ASSESSING THE MOUTH AND OROPHARYN

PLANNING
If possible, arrange for the client to sit with the head against a firm surface such as a headrest or examination table. This makes it easier for the client to hold the head still during the examination. Equipment Clean gloves Tongue depressor 2x2 gauze pads Penlight

Delegation
Assessment of the mouth and oropharynx is not delegated to UAP. However, many aspects are observed during usual care and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse.

IMPLEMENTATION
Performance 1. Prior to performing the procedure, introduce self and verify the client's Identity using agency protocol. Explain to the client what you are going to do why it is necessary, and how he or she can cooperate. Discuss flow the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: routine pattern of dental care, last visit to dentist; length of time ulcers or other lesions have been present; denture discomfort; medications client is receiving. 5. Position the client comfortably. seated if possible.

ASSESSMENT NORMAL FINDINGS LIPS AND BUCCAL MUCOSA

6. Inspect the outer lips for symmetry of contour, color, and texture. Ask the client to purse the lips as if to whistle. Uniform pink color (darker, e.g., bluish hue, in Mediterranean groups and dark-skinned clients) Soft, moist smooth texture Symmetry of contour Ability to purse lips

DEVIATIONS FROM NORMAL

Pallor; cyanosis Blisters; generalized or localized swelling; fissures, crusts, or scales (may result from excessive moisture, nutritional deficiency, or fluid deficit) Inability to purse lips (may indicate facial nerve damage) Pallor; leukoplakia (white patches), red, bleeding Excessive dryness Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules

7. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions.

Uniform pink. color (freckled brown pigmentation in darkskinned clients) Moist, smooth, soft, glistening and elastic texture (drier oral mucosa in elderly due to decreased salivation)

 Apply clean gloves. Ask the client to relax the mouth and for better visualization, pull the lip outward and away from the teeth. Grasp the lip on each side between the thumb and index finger. 1 Palpate any lesions for size, tenderness, and consistency. Inspect the front teeth and gums.

TEETH AND GUMS

8. Inspect the teeth and gums while examining the inner lips and buccal mucosa. Ask the client to open the mouth. Using a tongue depressor, retract The cheek. 2 View the surface buccal mucosa from top to bottom and back to front. A flashlight or penlight will help illuminate the surface. Repeat the procedure for the other side. 32 adult teeth Smooth, white, shiny tooth enamel Pink gums (bluish or brown patches in dark-skinned clients) Moist, firm texture to gums No retraction of gums (pulling away from the teeth)
Missing teeth; ill-fitting dentures

Brown or black discoloration of the enamel (may indicate staining or the presence of caries)
Excessively red gums Spongy texture; bleeding; tenderness (may indicate periodontal disease) _ Receding atrophied gums; swelling that partially covers the teeth

 Ask the client to open the mouth again. Using a penlight to assist visualization, move a finger along the inside cheek. Another finger may be moved outside the cheek. Examine the back teeth. For proper vision of the molars, use the index fingers of both hands to retract the cheek. 3 Ask the client to relax the lips and first close, then open, the jaw. Rationale: Closing the jaw assists in observation of tooth alignment and loss of teeth; opening the jaw assists in observation of dental fillings and caries. Observe the number of teeth, tooth color, the state of fillings, dental caries, and tartar along the base of the teeth. Note the presence and fit of partial or complete dentures.

 Inspect the gums around the molars. Observe for bleeding, color, retraction (pulling away from the teeth), edema, and lesions.' Assess the texture of the gums by gently pressing the gum tissue with a tongue depressor. 9. Inspect the dentures. Smooth, intact dentures Ask the client to remove complete or partial dentures. Inspect their condition, noting in particular broken or worn areas. fitting dentures; irritated and excoriated area under dentures

Tongue/Floor of the Mouth

10. Inspect the surface of the tongue for position; color, and texture. Ask the client to protrude. the tongue: Central, position Pink color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae (taste buds) Deviated from center (may indicate damage to hypoglossal [twelfth cranial] nerve); excessive trembling. Smooth red tongue (may indicate iron, vitamin B12 or vitamin B3 deficiency) Dry, furry tongue (associated with fluid deficit), white coating (may be oral yeast infection) Nodes, ulcerations, discolorations (white or red areas); areas of tenderness

11. Inspect tongue movement. Ask the client to roll the tongue upward and Move it from side to side. 12. Inspect the base of the tongue, the mouth floor, and the frenulum. Ask the client to place the tip of the tongue against the roof of the mouth. 13. Palpate the tongue and floor of the mouth for any nodules, lumps, or excoriated areas. To palpate the tongue, use a piece of gauze to grasp its tip (stabilize it), and with the index finger of your other hand, palpate the back of the tongue, its borders, and its base. 4 To assess function of the glossopharyngeal and hypoglossal nerves, see the neurologic assessment, later, in this chapter,

Moves freely; no tenderness

Restricted mobility

Smooth tongue base with prominent veins

Swelling ulceration

Smooth with no palpable nodules

Swelling nodules

SALIVARY GLANDS 14. Inspect salivary duct openings for any swelling or redness, PALATES AND UVULA 15. inspect the hard and soft palate for color, shape, texture, and the presence of bony prominences. Ask the client to open the mouth wide and tilt the head backward. Then, depress tongue with a tongue depressor as necessary, and use a penlight for appropriate visualization. 16. 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.

Same as color of buccal mucosa and floor of mouth Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture

Inflammation (redness and swelling) Discoloration (e.g., jaundice or pallor) Palates the same color Irritations Exostoses (bony growths) growing from the hard palate

Positioned in midline of soft palate

Deviation to one side from tumor or trauma; immobility, (may indicate, damage to trigeminal [fifth cranial] nerve or vagus [tenth cranial] nerve)

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 depressor against the tongue on the same side about halfway back while the client tilts the head back and opens the mouth wide, Use a penlight for illumination, if needed. 18. inspect the tonsils (behind the fauces) for color, discharge, and size:

presence of lesions, pla drainage

Pink and smooth , No discharge Of normal size or not visible Grade I (normal): The tonsils are behind the tonsillar pillars (the soft structures supporting the soft palate).

Inflamed Presence of discharge Swollen

Grade 2: The tonsils a between the piilars and

uvula." . Grade 3: The tonsils t

Present 19. Elicit the gag reflex by pressing the posterior tongue with a tongue depressor.

uvula grade 4: One or both extend to the midline o

oropharynx.

Absent-may indicate pr with glossopharyngeal (ninth cranial) or vagus (tenth cranial) nerves

20. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

20. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. EVALUATION Perform a detailed follow-up examination of neurological and other systems based on findings that deviated, from expected or normal for the client. Relate findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.