Hi, I'm Meris. And in this video, I'm going to be talking to you about the assessment of the mouth and throat. I'm going to be following along using our Health Assessment flashcards. These are available on our website, leveluprn.com, if you want to get a hard copy for yourself.
Or if you are more into the idea of digital flashcards, I would invite you to check out Flashables, which are our digital flashcards. Amazing, gives you access to all of our flashcard content on-the-go, in your pocket, at all times. All right, let's get started.
So first up, we're going to be talking about how to assess the mouth. When we are looking inside the mouth, we're going to be looking mostly, again, for things like symmetry, color, size, shape.
But one of the things that I am looking at when I look in my patient's mouth is I'm looking to see what those mucous membranes look like. Are they nice and pink and moist, or are they dry and cracked and pale, or are they red, or are they jaundiced or cyanotic in some capacity?
Remember, here, mucous membranes are a very good place for me to assess for changes to my patient's skin color, especially if they do not have white or fair-toned skin.
So when I'm looking in the mouth, I can also be assessing for some integumentary changes as well.
Things I want to look for when I'm talking about the throat, I'm going to be looking in the back of the throat and at the uvula, which is that thing that hangs down there in the back of the throat. And what I'm expecting to see is that when I have my patient say ah, right? We have them open their mouth, say ah, that's not just for fun.
What I'm doing here is I actually am trying to see that the uvula is going to rise, and it's going to rise midline during phonation, meaning when I say ah, that that uvula should rise midline during that time. So that's what I'm looking for when I ask my patient to say ah.
I'm also going to be looking at the palette, the hard and the soft palate to be assessing for that skin there. What does it look like? Is it intact? Is it smooth? Is it pink? All of those different things that I can be looking for.
Now, one of the most important things that you may be finding in your patient's throat is going to be their palatine tonsils.
So palatine tonsils are going to be these tonsils back here on either side of the throat. And if your patient has them, as in, if they are not surgically absent, then you need to be assessing them.
So what are we doing when we are assessing? We're going to assess the location of the tonsils and the size of them.
So do I see them? And they are both in the same-- they're one on either side, but they are occupying the same amount of space in my patient's throat.
Or do I have two tonsils, but one of them is really swollen and protruding further into the airway than the other? That's something that I'm going to need to know, right?
The other thing is that we can actually grade these tonsils. So when I look in my patient's mouth, I can assign a grade based on how large they are. And we will talk in a moment about unexpected findings.
However, the expected finding is for my tonsils to be 1+ or 2+. And that is what we should see on an average human being who does not have surgically absent tonsils.
And then if indicated, at this point in time, I can go ahead and assess cranial nerves 9, glossopharyngeal, 10, vagus, and 12 hypoglossal, at this time, because that would be all parts of the cranial nerves that are innervating the mouth and throat. So that is when that would be an indicated assessment if it is required for your patient at that time.
Now, when it comes to unexpected findings, remember that I told you that we expect to see a nicely hydrated mucous membrane when I look in the mouth. However, if I see dry or cracked lips or mucosa inside the mouth, this says to me it's not a well-hydrated mucous membrane, and that's probably because of dehydration.
So that is a very, very important indicator there. If I do see that dryness or cracking of the lips or the mucous membranes, you need to be considering that this could be related to your patient's hydration status.
But now I want to go back and talk about tonsil sizes here. So let's review really quickly. What are the different sizes of tonsils? How do we grade them? And why does it matter?
So size zero. If I give a zero to tonsils, then that means that they are not present. Usually, that means that they have been surgically removed.
A 1+ is going to mean that the tonsils are occupying 25% or less of the oropharynx, whereas a 2+ is going to be that the tonsils are occupying 26 to 50 percent of the oropharynx.
So think about that really quickly. What I just told you is that it is normal for tonsils to occupy up to 50% of the oropharynx. So if you think about the oropharynx, look in the back of their throat, and that from one side to the other is going to be what you're looking at, right? And that midline there right in the middle, if it comes all the way over, and this one comes all the way over, then that's occupying the full amount, so 50%. We're talking about it's occupying 50% of its side of the oropharynx, and that's considered normal.
Hear me on that, okay? Because next is 3+.
3+ tonsils are going to be those which occupy between 51 and 75 percent of the oropharynx. This is most commonly going to be seen in somebody who is having some sort of an acute infection. Maybe they have strep throat or some kind of a-- they're battling some kind of a cold or an illness.
But then 4+ means that the tonsils occupy greater than 75% of the oropharynx and may actually even touch. They may touch. This is considered 4+. If I have tonsils that are occupying more than 75% or they are touching, those are 4+ tonsils.
And why does that matter? Think about this so, so briefly. I just want you to think about what's going on back here, the airway, right? This is my whole airway. And if I have two tonsils, two palatine tonsils that are up against each other, touching one another, think about how much of my oropharynx is being taken up just by the presence of the tonsils. How am I going to be able to manage my secretions to swallow my food and even to protect my airway if it is partially or fully blocked by my tonsils?
So very important that your patient, especially with 4+ tonsils-- patient with big tonsils, but 4+ especially, they are at risk for airway compromise. And you've got to learn it, love it, get a necklace that says it because you know that if it is compromising the airway, it is a huge priority for you as a nurse and as a nursing student.
All right. Now let's test your knowledge of some key facts I provided in this video with some quiz questions.
What is the expected finding for tonsils?
1+ or 2+.
How should the nurse describe tonsils that occupy greater than 75% of the oropharynx?
4+.
All right. That is it for this video. I do hope that you found it useful. I would love for you to leave me a comment. Let me know something you learned or how many of those quiz questions you got right. All right. Thanks so much and happy studying.
[STORY TIME]
So I actually had my tonsils removed when I was 21 years old, which is not advised. If you need to have your tonsils out, you want it to be sooner rather than later. It's very hard surgery to recover from as an adult. But what I can tell you is that I had 4+ tonsils. I've had tonsils that were perpetually touching.
And this may be due to the fact that I have an inflammatory condition at baseline. I have an autoimmune condition, or this could just be that I'm somebody with big tonsils.
But I used to get strep throat like two, three, four, five times a year. And every year, up through the age of 21, which I'm very lucky, I didn't end up with rheumatic heart fever or anything like this, so.
But when I went to the ENT and he asked me to stick out your tongue and say, ah, I vividly recall him passing a light and going, "Yep, those are 4+ tonsils, and we will be removing them." And he's the one who taught me at the age of 21 about what the tonsil grading system means and essentially why we were going to take my tonsils out at 21. He asked me, "Are they always like this?" And I said, "Yeah, every day of my life." I didn't know what a big deal that was.
When they took them out, yes, it hurt a lot. And I had a lot of-- it took me a week to recover probably. However, I didn't know it was abnormal to have a sore throat every single day of your life. I just assumed everybody did.
I didn't know it was abnormal to get strep two, three, four, five times a year. Had no idea. I didn't know it was abnormal to have such a difficult time breathing while you sleep. As soon as they removed my tonsils, I have had strep throat one time since then. I'm 35 now.
So in 14 years, one time versus multiple times in a year. And my throat doesn't hurt anymore. It only hurts when I'm ill. Incredible.
But my daughter had the same thing. And I had an appointment set up to take her to her doctor, and I wasn't able to go with.
So I sent my husband a text message of, "Here's the things that I think are going on with her."
And he told me when he came back, he was like, "I read off to the doctor what you said: would like a referral to ENT for evaluation of 4+ tonsils."
And he said, "The doctor, the pediatrician, as I read it to her, kind of went and said, '4+ tonsils means that they're touching.'"
And he said, "Listen, I don't know. My wife is a nurse. She just told me to say this, like whatever."
And the pediatrician looked at my daughter's mouth and said, "And those are 4+ tonsils."
So they are rare. It is not a thing that I'm going to see in your average day-to-day person, but that does not mean that they don't exist in people just living their day-to-day lives walking around, having no idea that they had a huge threat to their airways.
