health module: throat

Which part of the throat is specifically responsible for preventing food and liquids from entering the trachea?

epiglottis

In the patient's electronic health record, the tonsils are graded as 4+. The tonsils would be:

Touching each other

Your assessment of a patient reveals that they have been experiencing dysphagia. Your subsequent assessments should address the risk of which complication?

Aspiration

the mouth and throat are the first part of the _______ system

digestive

why does the nurse assess the throat?

to assess the muscular passage, which serves as a channel for food and air

before the assessment, ask the patient about

• difficulty swallowing

• sores or lesions of the tongue

• current and past tobacco and alcohol consumption

the tongue manipulates solids and liquids in

mastication and deglutition

the tongue is involved in speech production and

taste

larynx

• located within the laryngopharynx

• consists of the:

  • epiglottis

  • esophagus

  • trachea

• voice box → houses vocal folds

tonsils

• collection of lymphoid tissues

• located posterior to the uvula

• small, pink, symmetrical

• may be large in size w/o being infected (children)

uvula is responsible for the

gag reflex

epiglottis

• flap-like structure

• rests at the superior of the trachea

• prevent liquid or food from entering the trachea during swallowing

esophagus

• fibromuscular tube

• connects the cavity of the mouth to the lower esophageal sphincter of the stomach

• transports food & liquid from mouth → stomach

• located posterior to the trachea

trachea

• ribbed tube

• connects the pharynx & larynx to the lungs

• epiglottis sits atop the trachea

  • closes off the trachea to prevent food or liquid from entering

• located: anterior to the esophagus

tongue

muscle tissue that covers the floor of the mouth

what is the necessary equipment to assess the throat?

• tongue depressor / tongue blade

• penlight

• gloves

if tonsils are present, they should be graded to size on a

scale

1+

visible

2+

between tonsillar pillars and uvula

3+

touching uvula

4+

touching each other

dysphagia/odynophagia

difficulty to swallow

dysphagia/odynophagia can result from:

• tumors: pharynx, esophagus, surrounding structures

• narrowing of esophagus

• inflammation secondary to GERD

• anxiety

• poorly fitting dentures or poor dental health in general

• neuromuscular diseases (stroke, parkinson’s disease, dementia)

• cancer

• head injury

• growth/lesions in respiratory tract / enlargement of surrounding glands / tissues

dysphagia increases risk of:

• reduction of nutritional intake

• aspiration: incomplete closure of vocal cords / impeded movement of epiglottis

sore throat and irritation can be related to:

• viral infections

  • flu

  • colds

  • measles

  • chicken pox

  • whooping cough

  • croup

  • infectious mononucleosis

• bacterial infections

  • strep throat

  • fever

  • pharyngeal exudates

  • anterior lymphadenopathy

  • no cough

• allergies

  • pollen

  • molds

  • cat/dog dander

  • house dust

• irritation

  • dry heat

  • chronic stuffy nose

  • pollutants

  • voice straining

• gerd

• tumors of throat, tongue, larynx

• hiv infection

• cancer

hoarseness

altered quality of the voice

hoarseness can result from:

• overuse of voice

• acute infections

• smoking

• inflammation from allergen or irritant exposure

• voice abuse

• hypothyroidism

• chronic infections (tuberculosis)

• tumors

• upper respiratory infections

• cancer of larynx

• gerd

• lesions of the throat

pharyngitis

• chronic hypertrophy of tonsils or adenoids

• recurrent strep infection

• throat appears bright red & exudes white or yellow fluid

sleep apnea

• increased risk for

  • hypertension

  • stroke

  • heart attack

  • motor vehicle accidents

  • squeezed appearance of the general population of the throat

strep throat

• red and white patches in throat

• difficulty swallowing

• tender or swollen neck lymph glands

• red and enlarged tonsils

hypertrophy of tonsils or adenoids

airway obstruction or sleep apnea, recurrent infections

cough

• sinus drainage

• allergen irritant exposure

• chronic sinusitis

• lung pathology

• asthma

• gerd

mucosal inflammation

infection or allergy

recurrent infections

• leave scars or crypts in tonsils

• collect food and oral debris

• appear as white crud like material

neoplasm

asymmetric tonsillar enlargement

peritonsillar abscess or “quinsy”

• collection of fluid in anterior tonsillar pillar

• increasing unilateral pain

• deviated uvula

• hot potato voice (sounds like person is speaking w/ mouthful of hot potatoes; found: epiglottis)

• dysphagia

• trismus: difficulty opening the mouth

aspiration

incomplete closure of vocal cords or impeded movement of epiglottis

oral cancer (late signs)

• difficulty chewing

• swallowing

• moving tongue or jaws

malocclusion

can cause difficulty chewing or swallowing

A client presents to the health care clinic with reports of two-day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute pain related to sore throat

Rationale: The client describes pain of two-day duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for fluid volume deficit.