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HMTNS Assessment Checklist

Head, Mouth, throat nose and sinuses checklist

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15 views3 pages

HMTNS Assessment Checklist

Head, Mouth, throat nose and sinuses checklist

Uploaded by

Patrick Santos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES


Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES


_____________________________________________________________
BACHELOR OF SCIENCE IN NURSING
NCM 101 – HEALTH ASSESSMENT
2nd Semester, A/Y 2023 - 2024

Name of Student: ______________________________ Date: ________________


Year & Section: _______________________________ Grade: _______________

PROCEDURE CHECKLIST:
ASSESSMENT OF HEAD, MOUTH, THROAT, NOSE & SINUSES
GATHER EQUIPMENT:

Head: Mouth, Throat, Nose, and Sinuses:


1. Gloves, clean or sterile 1. Gloves, clean or sterile
2. Penlight or flashlight 2. Cotton gauze pads
3. Small glass of water 3. Penlight
4. Stethoscope 4. Speculum attached to otoscope
5. Tongue blade or tongue depressors

NOT
A. PREPARATION DONE REMARKS
DONE
1 Review patient’s medical record.
.
2 Prepare the setting.
.
NOT
B. PROCEDURES DONE REMARKS
DONE
1 Introduce yourself to the patient.
.
2 Verify the client’s identity.
.
3 Explain the procedure, purpose, and emphasize
. confidentiality of information.
NOT
C. HEAD ASSESSMENT DONE REMARKS
DONE
1 Inspect head for size, shape, and configuration.
.
2 Palpate head for consistency while wearing gloves.
.
3 Inspect face for symmetry, features, movement,
. expression, and skin condition.
4 Palpate temporal artery for tenderness and
. elasticity.
5 Palpate temporomandibular joint for range of
. motion, swelling, tenderness, or crepitation by
placing index finger over the front of each and
asking client to open mouth. Ask if client has
history of frequent headaches.
D. MOUTH ASSESSMENT DONE NOT REMARKS
DONE
1 Note any distinctive odors.
.
2 Inspect and palpate lips, buccal mucosa, gums,
. and tongue for:
a. color variations (pallor, redness, white patches,
bluish hue)
b. moisture
c. tissue consistency
d. lesions (induration, roughness, vesicles, crusts,
plaques, nodules, ulcers, cracking, patches,
bleeding, Koplik spots, cancer sores)
e. Stensen and Wharton ducts.
3 Inspect gums for hyperplasia, and blue-black line.
.
4 Inspect teeth for number and shape, color (white,
. brown, yellow, chalky white areas), and occlusion.
5 Inspect and palpate tongue for color, texture, and
. consistency (black, hairy, white patches, smooth,
reddish, shiny without papillae), moisture, and size
(enlarged or very small).
NOT
E. THROAT ASSESSMENT DONE REMARKS
DONE
1 Inspect the throat for color, consistency, torus
. palatinus, uvula (singular).
2 Inspect the tonsils for color and consistency,
. grading scale (1+, 2+, 3+, 4+).
NOT
F. NOSE ASSESSMENT DONE REMARKS
DONE
1 Inspect and palpate the external nose for color,
. shape, consistency, tenderness, and patency of
airflow.
2 Inspect the internal nose for color, swelling,
. exudate, bleeding, ulcers, perforated septum, or
polyps.
NOT
G. SINUSES ASSESSMENT DONE REMARKS
DONE
1 Palpate the sinuses for tenderness.
.
2 Percuss and transilluminate the sinuses for air
. versus fluid or pus.
NOT
H. ANALYSIS OF DATA DONE REMARKS
DONE
1 Formulate nursing diagnoses (wellness, risk,
. actual)
2 Formulate collaborative problems.
.
3 Make necessary referrals.
.

Name of Clinical Instructor/Facilitator

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