HEALTH ASSESSMENT 5.

Increased temperature of the body

(LECTURE) cells
PROCESS INVOLVED IN HEAT LOSS
1. Radiation
THE GENERAL SURVEY
2. Conduction
1. Physical Appearance
3. Convection
- Age
4. Evaporation
- Sex
FACTORS AFFECTING TEMPERATURE
- Level of Consciousness
1. Age
- Skin Color
2. Diurnal variations
- Facial Features
3. Exercise
- Over all
4. Hormones
2. Body Structure
5. Stress
- Stature
ALTERATION IN BODY TEMPERATURE
- Nutrition
1. Pyrexia
- Symmetry
2. Hyperpyrexia
- Posture
3. Hypothermia
- Position
TYPES OF FEVER
- Body Build, Contour 1. Intermittent Fever
3. Mobility 2. Remittent Fever
- Gait 3. Relapsing Fever
- Range of motion 4. Constant Fever
4. Behavior DECLINE OF FEVER
- Facial expression - Crisis or flush or defervescence
stage.
- Mood and affect
- Lysis
- Speech CLINICAL SIGNS OF FEVER
- Dress 1. Onset (cold or chill stage) of fever
- Personal hygiene 2. Course of Fever
3. Defervescence
MEASUREMENT METHODS OF TEMPERATURE-TAKING
1. Oral
1. Weight
2. Rectal
2. Height 3. Axillary
3. Body Mass Index 4. Tympanic
4. Waist-to-hip ratio
5. Vital Signs PULSE
FACTORS AFFECTING THE PULSE RATE
TEMPERATURE 1. Age
2. Sex/Gender
FACTORS AFFECTING THE BODY’S 3. Exercise
HEAT PRODUCTION 4. Fever
1. Basal Metabolic Rate 5. Medications
2. Muscle Activity 6. Hemorrhage
3. Thyroxine output 7. Stress
4. Epinephrine, norepinephrine and 8. Position changes
sympathetic stimulation

AV
1
PULSE SITES Assessing Blood Pressure
1. Temporal Special Considerations Among
2. Carotid Infants and Children
3. Apical a. General Survey
4. Brachial b. Measurement
5. Radial - Weight
6. Femoral - Length
7. Posterior tibial - Head circumference
8. Popliteal - Chest Circumference
9. Pedal (Dorsalis Pedis) c. Vital Signs
ASSESSMENT OF THE PULSE - Temperature
1. Rate - Pulse
2. Rhythm - Respiration
3. Volume - Blood pressure
4. Arterial Wall Elasticity
5. Presence/Absence of bilateral PAIN
equality Pain is the most common form of
discomfort that human beings may
BLOOD PRESSURE experience. It can have a significant impact
‒
BP = Cardiac Output x Total on the individual’s health including physical
Peripheral Resistance or C.O. x TPR well-being, mental status, social function
- Systolic Pressure and spiritual dimension. Pain is the fifth vital
- Diastolic Pressure
sign.
- Pulse Pressure
- Hypertension Pain is a sensation of physical or
- Hypotension mental hurt or suffering that causes distress
- Orthostatic Hypotension or agony to the one experiencing it.
DETERMINATION OF BLOOD PRESSURE
‒ Blood volume -It is whatever the patient says it is.
- Peripheral resistance -It exists whenever the patient says it
- Cardiac Output does.
- Elasticity or Compliance of Blood - It is subjective in nature. Only the
Vessels person experiencing it may describe
- Blood Viscosity it.
FACTORS AFFECTING BLOOD - It is protective because it provides a
PRESSURE warning signal for tissue injury. It
1. Age helps minimize injury and is often a
2. Exercise protective injury – prevention
3. Stress mechanism.
4. Race THEORIES OF PAIN
5. Obesity
6. Sex/Gender 1. Pattern Theory
7. Medications 2. Specificity Theory
8. Diurnal Variations 3. Gate Control
9. Disease Process 4. Affect Theory
5. Parallel Processing Model

AV
2
FACTORS INFLUENCING THE PAIN INITIAL PAIN ASSESSMENT
EXPERIENCE
1. Where is your pain?
2. When did your pain start?
1. Age 3. What does your pain feel like?
2. Sex 4. How much pain do you have now?
3. Childhood 5. What makes your pain better or worse?
4. Cultural Background 6. How does pain limit your function or
5. Psychological Factors activities?
7. How do you usually behave when you are in
6. Previous Experience pain? How would others know you are in
7. Religious Beliefs pain?
8. Expected Response 8. What does this pain mean to you? What do
9. Setting you think you are having pain
10. Diagnosis PQRSTU Pain Assessment
11. Physical/ Mental Health P-rovocative or Palliative
12. Knowledge / Understanding Q-uality or Quantity
R-egion or Radiation
- Pain Threshold S-everity Scale
- Pain Tolerance T-iming
- Pain Perception U-nderstand Patient’s Perceptionn of the
- Bradykinin Problem
- Hyperalgesia PAIN ASSESSMENT TOOLS
Initial Pain Assessment
The Brief Pain Inventory
PHYSIOLOGY OF PAIN INFANTS AND CHILDREN
Infants are incapable of “self-report” on
TYPES OF RESPONSES TO PAIN pain, but it is important to remember that
infants do feel pain
1. Involuntary Responses Children 2 years of age can report pain and
2. Voluntary Responses point to its location. However, they cannot
THREE STAGES OF PAIN RESPONSE rate pain intensity at this developmental
1. Activation level.
2. Rebound Be aware that some children will try to be
3. Adaptation “grown-up and brave” and often deny
CLASSIFICATION OF PAIN having pain in the presence of a stranger or
if they are fearful or receiving a “shot”
a. Types of Pain Rating scales can be introduced at 4-5
- Cutaneous or Superficial Pain years of age. The Wong-Baker FACES
- Somatic Pain Pain Rating Scale is one example. The
- Visceral Pain child is asked to choose a face that shows,
- Referred Pain “how much hurt do you have now?”
- Intractable Pain
- Phantom Pain ACUTE PAIN BEHAVIORS
- Radiating Pain
- Psychogenic pain Acute Pain Behaviors Acute Pain Responses
- Intermittent Pain
b. Location
Tachycardia
c. Duration Elevated BP
d. Character/Quality Cardiac Increased Myocardial
e. Intensity/Severity Oxygen demand
Increased Cardiac
f. Factors Relieve/Aggravate Pain Output
g. Effects of ADL

AV
3
 Hypoventilation Deviations from normal
Pulmonary Hypoxia 1. Pallor, cyanosis, jaundice, erythema
Decreased cough Definition of Terms
Atelectasis
1. Pallor – the absence of underlying
Nausea red tones in the skin; may be most
Gastrointestinal Vomiting readily seen in the buccal mucosa
Paralytic Ileus
Oliguria - Results from inadequate
circulating blood or
Renal Urinary Retention hemoglobin &
subsequent reduction in
Musculoskeletal Spasm
Joint Stiffness tissue oxygenation.
2. Cyanosis – bluish discoloration of
Endocrine Increased adrenergic the skin & mucous membranes
(Epinephrine) activity
caused by reduced oxygen in the
Central Nervous System Fear blood.
Anxiety 3. Jaundice – a yellowish color of the
Fatigue
sclera, mucous membranes, and or
Immune Impaired cellular skin.
Immunity 4. Erythema – a redness associated
Impaired wound healing
with a variety of skin rashes.
POORLY CONTROLLED CHRONIC PAIN B. Inspect uniformity of skin color.
- Depression Normal Findings
- Isolation 1. Generally uniform except in areas
- Limited mobility and function exposed to the sun; areas of lighter
- Confusion pigmentation (palms, lips, nail beds)
- Family distress in dark-skinned people
- Diminished quality of life Deviations from normal
CHRONIC PAIN BEHAVIORS 1. Areas of either hyperpigmentation or
- Infants hypopigmentation
- The aging adult C. Observe and palpate skin moisture.
NEUROSURGERY FOR RELIEF OF PAIN Normal Findings
- Neurotomy 1. Moisture in skin folds and the axillae
- Rhizotomy (varies with environmental
- Cordotomy temperature & humidity, body
- Tractotomy temperature, and activity
- Gyrectomy Deviations from normal
- Hypophysectomy 1. Excessive moisture (e.g., in
PAIN MODULATION hyperthermia) excessive dryness
- Endogenous opioids. (e.g., in dehydration)
- Enkephalins D. Palpate skin temperature. Compare
- Endorphins the two feet and the two hands, using
- Dynorphins the backs of your fingers.
Normal Findings
ASSESSING THE SKIN 1. Uniform; within normal range
A. Inspect skin color. (best assessed Deviations from normal
under natural light & on areas not 1. Generalized hyperthermia (e.g., in
exposed to the sun) fever)
Normal Findings 2. Generalized hypothermia (e.g., in
1. Varies from light to deep brown; from shock)
ruddy pink to light pink; from yellow
overtones to olive
AV
4
 3. Localized hyperthermia (e.g., in
infection)
4. Localized hypothermia (e.g., in
arteriosclerosis)
D. Note skin turgor. (fullness or elasticity)
by lifting and pinching the skin on an
extremity.
Normal Findings
1. When pinched, the skin springs back
to previous state
Deviations from normal
1. Skin stays pinched or tented or
moves back slowly (e.g., in
dehydration)
E. Document findings in the client record.
Draw location of skin lesions on body
surface diagrams.
ASSESSING THE HAIR
A. Inspect the evenness of growth over
the scalp
Normal Findings
1. Evenly distributed hair
Deviations from normal
1. Patches of hair loss (i.e., alopecia)
B. Inspect hair thickness or thinness.
Normal Findings
1. Thick hair
Deviations from normal
1. Very thin hair (e.g., in
hypothyroidism)
C. Inspect hair texture and oiliness.
Normal Findings
1. Silky, resilient skin
Deviations from normal
1. Brittle hair (e.g., hypothyroidism);
excessively oily or dry hair
E. Note presence of infections or
infestations by parting the hair in
several areas and checking behind the
ears and along the hairline at the neck.
Normal Findings
1. No infection or infestation
Deviations from normal
1. Flaking, sores, lice, nits (louse
eggs), & ringworm
F. Document findings in the client
record.
AV
ASSESSING THE NAILS
Definition of Terms
1. Spoon nail – the nail curves upward
from the nail bed. (also called
Koilonychia)
2. Clubbing – the angle between the
nail and the nail bed is 180° or
greater
3. Beau’s lines – are horizontal
depressions in the nail that can
result from injury or illness
4. Paronychia – is an inflammation of
the tissues surrounding the nails
(also called ingrown nails)
A. Inspect fingernail plate shape to
determine its curvature and angle.
Normal Findings
1. Convex curvature; angle of nail plate
about 160°
Deviations from normal
1. Spoon nail; clubbing (180° or
greater)
B. Inspect fingernail and toenail texture
Normal Findings
1. Smooth texture
Deviations from normal
1. Excessive thickness or thinness or
presence of grooves or furrows (e.g.
Beau’s lines)
C. Inspect fingernail and toenail bed
color.
Normal Findings
1. Highly vascular & pink in
light-skinned clients; dark-skinned
clients may have brown or black
pigmentation in longitudinal streaks.
Deviations from normal
1. Bluish or purplish tints (may reflect
cyanosis); pallor (may reflect poor
arterial circulation)
D. Inspect tissues surrounding nails
Normal Findings
1. Intact epidermis
Deviations from normal
1. Hangnails; paronychia
(inflammation).
5
E. Perform BLANCH TEST of capillary
refill. Press 2 or more nails between
your thumbs & index fingers; look for
blanching and return the pink color to
the nail bed.
Normal Findings
1. Prompt return of pink or usual color
(generally, less than 4 seconds)
Deviations from normal
1. Delayed return of pink or usual color
(may indicate circulatory impairment)
F. Document findings in the client record
ASSESSING THE SKULL AND FACE
Definition of Terms
1. Normocephalic – refers to a normal
head size
2. Exophthalmos – a protrusion of the
eyeballs with elevation of the upper
eyelids, resulting in a startled or
staring expression
3. Moon face – a round face with
reddened cheeks resulting from
increased adrenal hormone
production
A. Inspect the skull for size, shape, and
symmetry.
Normal Findings
1. Rounded (normocephalic &
symmetrical, frontal, parietal, and
occipital prominences) smooth skull
contour
Deviations from normal
1. Lack of symmetry; increase skull
size with more prominent nose and
forehead; longer mandible (may
indicate excessive growth hormone
or increased bone thickness)
B. Palpate the skull for nodules or
masses and depressions. Use a
gentle rotating motion with the fingertips.
Begin at the front & palpate down the
midline, then palpate each side of the
head.
Normal Findings
1. Smooth, uniform consistency;
absence of nodules or masses
Deviations from normal
1. Sebaceous cysts; local deformities
from trauma
AV
C. Inspect the facial features. (e.g.,
symmetry of structures & of the
distribution of hair)
Normal Findings
1. Symmetric or slightly asymmetrical
facial features; palpebral fissures
equal in size; symmetrical nasolabial
folds
Deviations from normal
1. Increased facial hair; thinning of
eyebrows; asymmetric features;
exophthalmos; myxedema facies;
moon face
D. Inspect the eyes for edema and
hollowness.
Normal Findings
1. No edema & hollowness
Deviations from normal
1. Periorbital edema
E. Note symmetry of facial movements.
- Ask the client to elevate the
eyebrows, frown, or lower the
eyebrows, close the eyes tightly, puff
the cheeks, and smile and show the
teeth.
- Ask the client to identify various
taste places on the tip of tongue –
sugar, salt and identify areas of
taste. (Cranial Nerve VII – Facial
Nerve)
Normal Findings
1. Symmetrical facial movement
Deviations from normal
1. Asymmetric facial movement (e.g.,
eye on affected side cannot close
completely); drooping of lower eyelid
& mouth; involuntary facial
movements (i.e., tics or tremors)
F. Document findings in the client record
ASSESSING THE EYE STRUCTURES
AND VISUAL ACUITY
Definition of Terms
1. Visual acuity – the degree of detail
the eye can discern in an image
2. Visual field – the area an individual
can see when looking straight ahead
3. Myopia – nearsightedness
4. Hyperopia – farsightedness
6
 5. Presbyopia – loss of elasticity of the
lens thus loss of ability to see close
objects
6. Astigmatism – an uneven curvature
of the cornea that prevents
horizontal & vertical rays from
focusing on the retina
7. Conjunctivitis – inflammation of the
bulbar & palpebral conjunctiva
8. Dacryocystitis – inflammation of
the lacrimal sac
9. Hordeolum – is a redness, swelling,
tenderness of the hair follicle &
glands that empty at the edge of the
eyelids
10. Iritis – inflammation of the iris
11. Cataracts – the opacity of the lens
or its capsule
12. Glaucoma – disturbance in the
circulation of aqueous fluid which
causes increase intraocular pressure
13. Mydriasis – enlarged pupils
14. Miosis – constricted pupils
15. Anisocoria – unequal pupils
A. Inspect the eyebrows for hair distribution
and alignment and for skin quality and
movement. (ask client to raise & lower
the eyebrows)
B. Inspect the eyelashes for evenness of
distribution and direction of curl.
Normal Findings
1. Equally distributed; curled slightly
outward
Deviations from normal
1. Turned inward
C. Inspect the eyelids for surface
characteristics (e.g., skin quality &
texture), position in relation to the
cornea, ability to blink, and frequency of
blinking. For proper visual examination
of the upper eyelids, elevate the
eyebrows with your thumb & index finger
& have the client close the eyes. Inspect
the lower eyelids while the client’s eyes
are closed. (Cranial Nerve VI –
Trigeminal Nerve)
Normal Findings
1. Skin intact; no discharge; no
discoloration.
AV
2. Lids closed symmetrically
3. Approximately 15 – 20 involuntary
blinks per minute; bilateral blinking
4. When lids open, no visible sclera
above corneas & upper & lower
borders of cornea are slightly
covered
Deviations from normal
1. Redness, swelling, flaking, crusting,
plaques, discharge, nodules, lesions
2. Lids close asymmetrically,
incompletely, or painfully
3. Rapid, monocular, absent, or
infrequent blinking
4. Ptosis, ectropion, entropion; rim of
sclera visible between lid & iris
D. Inspect the bulbar conjunctiva (that
lying over the sclera) for color, texture,
and the presence of lesions. Retract the
eyelids with your thumbs & index
fingers, exerting pressure over the upper
& lower bony orbits, and ask the client to
look up, down, & from side to side
Normal Findings
1. Transparent; capillaries sometimes
evident; sclera appears white
(yellowish in dark-skinned clients)
Deviations from normal
1. Jaundiced sclera (e.g., in liver
disease); excessively pale sclera
(e.g., in anemia); reddened sclera;
lesions or nodules (may indicate
damage mechanical, chemical,
allergenic, or bacterial agents).
E. Inspect the palpebral conjunctiva
(that lining the eyelids) by everting the
lids. Note color, texture, & presence of
lesions. Evert both lower lids, & ask the
client to look up. Then gently retract the
lower lids with the index fingers.
Normal Findings
1. Shiny, smooth, and pink or red
Deviations from normal
1. Extremely pale (possible anemia);
extremely red (inflammation);
nodules or other lesions.
F. Inspect and palpate the lacrimal
7
 gland.
Normal Findings
1. No edema or tenderness over
lacrimal gland
Deviations from normal
1. Swelling or tenderness over lacrimal
gland
G. Inspect and palpate the lacrimal sac
and nasolacrimal duct.
H. Inspect the cornea for clarity and
texture. Ask the client to look straight
ahead. Hold a penlight at an oblique
angle to the eye, and move the light
slowly across the corneal surface.
Normal Findings
1. Transparent, shiny, & smooth;
details of the iris are visible
2. In older people, a thin grayish white
ring around the margin, called arcus
senilis, may be evident
Deviations from normal
1. Arcus senilis in clients under age 40
is abnormal
I. Inspect the anterior chamber for
transparency and depth. Use the
same oblique lighting used when testing
the cornea.
Normal Findings
1. Transparent
2. No shadows of light on iris
3. Depth of about 3mm
Deviations from normal
1. Cloudy
2. Crescent-shaped shadows on far
side of iris
3. Shallow chamber (possible
glaucoma)
J. Inspect the pupils for color, shape,
and symmetry of size.
Normal Findings
1. Black in color; equal in size;
normally 3 – 7 mm in diameter;
round, smooth border, iris flat &
round
Deviations from normal
1. Cloudiness, mydriasis, miosis,
anisocoria; bulging of iris towards
cornea
K. Assess each pupil’s direct and
AV
consensual reaction to light to
determine the function of the third
(Oculomotor) & fourth (Trochlear) cranial
nerves
Normal Findings
1. Illuminated pupils constricts (direct
response)
2. Nonilluminated pupil constricts
(consensual response)
Deviations from normal
1. Neither pupil constricts
2. Unequal responses
3. Absent responses
L. Assess each pupil’s reaction to
accommodation.
Normal Findings
1. Pupils constrict when looking at near
objects; pupils dilate when looking at
far objects; pupil converge when
near object is moved toward nose
Deviations from normal
1. One or both pupils fails to constrict,
dilate, or converge
M. Assess peripheral visual fields to
determine the function of the retina &
neuronal visual pathways to the brain &
second (Optic) cranial nerve.
Normal Findings
1. When looking straight ahead, client
can see object in the periphery
Deviations from normal
1. Visual field smaller than normal
(possible glaucoma); one-half vision
in one or both eyes (indicates nerve
damage)
N. Extraocular Muscle Tests — Assess
six ocular movements to determine eye
alignment and coordination. These can
be performed on clients over 6 months
of age (Cranial Nerve III, IV, VI –
Oculomotor, Trochlear, Abducens
Nerve)
Normal Findings
1. Both eyes coordinated, move in
unison, with parallel alignment.
Deviations from normal
8
 1. Eye movements not coordinated or
parallel; one or both eyes fail to
follow a penlight in specific direction,
e.g., strabismus (cross-eye or
squint).
2. Nystagmus other than end point
(may indicate neurologic
impairment)
O. Visual Acuity — Assess near vision by
providing adequate lighting & asking the
client to read from a magazine or
newspaper held at a distance of 36 cm
(14in.). If the client normally wears
corrective lenses, the glasses or lenses
should be worn during the test
Normal Findings
1. Able to read newsprint
Deviations from normal
1. Difficulty reading newsprint unless
due to aging process
P. Assess distance vision. (Cranial Nerve
II – Optic Nerve)
Normal Findings
1. 20/20 vision on Snellen chart
Deviations from normal
1. Denominator of 40 or more on
Snellen chart with corrective lenses
Q. Document findings in the client record.
Assessing the Ears and Hearing
A. Inspect the auricles for color,
symmetry of size, and position. To
inspect position, note the level at which
the superior aspect of the auricle
attaches to the head in relation to the
eye.
Normal Findings
1. Color same as facial skin
2. Symmetrical
3. Auricle aligned with outer canthus of
eye, about 10° from vertical
Deviations from normal
1. Bluish color of earlobes (e.g.,
cyanosis)
2. Pallor (e.g., frostbite)
3. Excessive redness (inflammation or
fever)
4. Asymmetry
5.
6. Low-set ears (associated with a
AV
congenital abnormality, such as
Down syndrome).
B. Palpate the auricles for texture,
elasticity, and areas of tenderness.
- Gently pull the auricle upwards,
downward & backward Fold the
pinna forward (it should recoil) Push
in on the tragus Apply pressure to
the mastoid process
Normal Findings
1. Mobile, firm, and not tender; pinna
recoils after it is folded
Deviations from normal
1. Lesions (e.g., cysts); flaky, scaly skin
(e.g., seborrhea); tenderness when
moved or pressed (may indicate
inflammation or infection of external
ear)
C. Assess client’s response to normal
voice tones.
- If a client has difficulty hearing the
normal voice, proceed with the
following tests. Perform the watch
tick test. Have the client occlude one
ear. Out of the client’s sight, place a
ticking watch 2–3 cm (1–2 in) from
the unoccluded ear. Ask what the
client can hear. Repeat with the
other ear.
Normal Findings
1. Normal voice tones audible
2. Able to hear ticking in both ears
Deviations from normal
1. Normal voice tones not audible (e.g.,
request nurse to repeat words or
statements, leans towards the
speaker, turns head, cups the ear, or
speaks in a loud tone of voice).
2. Unable to hear ticking in one or both
ears
D. Assessment Tuning Fork Tests
Perform Weber test to assess bone
conduction Conduct Rinne test to
compare air conduction to bone
conduction
Normal Findings
1. Sound is heard in both ears or is
localized at the center of the head
(Weber negative)
2. Air-conducted (AC) hearing is
9
 greater that bone-conducted (BC)
hearing, i.e., AC > BC (positive
Rinne)
Deviations from normal
1. Sound is heard better in impaired
ear, indicating a bone-conductive
hearing loss or sound is heard better
in an ear without a problem,
indicating sensorineural disturbance
(Weber positive)
2. Bone conduction time is equal to or
longer the air conduction time, i.e.,
BC > AC or BC = AC (negative
Rinne; indicates a conductive
hearing loss)
E. Document findings in the client record.
ASSESSING THE NOSE AND
SINUSES
A. Inspect the external nose for any
deviations in shape, size, or color and
flaring, or discharge from the nares.
Normal Findings
1. Symmetric & straight
2. No discharge & flaring
3. Uniform color
Deviations from normal
1. Asymmetric
2. Discharge from nares
3. Localized areas of redness or presence
of skin lesions
B. Lightly palpate the external nose to
determine any areas of tenderness,
masses, and displacements of bone and
cartilage.
Normal Findings
1. Not tender; no lesions
Deviations from normal
1. Tenderness on palpation; presence
of lesions
C. Determine patency of both nasal
cavities.
- Ask the client to close the mouth,
exert pressure on one nares, and
breathe through the opposite nares.
Repeat the procedure to assess
patency of the opposite nares.
Normal Findings
1. Air moves freely as the client
breathes through the nares
Deviations from normal
AV
1. Air movement is restricted in one or
both nares
D. Inspect the nasal cavities using a
flashlight or a nasal speculum. Observe
the presence of redness, swelling,
growths, and discharge.
Normal Findings
1. Mucosa pink
2. Clear, watery discharge
3. No lesions
Deviations from normal
1. Mucosa red, edematous
2. Abnormal discharge (e.g., purulent)
3. Presence of lesions (e.g., polyps)
E. Inspect the nasal septum between the
nasal chambers.
Normal Findings
1. Nasal septum intact and in midline
Deviations from normal
1. Septum deviated to the right or to
the left
F. Facial Sinuses – Palpate the maxillary
and frontal sinuses for tenderness.
Normal Findings
1. Not tender
Deviations from normal
1. Tenderness in one or more sinuses
G. Document findings in the client record.
ASSESSING THE MOUTH AND
OROPHARYNX
A. Inspect the outer lips for symmetry of
contour, color, and texture. Ask the
client to purse the lips as if to whistle.
Normal Findings
1. Uniform pink color (darker, e.g.,
bluish hue, in Mediterranean groups,
and dark-skinned clients)
2. Soft, moist, smooth texture
3. Symmetry of contour
4. Ability to purse lips
Deviations from normal
1. Pallor; cyanosis
2. Blisters; generalized or localized
swelling; fissures, crusts, or scales
(may result from excessive moisture,
nutritional deficiency, or fluid deficit)
3. Inability to purse lips (indicative of
facial nerve damage).
B. Inspect and palpate the inner lips and
10
 buccal mucosa for color, moisture,
texture, and the presence of lesions.
Normal Findings
1. Uniform pink color (freckled brown
pigmentation in dark-skinned clients)
2. Moist, smooth, soft, glistening, &
elastic texture (drier oral mucosa in
elderly due to increased salivation)
Deviations from normal
1. Pallor; white patches (leukoplakia)
2. Excessive dryness
3. Mucosal cysts; irritations from
dentures; abrasions, ulcerations;
nodules.
C. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
Normal Findings
1. 32 adult teeth
2. Smooth, white, shiny tooth enamel
3. Pink gums (bluish or dark patches in
dark-skinned clients)
4. Moist, firm texture to gums
5. No retraction of gums (pulling away
from teeth
Deviations from normal
1. Missing teeth; ill-fitting dentures
2. Brown or black discoloration of the
enamel (may indicate staining or the
presence of caries)
3. Excessively red gums
4. Spongy texture; bleeding;
tenderness (may indicate
periodontal disease)
5. Receding, atrophied gums; swelling
that partially covers the teeth
D. Inspect the surface of the tongue for
position, color, and texture. Ask the
client to protrude the tongue.
Normal Findings
1. Central position
2. Pink color (some brown
pigmentation on tongue borders in
dark-skinned clients); moist; slightly
rough; thin whitish coating
3. Smooth, lateral margins; no lesions
4. Raised papillae (taste buds)
Deviations from normal
AV
1. Deviated from center [may indicate
damage to hypoglossal (12th)
nerve]; excessive trembling
2. Smooth red tongue (may indicate,
vitamin B12, or vitamin B3 deficiency
3. Dry, furry tongue (associated with
fluid deficit)
4. Nodes, ulcerations, discoloration
(white or red areas); areas of
tenderness
E. Inspect tongue movement. — Ask the
client to roll the tongue upward and
move it from side to side. (Cranial Nerve
XII – Hypoglossal Nerve assessment)
Normal Findings
1. Moves freely; no tenderness
Deviations from normal
1. Restricted mobility
F. 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.
Normal Findings
1. Smooth tongue base with prominent
veins
Deviations from normal
1. Swelling, ulcerations
G. Palpate the tongue and 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.
Normal Findings
1. Smooth with no palpable nodules
Deviations from normal
1. Restricted mobility
H. Ask client to close eyes and identify
taste by placing sugar, salt, etc. on the
posterior part of the tongue (Cranial
Nerve IX – Glossopharyngeal Nerve
assessment)
Normal Findings
1. Able to identify taste
Deviations from normal
1. Unable to identify taste.
I. Inspect the hard and soft palate for
11
 color, shape, texture, and the presence 1. Inflamed
of bony prominences. 2. Presence of discharge
- Ask the client to open his mouth 3. Swollen
wide and tilt his head backward. M. Elicit the gag reflex by pressing the
Then, depress tongue with a tongue posterior tongue with a tongue
blade as necessary, and use a depressor.
penlight for appropriate visualization. Normal Findings
Normal Findings 1. Present
1. Light pink, smooth, soft palate Deviations from normal
2. Lighter pink hard palate, more 1. Absent [may indicate problems with
irregular texture glossopharyngeal (9th) or vagus
Deviations from normal (10th) nerve]
1. Discoloration (e.g., jaundice or N. Document findings in the client record
pallor) using forms or checklists supplemented
2. Palate the same color by narratives notes when appropriate.
3. Irritations
4. Bony growth (exostoses) growing
J. 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.
Normal Findings
1. Positioned in midline of soft palate
Deviations from normal
1. Deviation to one side from tumor or
trauma; immobility [may indicate
damage to trigeminal nerve (5th) or
vagus (10th) nerve]
K. 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
his head back and opens the mouth
wide. Use a penlight for illumination, if
needed.
Normal Findings
1. Pink & smooth posterior wall
Deviations from normal
1. Reddened or edematous; presence
of lesions, plaques, or drainage
L. Inspect the tonsils for color,
discharge, and size.
Normal Findings
1. Pink and smooth
2. No discharge
3. Of normal size
Deviations from normal

AV
12