ADVENTIST MEDICAL CENTER COLLEGE

San Miguel, Iligan City

SCHOOL OF NURSING

HEALTH ASSESSMENT
Related Learning Experience (Skills Lab)
Second Semester, AY 2022 – 2023

ASSESSMENT OF THE MOUTH, THROAT, NOSE, AND SINUSES RUBRIC

Name _______________________________________________________________________________________ Section _________ Date __________________ Score _______

I. COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
CRITERIA AND PROCEDURE EXCELLENT VERY SATISFACTORY SATISFACTORY POOR SCORE
4 3 2 1

Preliminaries Demonstrated all Demonstrated seven of Demonstrated Demonstrated five

 Gather equipment (clean gloves, penlight, 4x4-in gauze, tongue depressor, assessment (8) preliminary the preliminary six of the or less of the
form, pen, clipboard). activities activities preliminary preliminary
 Demonstrate courtesy, introduce self, and verify client’s identity. Explain to the client that activities activities
after the nursing health history, you will proceed to the physical assessment or physical
examination.
 Do hand hygiene and observe other infection control procedures.
 Provide a quiet environment.
 Be sure that the room is having a comfortable temperature.
 Ensure that during the interview, there are no interruptions and distractions.
 Provide privacy.
 Ask questions in a straightforward manner, be sensitive, and avoid being judgmental.
History of Present Health Concern EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
Tongue and Mouth Demonstrated Missed one to two Missed three to Missed five or more
1.Do you experience tongue or mouth sores or lesions? If so, explore the symptoms using complete and assessment interview four assessment assessment
COLDSPA. comprehensive on history of present interview on interview on
a. Character: Describe the size and texture of lesions. interview on health concern history of history of present
b. Onset: When did they first occur? Do you notice these more when you are under stress or history of present present health health concern
taking certain medications? Did they occur after any injury to your mouth? health concern concern
c. Location: Describe exactly where these lesions are located in your mouth?
d. Duration: How long have you had these lesions? Have you ever had these before and did they
go away?
e. Severity: Do these lesions keep you from eating, talking, or swallowing?
f. Palliative/relieving factors: What aggravates these lesions or makes them go away? What over-
the-counter (OTC) remedies and past prescriptions have you used?
g. Associated factors: Do you have any other symptoms with these lesions such as stress, pain,
bleeding? Describe.
2. Do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has this

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 been happening? Do you have any toothache? Have you lost any permanent teeth?

Nose and Sinuses

3. Do you have pain over your sinuses (cavities around nasal passages)?
4. Do you experience nosebleeds? Describe the amount of bleeding you have and how often it
occurs. What color is the blood?
5. Do you experience frequent clear or mucous drainage from your nose?
6. Can you breathe through both of your nostrils? Do you have a stuffy nose at times during the
day or night?
7. Have you experienced a change in your ability to smell or taste?

Throat
1. Do you have difficulty swallowing or painful swallowing? How long have you had this?
2. Do you have a sore throat? How long have you had it? Describe. How often do you get some
sore throats?
3. Do you experience hoarseness? For how long?
4. Have you ever had any oral, nasal, or sinus surgery?
5. Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?
What type? How much? How often?
6. Have you been diagnosed with seasonal environmental allergies (e.g., hay fever), drug allergies,
food allergies, or inset allergies? Describe the timing of the allergies (e.g., spring, summer) and
symptoms (e.g., sinus problems, runny nose, or watery eyes).
7. Do you regularly use any treatments or medications for conditions that affect the mouth, nose,
or throat or to control pain in the mouth, nose, throat, or sinuses (e.g., saline spray or use of over-
the-counter nasal irrigations, nasal sprays, throat spray, ibuprofen)? What are the results?

Family History and Lifestyle and Health Practices EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
1. Is there a history of mouth, throat, nose, or sinus cancer in your family? Demonstrated Missed one to two Missed three to Missed five or more
2. Do you smoke or use smokeless tobacco? If so, how much? Are you interested in quitting this complete and assessment interview four assessment assessment
habit? comprehensive on family history; interview on interview on family
3. Do you drink alcohol? How much and how often? interview on family lifestyle and health family history; history; lifestyle
4. Do you grind your teeth? history; lifestyle practices lifestyle and and health
5. Describe how you care for your teeth and your dentures. How often do you brush and use and health health practices practices
dental floss? practices
6.
7. When was your last dental examination?
8.
9. If the client wears braces: How do you care for your braces?
10. Do you avoid any specific types of foods?
11. If the client wears dentures: How do your dentures fit?
12. Do you brush your tongue?
13. How often are you in the sun? Do you use sunscreen products?
14. Describe your usual dietary intake for a day.

EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

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II. COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION Demonstrated all Missed one guideline Missed two Missed three or
Client Preparation (4) client on client preparation guidelines on more guidelines on
1. Ask the client to assume a sitting position with the head erect. preparation client client preparation
2. It is best if the client’s head is at your eye level. preparation
3. Explain the specific structures you will be examining, and tell the client who wears dentures, a retainer,
or rubber bands on braces that they will need to be removed for an adequate oral examination.
4. Tell client what you’re doing and your assessment findings and answer any question the client may have.

Mouth EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Inspection and Palpation Performed Missed one to two Missed three to Missed five steps or
1. Inspect and palpate the lips. Observe lip tissue consistency, color, moisture, and lesions. complete (14) and steps of mouth four steps of more of mouth
2. Inspect the teeth and gums. Ask the client to open and close mouth. Note occlusion, number and comprehensive assessment mouth assessment
shape, color and condition of teeth (white, brown, yellow, chalky white areas). Note any repairs such as assessment of the assessment
crowns and any cosmetics such as veneers. mouth
3. Ask the client to bite down as though chewing on something and note the alignment of the lower and
upper jaws.
4. Put on gloves and retract the client’s lips and cheeks to check gums for color and consistency.
5. Inspect the buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks to check
for color and consistency.
6. Inspect the Stensen ducts (parotid ducts), openings of the parotid salivary glands – located on the buccal
mucosa across from the second upper molar.
7. Inspect and palpate tongue (ask client to stick out the tongue) for color, texture and consistency (black,
hairy, white patches, smooth, reddish, shiny without papillae), moisture, size (enlarged or very small) and
mobility. Observe for fasciculations (fine tremors), and check for midline protrusion.
Palpate any lesions present for induration (hardness).
8. Assess the ventral surface of the tongue. Ask the client to touch the tongue to the roof of the mouth, and
use a penlight to inspect the ventral surface of the tongue, frenulum, and area under the tongue (dorsal
surface).
9. Palpate the area if you see lesions, if the client is over age 50, or if the client uses tobacco or alcohol.
Note any induration. Check also for short frenulum that limits tongue motion (the origin of “tongue-tied”)
10. Inspect for Wharton’s ducts – openings from the submandibular salivary glands – located on either side
of the frenulum on the floor of the mouth.
11. Observe the sides of the tongue. Use a square gauze pad to hold the client’s tongue to each side.
Palpate any lesions, ulcers, or nodules for induration.
12. Check the strength of the tongue. Place your fingers on the external surface of the client’s cheeks. Ask
the client to press the tongue’s tip against the inside of the cheek to resist pressure from your fingers.
Repeat on the opposite cheek.
13. Check the anterior tongue’s ability to taste. Place drops of sugar and salty water on the tip and sides of
the tongue with a tongue depressor.
14. Inspect the hard (anterior) and soft (posterior) palates. Ask the client to open the mouth wide while you
use a penlight to look at the roof. Observe color and integrity.

Uvula, Throat, and Tonsils EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

1. Assess the uvula. Apply a tongue depressor to the tongue (halfway between the tip and back of the
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tongue) and shine a penlight into the client’s wide open mouth. Performed Missed one step of the Missed two Missed three steps
complete (4) and uvula, throat, and steps of the of the uvula,
Note the characteristics and positioning of the uvula. Ask the client to say “aaah” and watch for the uvula comprehensive tonsils assessment uvula, throat, throat, and tonsils
and soft palate to move. assessment of the and tonsils assessment
uvula, throat, and assessment
2. Inspect the tonsils. Using the tongue depressor to keep the mouth open wide, inspect the tonsils for tonsils
color, size, and presence of exudate or lesions. Grade the tonsils (2+, 3+, or 4+).
3. Inspect the posterior pharyngeal wall. Keeping the tongue depressor in place, shine the penlight on the
back of the throat, and note any exudate or lesions.
4. Note odor. While the mouth is wide open, note any unusual or foul odor.

EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Nose Performed Missed one step of Missed two Missed three steps
complete (4) and nose assessment steps of nose of nose assessment
Inspection and Palpation comprehensive assessment
1. Before inspecting the nose, discard gloves and perform hand hygiene. assessment of the
2. Inspect and palpate the external nose for color, shape and symmetry, consistency, tenderness, and nose
patency of airflow by occluding each nostrils.
3. Check patency of airflow through the nostrils by occluding one nostril at a time and asking client to sniff
or exhale.
4. Inspect the internal nose with head tilt and with the use of an otoscope with a short wide-tip attachment
or you can also use a nasal speculum and penlight. Note for color, swelling, exudates, bleeding, ulcers,
perforated septum or polyps.

Sinuses EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Palpated and Palpated and Palpated and No attempt was
1. Palpate the sinuses (frontal sinuses by pressing upward just below the eyebrows & maxillary just below percussed the percussed one of the percussed two made to palpate
the eyes) for tenderness. frontal and facial sinuses correctly of the facial and percuss the
2. Percuss frontal sinuses above eyebrows and maxillary sinuses just below the eyes with direct/ immediate maxillary sinuses sinuses facial sinuses
percussion for tenderness. correctly incorrectly
Post-examination Activities EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
1. Show appreciation to your client for cooperating. Exhibited all (5) Missed one step of the Missed two Missed three or
2. Remove and discard gloves properly. post-examination post-examination steps of the more steps of the
3. Perform hand hygiene. activities activities post- post-examination
4. Dispose used equipment properly and disinfect materials that will still be reused prior to storing them. examination activities
5. Document findings in the client record supplemented by narrative notes. activities

CONFIDENCE EXCELLENT VERY SATISFACTORY SATISFACTORY POOR

Performed entire Performed entire Performed Not able to perform
procedure with procedure with entire entire procedure
great confidence moderate confidence procedure with with confidence
minimal
confidence
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 TIMING (AT LEAST 30 MINUTES) EXCELLENT VERY SATISFACTORY SATISFACTORY POOR
Performed entire Performed entire Performed Performed the
procedure within procedure with 5 entire entire procedure
the allotted time minutes excess on the procedure with with 15 minutes or
(20 minutes) allotted time 10 minutes more excess of the
excess on the allotted time.
allotted time

TOTAL
Note: Refer to your textbook for the rationale of each area of assessment.

Perfect Score: 44 points

Range of Scores:
42 – 44 --------------------------------------- Excellent
39 – 41 --------------------------------------- Very Satisfactory
36 – 38 --------------------------------------- Satisfactory
35 and below ------------------------------- Poor

Assessed by:
___________________________________
Name and Signature of RLE Instructor
/rsp
5/3/21