Nursing Interview Guide to Collect Subjective Data From the Client
QUESTIONS
Current Symptoms
1. Mouth problems (tongue or mouth sores or lesions,
gum or mouth redness, swelling, bleeding, or pain)?
COLDSPA: Exploring the symptoms with COLDPA can provide
data to determine if lesions are related to medications, stress,
infection, trauma, or malignancy. Lesions that last for more
than 2 weeks need to be explored further and referred.
2. Sinus problems (pain over sinuses, postnasal drip)?
3. Nose problems (nosebleeds, stuffy nose, cannot breath
through one or both nostrils, change in ability to smell
or taste)?
Rationale
(gingivitis). Red, swollen gums that bleed easily occur in early
gum disease
(periodontitis).destruction of the gums with tooth loss occurs
in more advanced gum disease.
Dental pain may occur with dental caries, abscesses, or
sensitive teeth.
Characteristics: Describe the size and texture of the lesions.
Onset: When did they first occur? Do you notice these more
when you are under stress or taking certain medications? Did
they occur after any injury to your mouth?
Locations: Describe exactly where these lesions are located
in your mouth.
Duration: How long have you had these lesions? Have you
ever had these before and did they go away?
Severity: Do these lesions keep you from eating, talking, or
swallowing?
Palliative/relieving factors: What aggravates these lesions or
makes them go away? What over-the-counter remedies and
past prescriptions have you used?
Associated Factors: Do you have any other symptoms with
these lesions such as stress, pain, bleeding? Describe
acute sinusitis.Pain, tenderness, swelling and pressure
around the eyes, cheeks, nose or forehead is seen in , which
is a temporary infection of the sinuses.
Chronic sinusitis, the sinuses become inflamed and swollen,
but symptoms last 12 weeks or longer even with treatment.
Nosebleeds are most commonly due to dry nasal membranes
and nose picking. Other causes:
acute and chronic sinusitis, allergies, anticoagulants, cocaine
use, common colds, deviated septum, foreign body in nose,
nasal sprays, nonsteroidal anti-inflammatory drugs (NSAIDs)
such as aspirin, chemical irritants, nonallergic rhinitis, or nose
trauma.
 Thin, watery, clear nasal drainage (rhinorrhea) can indicate a
chronic allergy or, in a client with a past head injury, a
cerebrospinal fluid leak.

Mucous drainage, especially yellow, is typical of a cold,

rhinitis, or a sinus infection.

congestion, obstruction, or a deviated septum.

Inability to breathe through both nostrils

A decrease in the ability to smell may occur with acute and

chronic upper respiratory infections, smoking, cocaine
use, or a neurologic lesion or tumor in the frontal lobe of the
brain or in the olfactory bulb or tract.

A decreased ability to taste may be reported by clients with

chronic upper respiratory infections or lesions of the
facial nerve (VII).

*The ability to smell and taste decreases with age.

Medications can also decrease sense of smell and taste in
older people.

Past History

1. Previous problems with mouth, throat, nose, or sinuses
(surgeries or treatment; how much and how often)?
Dysphagia (difficulty swallowing) or odynophagia (painful
swallowing) may be seen with tumors of the pharynx,
esophagus, or surrounding structures, narrowing of the
esophagus such as in post radiation, gastroesophageal reflux
disease (GERD), anxiety, poorly fitting dentures, or
neuromuscular disorders

Malocclusion may also cause difficulty chewing or

swallowing.

Throat irritation and soreness are commonly seen with viral

infections such as the flu, colds, measles, chicken pox,
whooping cough, croup, or infectious mononucleosis.

Additional causes include:

• Allergies
• Irritation
• Reflux
• Tumors

Hoarseness is associated with upper respiratory infections,

allergies, hypothyroidism, overuse of the voice, smoking or
inhaling other irritants, and cancer of the larynx. If hoarseness
lasts 2 weeks or longer, refer the client for further evaluation.

2. Use of nasal sprays? Overuse of nasal sprays may cause nasal irritation,
nosebleeds, and rebound swelling.

3. History of tooth grinding? Grinding the teeth (bruxism) may be a sign of stress or of
slight malocclusion. The practice may also precipitate
temporomandibular joint (TMJ) problems and pain.

4. Last dental exam? Fit of dentures? Poorly fitting dentures may lead to poor eating habits, a
reluctance to speak freely, and mouth sores or leukoplakia
(thick white patches of cells). Leukoplakia is a precancerous
condition.

Family History

1. Family history of oral, nasal, or sinus cancer or chronic There is a genetic risk factor for mouth, throat, nose, and sinus
problems? cancers
Lifestyle and Health Practices

1. Daily practice of oral care, tooth care, or denture care? Brushing twice a day with a soft bristle toothbrush, flossing
between teeth once a day, and oral hygiene can prevent
dental caries and gum disease

Clients with braces should avoid crunchy, sticky, and chewy

foods when wearing braces. These foods can damage the
braces and the teeth.

2. Usual diet? Poor nutrition increases one’s risk for oral cancers

3. History of smoking, use of, how much, and how Cigarette, pipe, or cigar smoking and use of smokeless
often? tobacco increase a person’s risk for oral cancer.

4. Use of alcohol (how much and how often)? Excessive use of alcohol increases a person’s risk for oral
cancer
 Physical Assessment Guide to Collect Objective Client Data

QUESTIONS Rationale Normal Findings Abnormal Findings

Mouth

1. Note any distinctive odors. While the mouth No unusual or foul odor is Fruity or acetone breath is
is wide open, noted. associated with diabetic
note any unusual ketoacidosis.
or foul odor.
An ammonia odor is often
associated with kidney
disease.

Foul odors may indicate an

oral or respiratory infection,
or tooth decay.

Alcohol or tobacco use may

be identified by breath odor.

Fecal breath odor occurs in

bowel obstruction

sulfur odor (fetor

hepaticus) occurs in
endstage liver disease.

2. Inspect and palpate lips, Inspect the 1.) Lips are smooth and 1.)
buccal mucosa. moist without lesions or Pallor around the lips
2B. buccal mucosa, gums, and Use a penlight swelling. (circumoral pallor) is seen in
and tongue
tongue for color variations anemia and shock.
depressor to
(pallor, redness, white patches, retract the lips 2.) In all clients, tissue is
bluish hue), moisture, tissue and cheeks to smooth and moist without Bluish (cyanotic) lips may
consistency, or lesions check color and lesions. Stenson’s ducts result from cold or hypoxia.
(induration, roughness, consistency (Fig. are visible with flow of
vesicles, crusts, plaques, 18-8). Also note saliva and with no Reddish lips are seen in
nodules, ulcers, cracking, Stenson’s ducts redness, swelling, pain, clients with ketoacidosis,
patches, bleeding, Koplik (parotid ducts) or moistness in area. carbon monoxide poisoning,
located on the
spots, cancer sores), Fordyce spots or and chronic obstructive
buccal mucosa
across from the granules, pulmonary disease (COPD)
second upper yellowish-whitish raised with polycythemia.
molars. spots, are normal ectopic
sebaceous glands Swelling of the lips
(edema) is common in local
*Oral mucosa is often or systemic allergic or
drier and more fragile in anaphylactic reactions.
the older client because
the epithelial lining of the 2.)
salivary glands Leukoplakia may be seen
degenerates. in chronic irritation and
smoking.
- precancerous
2C.Stensen and Wharton ducts lesion, and the
client should be
referred for
evaluation.

Whitish, curd-like patches

that scrape off over
reddened mucosa and
bleed easily indicate
“thrush” (Candida
albicans) infection.

Koplik’s spots (tiny whitish

spots that lie over reddened
mucosa) are an early sign
of the measles.
 Canker sores may be
seen, as may brown
patches inside the cheeks
of clients with adrenocortical
insufficiency

3.Inspect gums for hyperplasia, Put on gloves Red, swollen gums that
blue-black line. and retract the bleed easily are seen in
client’s lips gingivitis, scurvy (vitamin C
(Fig. 18-7) and deficiency), and leukemia.
cheeks to
check gums for Receding red gums with
color and loss of teeth are seen in
consistency periodontitis.

Enlarged reddened gums

(hyperplasia) that may
cover some of the normally
exposed teeth may be seen
in pregnancy, puberty,
leukemia, and use of some
medications, such as
phenytoin.

A bluish-black or
grey-white line along the
gum line is seen in lead
poisoning

4. Inspect teeth for number and Note the Thirty-two pearly whitish Clients who smoke, drink
shape, color (white, brown, number of teeth with smooth large quantities of coffee or
yellow, chalky white areas), teeth, color, surfaces and edges. tea, or have an excessive
occlusion. and condition. Upper molars should rest intake of fluoride may have
Note any directly on the lower yellow or brownish teeth.
repairs such as molars and the front
crowns and upper incisors should Tooth decay (caries) may
any cosmetics slightly override the lower appear as brown dots or
such as incisors. Some clients cover more extensive areas
veneers. Ask normally have only 28 of chewing surfaces.
the client to teeth if the four wisdom
bite down as teeth do not erupt. No Missing teeth can affect
though decayed areas; no chewing as well as
chewing on missing teeth. self-image.
something and
note the A chalky white area in the
alignment of tooth surface is a cavity
the lower and that will turn darker with
upper jaws. time. Malocclusion of teeth
is seen when upper or lower
incisors protrude.

Poor occlusion of teeth

can affect chewing, wearing
down of teeth, speech, and
self-image.

Brown or yellow stains or

white spots on teeth may
result from antibiotic therapy
or tooth trauma
5. Inspect and palpate tongue A. Ask client to A. Tongue should be deep longitudinal fissures
for color, texture, and stick out the pink, moist, a moderate seen in dehydration
consistency (black, hairy, white tongue. Inspect size with papillae (little
patches, smooth, reddish, shiny for color, protuberances) present. black tongue indicative of
without papillae), moisture, and moisture, size, bismuth (Pepto-Bismol)
size (enlarged or very small). and texture. B.The tongue’s ventral toxicity
Observe for surface is smooth, shiny,
A. Inspect and Palpate Tongue fasciculations pink, or slightly pale, with black, hairy tongue
(fine tremors), visible veins and no
and check for lesions. smooth, reddish, shiny
midline tongue without papillae
protrusion.
Palpate any An enlarged tongue
lesions present suggests hypothyroidism,
for induration acromegaly, or Down’s
(hardness). syndrome, and
angioneurotic edema of
B.Assess the anaphylaxis.
B. Ventral Surface of Tongue ventral surface
of the tongue. very small tongue
Ask the client suggests malnutrition. An
to touch the atrophied tongue or
tongue to the fasciculations point to
roof of mouth, cranial nerve (hypoglossal,
and use a CN 12) damage.
penlight to
inspect the
ventral surface
of the tongue,
frenulum, and
C.Palpating area under the area under the
tongue. tongue

C.Palpate the
area (Fig.
18-11) if you
see lesions, if
the client is
over age 50, or
if the client
uses tobacco
or alcohol.
Note any
induration.
Check also for
a short
frenulum that
limits tongue
motion (the
origin of
“tongue-tied”).

5.B Observe the sides of the 5.B No lesions, ulcers, or 5.B Canker sores may be
tongue. Use a square gauze nodules are apparent. seen on the sides of the
pad to hold the client’s tongue tongue in clients receiving
to each side (Fig. A). Palpate 5.C The tongue offers certain kinds of
any lesions, ulcers, or nodules strong resistance. chemotherapy; Leukoplakia.
for induration.
5.D The client can 5.C Decreased tongue
distinguish between strength may occur with a
sweet and salty. defect of the twelfth cranial
nerve—hypoglossal—or
5.E The hard palate is with a shortened frenulum
pale or whitish with firm, that limits motion.
transverse rugae
(wrinkle-like folds). 5.D Loss of taste
discrimination occurs with
++No redness of or zinc deficiency, a seventh
exudate from uvula or cranial nerve (facial)
soft palate. Midline defect, chronic sinus
elevation of uvula and infections, and certain
symmetric elevation of medication use
the soft palate.
5.C Check the strength of the 5.E candidal infection may
tongue. Place your fingers on appear as thick white
the external surface of the plaques on the hard palate.
client’s cheek. Ask the client to Deep purple, raised, or flat
press the tongue’s tip against lesions may indicate a
the inside of the cheek to resist Kaposi’s sarcoma.
pressure from your fingers.
Repeat on the opposite cheek. A yellow tint to the hard
palate may indicate
5.D Check the anterior jaundice because bilirubin
tongue’s ability to taste. adheres to elastic tissue
Place drops of sugar and salty (collagen).
water on the tip and sides of
tongue with a tongue An opening in the hard
depressor. palate is known as a cleft
palate.
5.E Inspect the hard
(anterior) and soft (posterior) ++ Asymmetric movement
palates and uvula. Ask the or loss of movement may
client to open the mouth wide occur after a
while you use a penlight to look cerebrovascular accident
at the roof. Observe color and (stroke).
integrity.
Palate fails to rise and uvula
++Assess the uvula. deviates to normal side with
Apply a tongue depressor to cranial nerve X (vagus)
the tongue (halfway between paralysis.
the tip and back of the tongue)
and shine a penlight into the
client’s wide-open mouth (Fig.
18-15). Note the characteristics
and positioning of the uvula.
Ask the client to say “aaah” and
watch for the uvula and soft
palate to move.

.Throat

1. Inspect the throat for color, Keeping the Throat is normally pink, A bright red throat with
consistency, torus palatinus, tongue depressor without exudate or white or yellow exudate
uvula (singular). in place, shine lesions indicates pharyngitis.
the penlight on
the back of the
throat. Observe Yellowish mucus on throat
the color of the may be seen, with
throat, and note postnasal sinus drainage
any exudate or
lesions. Before
inspecting the
nose, discard
gloves and
perform hand
hygiene
2. Inspect the tonsils for color Using the tongue Tonsils may be present or Tonsils are red, enlarged
and consistency; grading depressor to absent. They are (to 2+, 3+, or 4+), and
scale (1+, 2+, 3+, 4+). keep the mouth normally pink and covered with exudate in
open wide,
symmetric and may be tonsillitis.
inspect the
tonsils for color, enlarged to 1+ in healthy
size, and clients (Figure 18-17, p. They also may be indurated
presence of 360). No exudate, with patches of white or
exudate or swelling, or lesions yellow exudate
lesions. Grade should be present.
the tonsils.

Nose

1. Inspect and palpate the Color is the same as the Nasal tenderness on
external nose for color, shape, rest of the face; the nasal palpation accompanies a
consistency, tenderness, and structure is smooth and local infection.
patency of airflow. symmetric; the client
reports no tenderness. 1.B Client cannot sniff
1.B Check patency of air flow through a nostril that is not
through the nostrils by 1.B Client is able to sniff occluded, nor can he or she
occluding one nostril at a time through each nostril while sniff or blow air through the
and asking client to sniff. other is occluded. nostrils.

This may be a sign of

swelling, rhinitis, or a
foreign object obstructing
the nostrils.

A line across the tip of the

nose just above the fleshy
tip is common in clients with
chronic allergies.

2. Inspect the internal nose for To inspect the The nasal mucosa is dark Nasal mucosa is swollen
color, swelling, exudate, internal nose, pink, moist, and free of and pale pink or bluish
bleeding, ulcers, perforated use an otoscope exudate. The nasal gray in clients with
with a short
septum, or polyps. septum is intact and free allergies. Nasal mucosa is
wide-tip
attachment or of ulcers or perforations. red and swollen with upper
you can also use Turbinates are dark pink respiratory infection.
a nasal speculum (redder than oral
and penlight (Fig. mucosa), moist, and free
18-18). of lesions.
____________
Use your
nondominant
hand to stabilize
and gently tilt the
client’s head
back. Insert the
short wide tip of
the otoscope into
the client’s nostril
without touching
the sensitive
nasal septum
Slowly direct the
otoscope back
and up to view
the nasal
mucosa, nasal
septum, the
inferior and
middle
turbinates, and
the nasal
passage (the
narrow space
between the
septum and the
turbinates).
Sinuses

1. Palpate the sinuses for Nurse can Frontal and maxillary Frontal or maxillary sinuses
tenderness. examine the sinuses are nontender to are tender to palpation in
sinuses through palpation, and no clients with allergies or
palpation,
1.B Palpating the frontal crepitus is evident. acute bacterial
percussion, and
sinuses. transillumination. rhinosinusitis. If the client
Palpate the has a large amount of
frontal sinuses by exudate, you may feel
using your crepitus upon palpation over
thumbs to press the maxillary sinuses.
up on the brow
on each side of
nose.

Palpate the
maxillary sinuses
by pressing with
thumbs up on the
maxillary sinuses
1.C Palpating the maxillary
sinuses

2. Percuss and transilluminate 2. B The sinuses are not 2.B The frontal and
the sinuses for air versus fluid tender on percussion. maxillary sinuses are tender
or pus. upon percussion in clients
2.C A red glow with allergies or sinus
2. B Percuss the sinuses. transilluminates the infection.
Lightly tap (percuss) over the frontal sinuses. This
frontal sinuses and o indicates a normal, 2.C Absence of a red glow
air-filled sinus. usually indicates a sinus
2.C Transilluminate the filled with fluid or pus.
sinuses. If sinus tenderness A red glow
was detected during palpation transilluminates the Absence of a red glow
and percussion, maxillary sinuses. The usually indicates a sinus
transillumination will let you see red glow will be seen on filled with fluid, pus, or
if the sinuses are filled with fluid the hard palate. thick mucus
or pus. Transilluminate the
frontal sinuses by holding a
strong, narrow light source
snugly under the eyebrows (the
room should be dark). Repeat
this technique for the other
frontal sinus

Transilluminate the maxillary

sinuses by holding a strong,
narrow light source over the
maxillary sinus and asking the
client to open his or her mouth.
Repeat this technique for the
other maxillary sinus
 Positioning for
transillumination of frontal
sinuses; note the red glow.

Positioning for
transillumination of maxillary
sinuses. Observe for a dim
red glow on the hard palate.

Abnormal Findings: Page 379-367