Which findings should the nurse note as normal when assessing the mouth and throat of an infant?
Usually the client is positioned sitting upright; newborns or young children can be held by their parent/caregiver. Wear gloves because this assessment involves contact with body fluids from the mucus membranes. You will also need a tongue depressor and a penlight. Show
Inspection of LipsInspect the lips for swelling, colour, lesions, or malformations. Also inspect the lips for moisture and texture, which are interrelated. The steps for this are as follows: 1. Identify any presence and location of swelling and redness.
2. Note the colour.
3. Identify the presence, location, size, and description of any lesions and malformations, including the colour and presence of any discharge.
4. Note the moisture and texture.
Inspection of Oral MucosaSystematically inspect all parts of the mucosa. Shine a penlight in the mouth to illuminate the area. You can ask the client to pull their top lip up and then their bottom lip down, or use a gloved hand or tongue depressor to perform this action so you can inspect the mucosa on the inside of the lips. Most clients can open their mouth wide and tip their head back so that you can observe the palate and also put the tip of their tongue behind their front teeth so that you can observe the floor of the mouth and under the tongue. You can use a tongue depressor to expose the buccal mucosa. To expose the pharynx, ask the client to stick their tongue out and say “ahhh” or pretend to yawn. You may need to use the tongue depressor to press the tongue down. If so, avoid using it in the middle of the tongue as this may elicit a gag reflex. Inspection of the mucosa of the oral cavity includes observing the insides of the lips and the buccal mucosa (inside of checks), the tongue, the floor of mouth (under the tongue) and the hard and soft palate, the pharynx, and salivary glands. See Figure 5.2 for anatomical locations of the oral cavity. Figure 5.2: Anatomical locations of oral cavity Use the following steps: 1. Note moisture or dryness.
2. Inspect the mucosa of the lips and buccal mucosa for colour, lesions, swelling, and nodules.
3. Inspect the tongue, floor of the mouth, and hard and soft palate for colour, lesions, swelling, nodules, and malformations.
4. Inspect the pharynx for colour, swelling, lesions, and nodules, and describe the tonsils.
5. Note the findings.
Teeth and GumsAssessment of the teeth and gums includes inspection and palpation. Use a penlight to illuminate the back of the mouth. Begin by asking the client to smile to expose the teeth, and use a tongue depressor or your gloved finger to expose the gums and the back teeth. Remember: your assessment of the teeth and gums does not replace a routine dental assessment. Assessment of the teeth and gums involves the following steps: 1. Inspect the colour of the teeth.
2. Inspect for missing, chipped, or broken teeth.
3. Inspect for missing or loose fillings.
4. Inspect the gums for colour, swelling, and bleeding.
5. Palpate for loose teeth and palpate the gums for pain.
6. Note the findings.
Respond immediately if a client has swollen lips consistent with other signs of anaphylaxis (e.g., hives, pruritus, dyspnea, dysphagia, tachycardia, hypotension). If so, did they just receive a vaccine or were they exposed to an allergen (e.g., a food or bee sting) that they are allergic to? If so, call for help and notify the physician/nurse practitioner immediately. If you are permitted to do so, administer epinephrine. Continue to monitor the client because anaphylaxis is life-threatening. If the client shows signs of cyanosis or pallor, perform a primary survey to assess for clinical deterioration. Usually a client with discolourations in lips or mucous membranes will have other respiratory- or cardiovascular-related cues such as dyspnea, low oxygen saturation, tachypnea, and/or angina. If the client has dry and cracked lips and dry mucous membranes with no other signs of dehydration, increasing fluid intake will usually resolve the issue. This could involve administering a rehydration solution that contains electrolytes; other forms of fluid intake can include ice chips (or popsicles for children), especially if the client is nauseated. Further assessment and intervention may be needed if signs of more advanced dehydration are observed: poor skin turgor, oliguria, dark urine, altered level of consciousness, tachycardia, and hypotension. With newborns and infants, you should assess for sunken fontanelles, decreased wet diapers, and drowsiness. An infant may also show reduced or absent tears when crying. For a hospitalized client with signs of advanced dehydration, perform a primary survey to assess for signs of clinical deterioration, increase intravenous fluids to rehydrate, and treat any other related symptoms such as diarrhea, vomiting, and fever. Report any cues that suggest clinical deterioration to the physician/nurse practitioner. Lesions, nodules, discolourations, and enlarged tonsils are not usually urgent priorities for treatment, but you should complete a focused assessment (subjective and objective) to document them and report your findings to the physician/nurse practitioner. If tonsils are enlarged, you should assess the colour and the presence of exudate. If tonsils are touching the uvula or each other, you should assess for any breathing or swallowing issues. These associated symptoms require prompt intervention. Any issues associated with teeth (particularly loose, broken, or chipped teeth or missing or loose fillings) and gums usually require referral to a dentist. You should be concerned when the client indicates they have a lesion in their mouth that will not heal or a lump. These can sometimes be associated with oral cancers, which are commonly found on the floor of the mouth, inferior side of tongue, the buccal mucosa or the soft palate. A common cause of oral cancers is tobacco use. This image shows a throat infection called tonsillitis. Evidence of the infection is shown through swelling, redness and white patches (pus) on the tonsils. This pus consists of dead bacteria, white blood cells, and cellular debris Image from: This work has been released into the public domain by its author, Michaelbladon at English Wikipedia. This applies worldwide. Michaelbladon grants anyone the right to use this work for any purpose, without any conditions, unless such conditions are required by law. Which findings should the nurse note as normal on palpation of the head?Inspection and Palpation
The skull should fill symmetrical and smooth. There should be no tenderness on palpation. Inspect the face for symmetry with the eyebrows, the nose, and the mouth. Make note of any abnormal facial features or swelling or involuntary ticks of the muscles.
Which nose assessment findings would be considered abnormal?Normal findings might be documented as: “External nose is symmetrical with no discolouration, swelling or malformations. Nasal mucosa is pinkish red with no discharge/bleeding, swelling, malformations or foreign bodies.” Abnormal findings might be documented as: “Bright red nasal mucosa with purulent discharge.”
Which assessment findings would the nurse consider abnormal?Abnormal findings include: Crepitus, swelling , pain/tenderness, limited or no range of motion, hyperactive response, pain, tenderness, no response, hyperactive response.
What are 3 things to check when assessing the head?Examination of the head
Inspect the skin and scalp. Palpate skull (especially if patient complains of tenderness or recent trauma). Assess facial sensation and motor function.
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