Tuon na

• Structures to be examined

  • Mouth
  • Throat
  • Nose
  • Sinus
• Preparing the client


  1. Ask the client to assume sitting position with head erect

  2. Explain specific structures you will be examining

  3. Remove dentures, retainer, or rubber bands on braces
• Equipment


  • Gloves (if there is mucous membrane)
  • 4x4 inch gauze pad
  • Penlight
  • Short, wide tipped speculum attached to the head of an otoscope
  • Tongue depressor
  • Nasal speculum
• When preparing to examine the nose and mouth

  • Be able to understand the relationship among the structures of the mouth, throat, nose, and sinuses
  • Know age related changes of the oral cavity and nasal sinus structures
  • Be aware of ethnocultural phenomena related to oral and nasal health
  • Refine examination technique
• Assessment Procedure: Mouth


  1. Inspect the lips. Observe lip consistency and color

  2. Inspect the teeth and gums. Ask the client to open mouth. Note the number, color, condition and alignment of the teeth

  3. Put on gloves and retract the client's lips, and check gums for color and consistency

  4. Inspect the Buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks to check color and consistency

  5. Inspect and palpate the tongue. Ask the client to stick out the tongue. Inspect for color, moisture, size and texture. Observe for fasciculations (fine tremors) and check for midline protrusion. Palpate any lesions present for induration (thickening)

  6. Assess the ventral surface of the tongue. Inspect and palpate the ventral surface of the tongue, frenulum, and the area under the tongue

  7. Observe the sides of the tongue; use a square gauze pad to hold the client's tongue to each side. Palpate any lesions, ulcers or nodules

  8. Check the strength of the tongue. Ask the client to press the tongue's tip against the inside of the cheek to resist pressure from your fingers. Repeat on the opposite cheek

  9. Check the anterior tongue's ability to taste. By placing drops of sugar and salty water on the tip and sides of tongue with a tongue depressor

  10. Inspect the hard (anterior) and soft (posterior) palates and uvula. Ask the client to open mouth wide while use a penlight to look at the roof. Observe color and integrity

  11. Note odor. While the mouth is open wide, note any unusual or foul odor

  12. Assess the uvula. Apply a tongue depressor to the tongue. And shine a penlight into the client's wide open mouth. Note the characteristics and positioning of the uvula. Ask client to say "aaaah" and watch for the uvula and soft palate to move

  13. Inspect the tonsil's color, size and presence of exudates or lesions

  14. Inspect the posterior pharyngeal wall. Shine the penlight on the back of the throat. Observe the color of the throat and note any exudates or lesions
• Normal Findings: Mouth


  • Lips and mouth are moist without lesion or swelling
  • (32)Thirty-two pearly white teeth with smooth surfaces and edges. Upper molar should rest directly on the lower molars and the front upper incisors should slightly override the lower incisors
  • No repaired or decayed areas, no missing teeth or appliances
  • Buccal mucosa should appear pink
  • Stenson's ducts are visible with flow of saliva and with no redness, swelling, pain, or moistness in area
  • Oral mucosa is often drier and more fragile in the older client
  • Tongue should be pink, moist, moderate in size with papillae (little protuberance) presence
  • Tongue's ventral surface is smooth. Shiny, pink or slightly pale with visible veins and no lesions
  • The older client may have varicose veins on the ventral surface of the tongue
  • The frenulum is midline; Wharton's ducts are visible with salivary flow or moistness in the area. The client has no swelling, redness, or pain
  • No lesions, ulcers, or nodules are apparent on the tongue
  • The tongue offer strong resistance
  • A person has an ability to taste between the salty and sweet
  • The hard palate is pale or whitish with firm, transverse rugae (wrinkled-like folds)
  • A bony protuberance in the midline of the hard palate, called a torus palatines is a normal variations seen more often in females
  • No unusual or foul odor is noted
  • The uvula is fleshy, solid structure that hangs freely in the midline
  • Tonsils may be present or absent. They are normally pink and symmetrical
  • Throat is normally pink without exudates or lesions
• Abnormal Findings: Mouth


  • Pallor around the lips. Swelling of the lips
  • Yellow or brownish color teeth. Presence of tooth decay
  • Missing teeth or malocclusion
  • Lesions, ulcers, nodules, or hypertrophied duct openings on either side of frenulum
  • Presence of chancre sores on the sides of the tongue
  • Decreased tongue strength
  • Loss of taste
  • A thick white plaques on the hard palate
  • Yellow tint to the hard palate
  • Fruity or acetone breath
  • A bifid uvula looks it is split in two or partially severed
  • Tonsils are red, enlarge, and covered with exudates
• Nose: Inspection and palpation

  1. Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness

  2. Check patency of airflow through the nostrils by occluding one nostril at a time and asking the client to sniff

  3. Inspect the internal nose. Use an otoscope with a short wide-tip attachment. View the nasal mucosa, nasal septum, the inferior and middle turbinates, and the nasal passage
• Normal Findings: Nose


  • Color is the same as the rest of the face; the nasal structures is smooth and symmetric ; no tenderness
  • Client is able to sniff through each nostril while other is occluded
  • The nasal mucosa is dark pink, moist, and free of exudates
  • The nasal septum is intact and free of ulcers or perforations
  • Turbinates are dark pink redder than oral mucosa, moist and free of lesions
• Abnormal Findings: Nose


  • Nasal tenderness on palpation
  • Cannot sniff through a nostril that is not occluded, nor can blow air through the nostril
  • Nasal mucosa is swollen and pale pink or bluish gray
  • Purulent nasal discharge
  • Bleeding (epistaxis) or crusting(flaking)
  • Ulcers of the nasal mucosa or perforated septum
• Sinuses: Palpation


  1. Palpate the sinuses by using thumb to press up on the brow on each side of the nose

  2. Palpate the maxillary sinuses by pressing with thumbs up on the maxillary sinuses
• Sinuses: Percussion


  1. Percuss the sinuses by slightly tap over the frontal sinuses and over the maxillary sinuses for tenderness

  2. Transilluminate the sinuses by holding a strong, narrow light source snugly under the eyebrows (the room should be dark). Use other hand to shield the light

  3. Transilluminate the maxillary sinuses by holding a strong, narrow light source over the maxillary sinus and asking the client to open the mouth
• Normal Findings: Sinuses


  • Frontal and maxillary sinuses are non tender to palpation and no crepitus is evident
  • The sinuses are not tender on percussion
  • A red glow transilluminate the frontal and maxillary sinuses. This indicates a normal air filled sinus
• Abnormal Findings: Sinuses


  • Frontal or maxillary sinuses are tender to palpation and percussion in clients with allergies
  • Absence of a red glow usually indicates a sinus filled with fluid, pus or thick mucus
• Perforated septum
• Equipment: Thoracic and Lung Assessment

  • Examination gown and drape
  • Gloves
  • Stethoscope
  • Light source
  • Mask
  • Skin marker
  • Metric ruler
• Thoracic Cage: Anterior


  • Anterior vertical lines
  • Posterior vertical lines
  • Lateral Vertical Lines
• Assessment Procedure: Inspection


  1. Inspect for nasal flaring and pursed lip breathing

  2. Observe color of face, lip, and chest

  3. Inspect color and shape of nails
• Normal Findings: Inspection


  • Nasal flaring is not observe
  • The client has evenly colored skin tone without unusual or prominent discoloration
  • Pink tones should be seen in the nail beds. There is normally a 160 degree angle between the nail base and the skin
• Abnormal Findings: Inspection


  • Nasal flaring with labored respirations
  • Purse lip breathing maybe seen in asthma
  • Cyanosis makes white skin appear blue-tinged
  • Purple complexion maybe seen in client's with COPD (Chronic Obstructive Pulmonary Disease or CHF(Congestive Heart Failure)
  • Pale or cyanotic nails may indicate hypoxia
• Posterior Thorax: Inspection, palpation and percussion

  1. Scapulae are symmetric and non protruding

  2. Shoulders and scapulae are at equal horizontal position

  3. Spinous process appears straight and thorax appears symmetric with ribs

  4. Kyphosis, an increase curve of the thoracic spine is common in older clients

  5. Expansion of the lower chest is noted during inspiration

  6. No tenderness, pain, or unusual sensations. Temperature should be equal bilaterally when palpated

  7. No palpable crepitus (clicking, cracking, creaking, crunching, grating or popping sound when a joint is moved)

  8. Skin and subcutaneous tissue are free of lesions and masses

  9. Fremitus is symmetric and easily identified in the upper regions of the lungs

  10. Chest expands when takes a deep breath, the examiner's thumb should move 5 to 10 cm apart symmetrically

  11. Elicited resonance percussion tone that is elicited over normal lung tissue

  12. While percussion elicits flat tones over scapula

  13. Excursion should be equal bilaterally and measure 3 to 5 cm in adults

  14. Level of diaphragm maybe higher on the right because of the position of the liver

  15. 3 types of normal breath sounds may be auscultated- bronchial, bronchovesicular, and vesicular

  16. No adventitious sounds, such as crackles (discrete and discontinuous sounds) or wheezes (musical continuous) are auscultated

  17. Bronchophony –voice transmission of ninety-nine is soft, muffled, and distinct. The sound of voice maybe heard but the actual phrase cannot be distinguished

  18. Egophony – voice transmission will be soft and muffled but the letter "E" should be distinguishable

  19. Whispered Pectoriloquy – transmission of sound (one –two-three) is very faint and muffled. It maybe inaudible
• Abnormal Findings: Posterior Thorax

  • Spinous processes that deviate laterally in the thoracic area may indicate scoliosis
  • If trapezius, or shoulder are used to facilitate inspiration
  • If leans forward and uses arm to support weight and lift chest to increase breathing capacity, referred as tripod position. This is often seen in COPD
  • Tender or painful areas may indicate inflamed fibrous connective tissue
  • Uneven excursion maybe seen with inflammation
  • Diminished or absent breath sounds often indicate that little or no air in and out of the lung are being auscultated
  • Bronchophony – the words are easily understood and louder over area of increase density. This may indicate consolidation from pneumonia, atelectasis or tumor
  • Egophony – over areas of consolidation or compression, the sound is louder and sounds like "A"
  • Whispered Pectoriloquy – over areas of consolidation or compression, the sound transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope
• Anterior Thorax: Inspection and Palpation

  1. The anteroposterior diameter is less than the transverse diameter. Sternum is positioned at midline straight

  2. Sterna retractions not observed

  3. The sternum and ribs may be more prominent in older clients because of loss of subcutaneous fats

  4. Ribs slope downward with symmetric intercostals spaces. Coastal angle is within 90 degrees

  5. Respiration is relaxed, effortless and quiet

  6. They are of regular rhythm and normal depth at a rate of 12 – 20 per minute in adults

  7. Tachypnea and bradypnea may be normal is some clients

  8. No retractions or bulging of intercostals spaces are noted

  9. Use of accessory muscles is not seen with normal respiratory effort
• Abnormal Findings: Anterior Thorax

  • Anteroposterior equals transverse diameter
  • Pectus excavatum, is markedly sunken sternum and adjacent cartilages or funnel chest
  • Sternal retractions are noted with severely labored breathing
  • Pectus carinatum – is a forward protrusion of the sternum causing adjacent ribs to slope
  • Barrel chest – configuration result in more horizontal position of the ribs and costal angle
  • Labored and noisy breathing is often seen with severe asthma or chronic bronchitis
  • Neck muscles are used to facilitate inspiration
• If a productive cough occurs during assessment of the thorax and lungs, the sputum should be assessed for color, consistency, and amount.
• Palpate over the spine and posterior thorax.

  Use the palmar surface of the hand to palpate for temperature, tenderness, muscle development, and masses.
• Assess Thoracic expansion


  Instruct patient to take a deep breath. Assess for tactile fremitus by using the palm of the hands to palpate over the posterior thorax and while the patient says "ninety-nine".
• Auscultate the lungs


  Auscultate the lungs across and down the posterior thorax to the bases of lungs as the patient breathes slowly and deeply through the mouth.
• Pectus excavatum
• Sternal retractions
• Pectus carinatum
• Ration


  If a productive cough occurs during assessment of the thorax and lungs, the sputum should be assessed for color, consistency, and amount
• Palpate the thorax


  1. Use the palmar surface of the hand to palpate for temperature, tenderness, muscle development, and masses

  2. Palpate over the spine and posterior thorax
• Assess tactile fremitus


  1. Instruct patient to take a deep breath

  2. Assess for tactile fremitus by using the palm of the hands to palpate over the posterior thorax and while the patient says "ninety-nine"

  3. Palpate over the spine and posterior thorax
• Assess thoracic expansion


  1. Stand behind the patient, placing both thumbs on either side of the patient's spine at the level of T9 or T10

  2. Ask the patient to take a deep breath and note movement of your hands
• Auscultate the lungs


  Auscultate the lungs across and down the posterior thorax to the bases of lungs as the patient breathes slowly and deeply through the mouth
• Abnormal thoracic findings


  • Pectus excavatum
  • Pectus carinatum
  • Sternal retractions
  • Barrel chest
• Preparing the client for breast and lymphatic assessment

  • Having the client sit in an upright position
  • Explain that it will be necessary to expose both breasts to compare for symmetry during inspection
• Physical assessment of the breasts and axilla


  • Primarily conducted to identify any lumps in the breasts and/or enlargement or pain in axillary lymph nodes
• Breast examination procedure


  1. Explain to the client what are the steps of the examination are and the rationale for them

  2. Warm your hands

  3. Observe and inspect breast skin, areolas, and nipples for size, shape, rashes, dimpling, swelling, discoloration, retraction, asymmetry, and other unusual findings

  4. Palpate breasts and axillary lymph nodes for swelling, lumps, masses, warmth, or inflammation, tenderness, and other abnormalities

  5. Perform the physical assessment just as carefully on male clients