METHODICAL INSTRUCTION FOR STUDENTS OF THE RN-BSN PROGRAM 1 COURSE

Nursing Faculty

LESSON № 6 (PRACTICAL – 6 HOURS)

 

Theme 1: Assessment of Nose, Mouth, and Throat.

Aim: To be able to perform physical assessment of nose, mouth and throat and to show abnormal findings. 

Professional orientation of students: The head, face, and neck form a large portion of what is often referred to as the head, nose, and throat (HEENT) system. This is actually a complex set of varied organs, combined during assessment because of their proximity to one another and the integration among the components of the system. The HEENT encompasses almost all of the systems: integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine, and lymphatic. The vascular, neurological, and musculoskeletal components of the HEENT, as well as the eyes and ears are covered in separate chapters. The components addressed in this chapter include the head, face, nose sinuses, neck ,mouth ,and pharynx. These components are complex in their actions and are involved in expression, communication, nourishment, respiration, and sensation, among other functions. Furthermore, disorders involving the head and face can be devastating to patients because they can greatly affect appearance. Even minor disorders involving the head, face, or neck can be perceived as disfiguring by patients.

Methodology of Practical Class. (9.00-12.00)

Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):

During examination of the patient students have to use such communicative algorithm:

Complaints and anamnesis taking in patients

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Take complaints and anamnesis in a patient.

5. Explain to the patient results of his/her lab tests correctly and accessibly.

6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.

7. Conversation accomplishment.

Objective examination:

Physical methods of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient, what examinations will be carried out and get his/her informed consent.

5. Find a contact with the patient and make an attempt to gain his/her trust.

6. Inform about the possibility of appearing of unpleasant feelings during the examination.

7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).

8. Examination (demonstration of clinical skill).

9. Explain to the patient results of his/her lab tests correctly and accessibly.

10. Conversation accomplishment.

Estimation of laboratory and instrumental investigations

Informing about the results of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient results of his/her lab tests correctly and clearly.

5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).

Planning and prognosis the results of the conservative treatment

Friendly facial expression and smile.

1. Gentle tone of speech.

2. Greeting and introducing.

3. Correct and clear explanation of necessary treatment directions.

4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.

5. Conversation accomplishment.

Work 1. Examination of Nose, Sinuses, Mouth, and Oropharynx

I. Anatomy & Physiology II. Health History A. History of Trauma B. Headaches D. Sinus infections E. Nasal discharge (post nasal drip) F. Prolonged nosebleeds G. Medication use H. Mouth lesions I. Difficulty swallowing/chewing J. Voice hoarseness K. Allergies L. Neck injury/neck surgery M. Use of tobacco N. Bruxism O. Mouth care III C. Nose 1. Inspect a. Symmetry and contour b. Deformity, swelling, discoloration c. Flaring of nares d. Direct inspection with nasal speculum and penlight 2. Palpate a. Tenderness b. Nasal patency D. Sinuses 1. Inspect frontal and maxillary sinuses for inflammation and edema 2. Palpate for tenderness 3. Percuss for tenderness 4. Transillumination E. Mouth and Oropharynx 1. Inspect a. Unusual breath odors b. Oral mucosa c. Gingival surfaces d. Condition of teeth e. Tongue - pink, rough, midline depression - Hypoglossal nerve function (CN 12) - Examine underside - Lingual frenulum f. Hard and soft pallets g. Tonsils Graded 0 to +4   0 tonsils behind the pillars +1 tonsils are peaking from pillars +2 tonsils are between pillars and uvula +3 tonsils are touching uvula +4 tonsils are extending to midline 2. Palpate a. Palpate upper and lower lips and tongue to evaluate muscle tone and surface structure 3. Examine oropharynx with tongue depressor and penlight (glossopharyngeal vagus nerves)

Seminar discussion of theoretical issues. (12.00-14.00)

Individual Students Program.

Test evaluation and situational tasks. (14.15.-15.00)

1.  The nurse is caring for a client with an outbreak of stomatitis. What complication of this disorder is considered most life threatening to the client?

a.	Pain
b.	Bleeding
c.	Infection
d.	Xerostomia

2.  Which of the following clients is most at risk for developing aphthous stomatitis?

a.	32-year-old woman in the luteal phase of the menstrual cycle
b.	23-year-old woman in the first trimester of pregnancy
c.	53-year-old man who eats spicy foods
d.	72-year-old man who wears dentures

3.  Which statement regarding oral candidiasis is true?

a.	It is an inflammatory mucocutaneous disease.
b.	It is an acute bacterial infection of the gingiva.
c.	It is a complication of long-term antibiotic therapy.
d.	It is a risk factor for the development of oral cancer. 4.      You observe yellow-tinged sclera on a client with dark skin. Based on this observation, what is your best action? a. Examine the soles of the client's feet. b. Nothing; this is a normal finding on all people with dark skin. c. Inspect the client's oral mucosa and hard palate for other indications of jaundice. d. Notify the physician of the possibility that the client has hepatitis or another liver disorder. 5.      You observe clubbing of the fingers in an older man. What is your interpretation of the significance of this finding? a. You should ask the client if this condition has been present since birth. b. This finding is most commonly associated with chronic disorders of impaired gas exchange. c. You should ask the client about his occupation and hobbies and any other activities involving exposure of the hands to harsh chemicals. d. Clubbing of the fingers is a common age-related change and is considered a normal finding among older adults, especially men. 6.      What problem are you alerted to in a client who has chronically inflamed soft tissue folds around the nail plates on all fingers? a. Probable fungal infection b. Long-term use of nail polish c. Poorly controlled diabetes mellitus d. Frequent intermittent exposure to water 7.      The older client asks you if the white rings around her eyes are cancer of the eye or cataracts. What is your best response? a. “Yes, they are actually benign tumors and do not need to be removed.” b. “No, these rings are a normal change as people age and do not affect vision.” c. “No, these rings may be early indications of glaucoma and should be evaluated by your doctor.” d. “Yes, these rings are immature cataracts and will need to be removed when they grow large enough to affect your vision.” 8.      What is the priority nursing diagnosis for the older adult client who has very thin skin on the backs of the hands and arms? a. Risk for Injury b. Risk for Infection c. Risk for Disuse Syndrome d. Risk for Imbalanced Body Temperature: hyperthermia 9.      The client has two skin lesions, each the size of a nickel, on his chest. Both lesions are flat and a darker color than the rest of the client's skin. How would you document this finding? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles 10.    What technique should you use to obtain a specimen for culture from a client who has crusted skin lesions on the upper back that indicate a possible bacterial infection? a. Remove several crusts and swab the underlying exudate. b. Remove a crust from the center of the cluster of lesions and send it to the laboratory. c. First, dampen the culture swab with sterile water, and then roll the swab over the central crusts. d. Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the laboratory.

 

Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.

(the instructor has tests & situational tasks)

 

Student should know:

1. Recall anatomy and physiology relevant to the nose, sinuses, mouth, and oropharynx.

2. Describe questions and related rationale used to obtain health history data about nose, sinuses, mouth, and oropharynx.

3. Develop a systematic approach to symptom analysis for the commonly occurring problems of nasal discharge, sinus congestion, nosebleed, snoring, mouth pain, difficulty swallowing, sore throat, an hoarseness or voice change.

4. List assessment factors for the paranasal sinuses and the nose.

5. Describe the techniques for assessing the paranasal sinuses, and internal and external structures of the nose.

6. Identify the techniques for assessing sense of smell (CN I).

7. List factors to de assessed in examining the mouth and oropharynx: lips, gums, buccal mucosa, tongue, palate, uvula, pharynx, and tonsils.

8. Describe techniques for assessing the mouth and tonsils.

9. Identify the technique for assessing sense of taste and movement of structures in the mouth and pharynx (CN VII, IX, X, XII ).

10. Describe normal assessment findings for nose, sinuses, mouth, and oropharynx.

11. Describe cultural, age-related variations related to the nose, sinuses, mouth, and oropharynx.

12. Discuss health promotion practices to the nose , sinuses, mouth, and oropharynx.

13. Describe common variations (health alterations) of the nose, sinuses, and oropharynx.

14. Discuss health promotion practices relative to the head and neck.

15. Describe common variations (health alterations) o the head and neck.

Student should be able to:

1. Communication skills with the patient

2. To promote the interview with the patients

3. To collect all the subjective and objective data of the patient

4. Demonstrate the assessment of the:

• Mouth

• Nose

• Throat

Correct answers of test evaluations and situational tasks:

1. Answer: C

2. Answer: A

3. Answer: C

4. Answer: D

5. Answer: B

6. Answer: C

7. Answer: C

8. Answer: B

9. Answer: D

10. Answer:         B

References:

А–Basic: http://intranet.tdmu.edu.ua/data/kafedra/internal/distance/classes_stud/English/1course/Heath%20Assessment%20Practicum/Health%20Assessment%20Practicum/06.%20Assessment%20of%20Nose,%20Mouth%20and%20Throat.htm

Jarvis, C. (2011). Physical examination and health assessment. (6^th ed.). Philadelphia: W.B. Saunders

В – Additional:

Weber, J. & Kelley, J., (2010).  Health assessment in nursing. (4th Ed.). Lippincott ISBN: 978-0-781-78160-2

Weber, J. & Kelley, J., (2010).  Health assessment in nursing lab manual. (4th Ed.). Lippincott ISBN: 978-0-781-78161-9

Mosby’s Dictionary of Medicine, Nursing, and Health Professions, 

(2009). (8^th ed.) St. Louis: Elsevier ISBN: 9780323052900

Venes, D. editor (2009) Taber’s Cyclopedia Medical Dictionary (21^th ed.). Philadelphia: F.A. Davis. ISBN:  9780803615595

 

Methodical instruction has been worked out by: O. Krekhovska-Lepyavko MD, BSN, MSN

 

 

Methodical instruction was discussed and adapted at the Department sitting

June 12, 2013. Minute № 13