Class notes
Nur 101 Clinical Skills Notes
- Course
- NUR 101
- Institution
- Evergreen Valley College
Step of procedures clinical skills. include the alert for each procedure.
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Assessing the Nose, Mouth, and ThroatSupplies
Tongue blades
Pen light
Nasal speculum
Sterile gauze
Clean gloves
1. Examine the external nose in four steps. (I will exam your nose)
a. Inspect the nose. - Note its size, shape, color (straight, skin is smooth and unswollen,
match color w/ face
b. Observe the nares for discharge and flaring or narrowing. - Nares are oval shapes and
columella is midline
c. Palpate the bridge and soft tissues of the nose. - The nasal is firm and stable without
tenderness, masses or bone
d. Evaluate nasal patency. (When I block this nostril, try to breath in and out through
the other).
- Check the open naris, the breathing should be noiseless and easy
Children under 7 age, fontal sinuses not develop yet, so focus on maxillary sinuses
2. Assess the nasal cavity. Observe three aspects. (Use 1 hand to move patient head, insert
nasal speculum to inspect
a. Inspect the nasal mucosa. – deep pink and glistening without discharge, masses
b. Inspect the nasal septum. – have same color, firm and unswollen, septum have no
perforation, bleeding, or crusting
c. Test the sense of smell and CN I.
3. Examine the sinuses.
a. Inspect the front and maxillary sinus areas – No swelling
b. Palpate the frontal sinuses (press thumb against brow bone). Palpate the maxillary
sinuses (zygomatic progresses).
NO TENDERESS/SWELLING
Examine the mouth, oral cavity, and oropharynx.
4. Inspect and palpate the lips – Pink, smooth, symmetric, without swelling, lesions, surface
abnormalities
5. Have the patient clench the teeth and give a big smile.
6. Examine the buccal mucosa, gums, and teeth using four key assessments. (the upper molars
should be interdigitate w. lower molar)
Can you open your mouth, please
a. Observe the mucous membrane. Inspect oral structure, using tongue blade and bright
light
b. Inspect the gums – appear slightly stipple and pink with clearly define tight margin at
each tooth
c. Palpate the gums – free of lesions, induration, thickening, masses, and tenderness
, d. Inspect and count the teeth. – using tongue blade to probe each tooth, which should be
firmly anchored. NOTE ANY WEAR,NOTHCHES,CARIES,MISSING OR LOOSE
TEETH
Can you stick out your tongue and hold it please
7. Examine the oral cavity in seven ways.
a. Inspect the dorsum of the tongue. – dull red, moist, and glistening, without coating or
ulcerations, tongue should protrude fully, remain midline and show no deviation or
tremor.
b. Test CN XII.
Now I need to look under your tongue. Can you touch the tip of your tongue to the top of your
front teeth?
c. Have the patient touch the tip of the tongue to the palate behind the upper incisors while
you inspect the floor of the mouth and the ventral surface of the tongue – is pink and
smooth with large veins between the frenulum and fimbriated folds, with no swelling or
varicosities.
OLDER PATIENT: varicose vein under the tongue are expected variation
d. Inspect the lateral borders of the tongue (grab gauze around the tongue and pull the
tongue to each side) – No red or white margins or ulcerations
Now I going inside to feel your mouth
e. Palpate the tongue and the floor of the mouth. – tongue feels smooth and even in
texture, no nodules, ulcerations, or areas of induration
Now I need to you tilt your head back and open wide so I can look at the roof of your mouth
f. Inspect the palate and uvula.
Now I need you to open line and say A
g. Evaluate soft palate movement, (as patient vocalizes) – palate rise symmetrically and
uvula should remain midline
8. Assess the oropharynx in three ways.
a. Inspect the oropharynx and tonsillar pillars.
b. Observe the posterior wall of pharynx (retropharyngeal wall). The tonsil should be pink
as pharynx and should not project pass tonsillar pillar. retropharyngeal wall should pink,
smooth with small vessels and spot of lymphatic tissue
c. Touch the posterior wall of the pharynx on each side to elicit the gag reflex. The gag
reflex should be present on both sides. Testing with a tongue blade on each side of the
oropharynx is part of assessing the gag reflex. There should be a bilateral response to
the gag reflex
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