Assessment of the Mouth and Throat

Introduction

• Presenter: Maris
• Resources:
  • Health assessment flashcards available at leveluprn.com
  • Digital flashcards available via Flashables

Assessing the Mouth

• Key Features to Assess:
  • Symmetry, color, size, shape
  • Important to check mucous membranes:
    • Should be pink and moist
    • Watch for dryness, cracking, paleness, redness, jaundice, or cyanosis
  • Mucous membranes provide insights into integumentary changes, especially for non-fair skin tones

Assessing the Throat

• Key Features to Assess:
  • Uvula:
    • Should rise midline during phonation (e.g., patient saying "ah")
  • Palate:
    • Check both hard and soft palate for intactness, smoothness, and pinkness
• Palatine Tonsils:
  • Assess location and size
  • Evaluate symmetry and swelling
  • Tonsil grading:
    • 1+ and 2+ are expected findings in non-surgically absent tonsils
• Cranial Nerves:
  • Assessment possible for nerves 9 (Glossopharyngeal), 10 (Vagus), and 12 (Hypoglossal)

Tonsils: Grading and Implications

• Tonsil Grading Scale:
  • 0: Absent (surgically removed)
  • 1+: Occupying up to 25% of oropharynx
  • 2+: Occupying 26-50% of oropharynx (considered normal)
  • 3+: Occupying 51-75%, often due to acute infections
  • 4+: Occupying more than 75% or touching (risk for airway compromise)
• Clinical Significance:
  • 4+ tonsils pose a risk for airway blockage
  • Airway management and protection become priorities in patients with significant tonsil enlargement

Unexpected Findings

• Dehydration Indicators:
  • Dry or cracked lips/mucosa suggest dehydration
• Relevance of Tonsil Size:
  • Larger than expected tonsils (3+ or 4+) are often due to infections or underlying conditions

Personal Experience

• Maris shared her experience with 4+ tonsils:
  • Frequent strep throat and sore throat
  • Post-surgery improvement: Rare strep throat occurrences
  • Similar condition observed in her daughter

Conclusion

• Importance of tonsil assessment in nursing practice
• Encouragement to review and use provided resources for better understanding

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Quiz Recap

• Expected Tonsil Finding: 1+ or 2+
• Description for 75%+ Occupancy: 4+ tonsils.