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Nursing Assessment of the Mouth
The mouth is the beginning of the digestive system and a big part of the airway for the respiratory system. This is a very important part of the total patient health assessment. Prior to beginning any assessment of the mouth, make sure to ask the patient to remove any dentures or partials. It's also important to begin the assessment with a dental health questionnaire. This should include asking the patient if they are experiencing any toothaches, hoarseness, dysphagia(difficulty swallowing), altered taste or a frequent sore throat. Also, whether they have noticed any sores, lesions or bleeding of the gums. It is equally important to question the patient on current and previous smoking, chewing and alcohol consumption.
- The lips should be symmetrical, pink, smooth and moist. There should be no growths, lumps or discoloration of the tissue.
- If the lips are asymmetrical, cyanotic, cherry red, pale or dry.
Diseases of the Lips
- Mucocele, Aphthous ulcer, Angular stomatitis, Carcinoma, Cleft lip, Leukoplakia, Herpes simplex and Chelitis
"The condition of the teeth is an index of the person's general health." The patient's teeth should be clean with no decay, appear white and shiny enamel with smooth surfaces and edges. Adults should have a total of 32 teeth with 16 teeth in each arch. Children by the age of 2 1/2 have a total of 20 deciduous teeth with 10 in each arch.
- Missing teeth, loose or broken teeth and misaligned teeth
Diseases of the teeth
Place a tongue depressor between the patient's teeth and cheek and gently retract the cheek to inspect the gums. The gums of the upper and lower teeth should be inspected. The gums should appear symmetrical, moist, pink/coral with tight well defined margins. There may be a dark melanotic line along the gingival margin found normally in African-Americans.
- Include swelling, cyanotic, pale, dry, spongy texture, bleeding, or discolored gums.
Diseases of the Gums
- Leukoplakia, Epulis, Gingival Hyperplasia, Gingivitis, Periodontitis and Aphthous ulcer (canker sore)
Hold the patient's cheek open using a tongue blade. Then,inspect the tissues by shining a penlight on the inside surface of the cheek. The tissue should appear to be moist, smooth, glistening and pink. The Stensen's duct is located opposite the second molar in the buccal mucosa.
- If the buccal mucosa is dry, cyanotic, or pale.
Diseases of the Buccal Mucosa
To assess the patient's hard palate have the patient tilt their head back and open their mouth. Then, visual inspect the hard palate using a penlight. The palate should appear whitish in color with a firm texture and irregular transverse rugae.
- Includes the palate looking yellow or showing extreme pallor.
Diseases of the Hard Palate
Have the patient open their mouth and shine a penlight on the posterior portion of the roof of the patient's mouth. The soft palate should be light pink, smooth and upwardly movable. Next, use a tongue blade and press down on the patient's tongue while asking the patient to say "ah". The uvula should look like a pendant hanging in the midline and rise with the soft palate while saying "ah".
- Includes the uvula deviates from the midline, asymmetrical rise of the soft palate and/or uvula and reddening of the soft palate and/or uvula.
Diseases of the Soft Palate/Uvula
If cranial nerve 10 is injured, one cannot raise the soft palate when opening one's mouth.
Inspect the dorsal (top) of the tongue by having the patient stick their tongue out of their mouth. The dorsal side of the tongue should be symmetrical protrusion of the tongue. The tongue should be pink, moist with a slightly rough surface from the papillae. Also, present may be a thin, whitish coating on the tongue. To inspect the sides of the tongue, use a gloved hand to hold the tongue with a piece of gauze and move the tongue side to side. The side of the tongue should be pink, moist, smooth and glistening. Finally, have the patient touch the tip of their tongue against the roof of their mouth. The ventral (bottom) surface of the tongue should be pink, smooth, moist, prominent veins, glistening and free of lesions. The frenulum should be centered under the tongue.
- Includes markedly reddened, cyanotic or extreme pallor
Diseases of the Tongue
- Scrotal tongue, Fissured tongue, Migratory glossitis(geographical tongue), Atrophic glossitis, Black Hairy tongue, Caviar lesions, Carcinoma, Macroglossia, Candidiasis, Aphthous ulcer and Leukoplakia
Tonsils (if present)
Have the patient open their mouth and, using a tongue blade, gently press down on the tongue. Then, using a penlight, inspect the back of the patient's throat. The tonsils should be pink, symmetrical and normal sized. The tonsils can be graded in size using this guideline.
- 1+ Visible
- 2+ Halfway between tonsillar pillars and uvula
- 3+ Touching the uvula
- 4+ Touching each other
- Includes bright red and enlarged tonsils or presence of white or yellow tonsillar exudate.
Diseases of the Tonsils
Concerns for Special Populations
Patients who are diagnosed with Down syndrome and cretinism have delayed tooth eruption. Also, it's important to know that prolonged thumb sucking may cause problems with the proper growth of the mouth and the alignment of teeth.
Gingivitis is one of the most prevalent oral problems associated with pregnancy. "It has been reported to occur in 60 to 75 percent of all pregnant women."
- Jarvis, Carolyn (2008). 5th edition. Physical Examination & Health Assessment. ISBN 978-1-4160-3243-4. Missing or empty