Question

Module 06 Lab Assignment – Documentation of an Assessment of Nose, Mouth, Throat, and Neck

You will perform a history of a nose, mouth, throat, or neck problem that your instructor has provided you or one that you have experienced, and you will perform an assessment including nose, mouth, throat, and neck. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Nose, Mouth, Throat, and Neck Assignment

Answer 1

Assesment of Nose

The examination of the nose includes inspection of external and internal structures. Inspection of the nasal passage through an otoscope allows only for examination of the vestibule, anterior portion of the septum, and the inferior and middle turbinates.

Inspect and palpate the client nose and sinuses. The structures assessed include the external nose,vestibule, nasal mucosa, septum, turbinates, nasal canals, and sinuses. Function of the first cranial nerve is usually not tetsted unless a deficit in the sense of smell is reported or suspected.

Inspection

Using the otoscope, note any swelling, discharge, bleeding or foreign bodies.

Palpation

Checking the sinuses, patient should feel firm pressure but no pain.

What is considered an abnormality

* Pain

* Trauma

* Sores or lesions

* Epistaxis

* Allergies

* Discharge

Expamle:

Epistaxis may result from irritation, trauma, infection,foreign bodies or tumors.

Self Treatmet: Sitting upright, leaning slightly forward and pinching both nostrils shut for 5-10 minutes may help stop nose bleed.

Medical Treatment: Treatments to be considered include topical vaso constriction, chemical cautery, electro cautery, nasal packing, posterior gauze packing, use of a balloon system (including a modified foley catheter) and arterial ligation or embolization.

Assesment of Mouth

A mouth assessment is performed as part of a patients's health assessment. The mouth is the beginning of the digestive system and a substantial part of the respiratory tract. Before an assessment of the mouth, the patient is advised to remove any dentures.

Inspects the lips for color, symmetry, moisture, and texture. Inspect the teeth for alignment , color, number, surface characteristic and stability. Note the oder of the breath as well.

Abnormal findings include swelling, cyanosis, paleness, dryness, bleeding or discoloration. Diseases include leukoplakia, giingival hyperplasia, gingivitis, periodontitis and aphthous ulcer.

Expamle:

Gingivitis : is a common and mild form of gum disease that cause irritation, redness and swelling. It can lead to much more serious gum disease called periodontitis and tooth loss.

The most common cause of gingivitis is poor oral hygiene. Good oral health habits, such as brushing atleast twice a day, flossing daily and getting regular dental checkups can help prevent and reverse gingivitis.

Medical Management :

Antibiotics - treatment with antibiotics, such as metronidazole or amoxicillin.

Analgesics : Paracetamol and Ibuprofen

Assessment of Throat

Throat

* Oropharynx

* Tonsils

* Nasopharynx

Inspection of the Throat

* Position, size, color and general appearance of tonsils and uvula

* Gag reflex

* Color of Oropharynx

* Presence of swelling, exudate, lesions

Abnormal findings include Halitosis, oral lesion, swelling, oral thrush,ulceration, difficulty in swallowing, hoarseness of voice. Tonsils and uvula are red and swollen.

Example:

Tonsillitis : inflamation or infection of the tonsils is medically termed as tonsillitis. Tonsils are protective glands that are situated on both sides in the throat. Bacterial and viral infections can cause tonsillitis.

Medical Management:

Antibiotics : If tonsillitis is caused by a bacterial infection, prescribe a course of antibiotics. Pencillin prescribeed for tonsillitis caused by group A streptococcus.

Assessment of Neck

Begin inspection with observation of the head and neck for any gross abnormalities that would interfere with respiration. Note the odor of the breath and whether sputum is present. Note nasal flaring, breathing with pursed lips or cyanosis of the mucos membranes. Record the use of accessory muscles, such as flexion of the sternocleidomastoid muscle.

Abnormal findings include neck pain, neck strain, osteoarthritis, cervical spondylosis, spinal stenosis, poor posture etc