N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide Assess the palates and uvula. o Normal: Light pink, smooth soft palate, lighter pink, irregular hard palate, and uvula positioned in the midline of the hard palate o Deviations from normal: Jaundiced or pale soft palate, hard palate same coloras soft palate, bony growths from the hard palate, lesions or abrasions of the palates, uvula deviated to one side or another from the midline of the hard palate • Assess the oropharynx: Press a tongue blade on top of the tongue halfway back to expose the oropharynx. o Normal: Posterior wall pink and smooth with no lesions o Deviations from normal: Posterior wall reddened or swollen, lesions, or drainage • Assess the tonsils. o Normal: Normal size or not visible; pink and smooth with no drainage o Deviations from normal: Reddened, swollen, with discharge or lesions; size grades including:  Grade 1: Tonsils behind the pillars supporting the soft palate  Grade 2: Tonsils between the pillars and uvula  Grade 3: Tonsils touch the uvula  Grade 4: One or both tonsils extend to the midline of the oropharynx • Assess the gag reflex: Press down on the posterior tongue with a tongue depress. o Normal: Patient gags when touched on the posterior tongue o Deviations from normal: Absent reflex Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal mouth or throat findings. Record and report any significant deviations from the normal. 2.8 Neck There is no special equipment needed for the neck exam. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • 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, and how the •

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