N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide • Wash hands before starting the exam, any time the hands or gloves become soiled, and upon completion of the exam. • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Presence of lesions in mouth or throat o Dentures or bridges o Last dental visit • Assess the outer lips: View the lips and instruct the patient to purse the lips in a "whistling" position. o Normal: Uniform color ranging from pink to bluish tinged in dark-skinned patients, moist, smooth texture, symmetrical, and able to purse lips o Deviations from normal: Pale or cyanotic, dry, cracked or crusted, blisters, asymmetrical, and unable to purse lips • Assess the inner lips and buccalmucosa. o Normal: Uniform color ranging from pink to freckled brown in dark-skinned patients, moist, smooth, elastic texture, and no lesions or blisters o Deviations from normal: Pale or white patches, excessively dry (some dryness may be normal in elderly), cysts, abrasions, blisters, ulcers, or nodules • Assess the teeth (or dentures) and gums. o Normal: Adults typically have 32 teeth (unless history of extractions), and smooth, shiny tooth enamel in various shades of white; uniform gum color ranging from pink to bluish or dark in dark-skinned patients; firm gum texture, non-tender gums, no lesions on gums, no retraction of gums from teeth, and no abrasions from dentures (if applicable) o Deviations from normal: Missing teeth or ill-fitting dentures, discoloration of the enamel, excessive redness of the gums, bleeding of the gums, spongytexture of gums, tenderness of gums, receding or swollen gums, and lesions on thegums • Assess the tongue: Inspect and palpate all areas of the mouth with gloved hands. o Normal: Central position, uniform color ranging from pink to some brown pigment on edges of tongue in dark-skinned patients; moist, slightly rough texture, smooth edges, no lesions, raised taste buds, freely moveable, no tenderness, smooth tongue base with prominent veins, and floor of mouth smooth with no nodules o Deviations from normal: Deviation from central position, tongue trembling, red or pale color, dry or furry, smooth texture, lesions, limited mobility, tenderness, swelling or ulcerations on tongue base, swelling, ulcerations, or nodules on floor of mouth • Assess the salivary glands. o Normal: Color at salivary gland openings are the same as buccal mucosa o Deviations from normal: Color at salivary gland openings are red and swollen

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