Nursing Assessment of Mouth, Throat, and Gas Exchange

Importance of Mouth Assessment

• The mouth is the entry point of the digestive system.
• Oral health directly influences nutrition and speech.

Assessment Procedures

• Hygiene Protocol:
  • Wash hands.
  • Correctly identify the patient.
  • Ensure patient comfort and safety.
• Inquiry Before Assessment:
  • Toothaches.
  • Altered taste.
  • Sores, lesions, or bleeding gums.
  • Tobacco and alcohol consumption history.

Assessment of Lips

• Check for:
  • Color:
  • Pallor may indicate anemia.
  • Bright red suggests possible other conditions.
  • Dryness and lesions:
  • Dryness or cracking can indicate dehydration.
  • Lesions or ulcers may suggest viral infections.
• Abnormal Findings:
  • Circumolar pallor: anemia, shock.
  • Bluish lips: hypoxia or cold.
  • Reddish lips: diabetic ketoacidosis, carbon monoxide poisoning.

Assessment of Teeth

• Inspect for:
  • Color, condition, and cleanliness.
  • Absence of decay and presence of dentures.
• Normal Findings:
  • Adults: 32 teeth (16 in each quadrant).
  • Children (age 2.5): 20 deciduous teeth.
• Abnormal Findings:
  • Discoloration: yellow/brown indicates smoking or high fluoride intake.
  • Stains or spots due to antibiotics or trauma.
  • Cavities can appear as chalky white areas that darken.

Assessment of the Tongue

• Inspect:
  • Symmetry and position (should be midline).
  • Color and surface texture (pink, moist, with papillae).
  • Thin white coating may be present.
• Abnormal Findings:
  • Smooth, shiny tongue: vitamin deficiencies (B12, niacin).
  • Whitish patches: thrush (oral candidiasis).
  • Enlarged tongue: hypothyroidism, down syndrome.

Assessment of Cheeks and Interior Structures

• Use a tongue blade to hold open the cheek for examination.

Throat Assessment

• Procedure:
  • Ask patient to open mouth and tilt head back.
  • Use a tongue depressor and light to inspect soft palate, uvula, and tonsils.
  • Assess for:
  • Color and symmetry.
  • Swelling or ulceration.
• Tonsil Assessment: Size classifications:
  • 1+: visible.
  • 2+: between pillars and uvula.
  • 3+: touching uvula.
  • 4+: touching each other.
• Common Symptoms:
  • Dysphasia (difficulty swallowing): may result from tumors, anxiety, GERD.

Common Throat Issues

• Sore Throat: Sources may include:
  • Viral infections (influenza, colds).
  • Bacterial infections (strep throat).
• Hoarseness Causes:
  • Overuse of voice, infections, allergies, tumors.
• Assessment of Nose:
  • Functions: breathing, filtering air, sense of smell.
  • Inspect both surfaces, test for obstructions, palpate for tenderness.

Abnormal Findings in Nose

• Clear discharge: allergy or viral infection.
• Purulent discharge: bacterial infection.
• Raccoon eyes may indicate severe conditions (e.g., skull fractures).

Gas Exchange Overview

• Definition: The process of delivering oxygen to cells and removing carbon dioxide.
• Essential functions: integration between neurological, respiratory, and cardiovascular systems.
• Key Terms:
  • Ischemia: insufficient blood flow to tissues.
  • Hypoxia: inadequate oxygen at cellular level.
  • Anoxia: complete absence of oxygen.
• Consequences of Impaired Gas Exchange:
  • Symptoms: fatigue, tachycardia, tachypnea, and risk of death.

Objective Signs of Inadequate Oxygenation

• Observations:
  • Tripod positioning indicates distress.
  • Nasal flaring, intercostal retractions may occur.
• Risks:
  • Smoking is a significant risk factor.

Health Promotion

• Promote healthy behaviors to optimize gas exchange including smoking cessation and immunizations.
• Monitor signs of respiratory issues in high-risk populations.

Assessment of Cardiovascular System

• Heart Sounds:
  • Listen for S1 and S2 using diaphragm.
  • The locations for auscultation include:
  • Aortic area: 2nd intercostal space (right).
  • Pulmonic area: 2nd intercostal space (left).
  • Mitral area: 5th intercostal space (left).
• Pulses Assessment:
  • Carotid pulse should be strong and regular, ideally rated 2+.

Conclusion on Assessment Techniques

• Use systematic approaches such as inspection, palpation, and auscultation across different body systems (abdomen, heart, throat).
• Monitor vital signs and subjective data to guide further actions in clinical practice.