and its base.
 Republic of the Philippines
President Ramon Magsaysay State University
(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
14. Inspect salivary duct openings for any swelling or redness.
15. Inspect the hard and soft palate for color, shape, texture, and
the presence of bony prominences.
 Ask the client to open mouth wide and tilt head backward. Then,
depress tongue with a tongue blade as necessary, and use a penlight
for appropriate visualization.
16. Inspect the uvula for position and mobility while examining the
palates.
 To observe the uvula, ask the client to say “ah” so that the soft
palate rises.
17. Inspect the oropharynx for color and texture.
 Inspect one side at a time to avoid eliciting the gag reflex. To
expose one side of the oropharynx, press a tongue blade against the
tongue on the same side about halfway back while the client tilts
head back and opens mouth wide. Use a penlight for illumination, if
needed.
18. Inspect the tonsils for color, discharge and size.
19. Elicit the gag reflex by pressing the posterior tongue with a
tongue blade.
20. Document findings in the client record.

Actual Score Actual Score

Computation: ×60+ 40= ×60+ 40=Grade
Total Score ❑

Grade:_______________

Remarks:__________________________________________________________________________
__________________________________________________________________________________
____________________________________________________

Evaluated by:

___________________

Clinical Instructor

Conforme:

___________________

Signature of Student