Documenting sinus assessment findings: note tenderness or pain and other observations

Outline (quick skeleton)

• Why documenting sinus findings properly matters

• The key rule: note tenderness or pain experienced

• Other important findings to include (symmetry, fullness, discharge)

• How to phrase the notes: practical examples and templates

• Common slips to avoid

• Why these details matter for care and communication

• Quick takeaways you can use right away

Article: Clear, Compassionate Sinus Documentation: What to Note and Why It Matters

Let’s talk about the sinuses. They’re small cavities, yes, but they pack a big punch when they’re inflamed or infected. In nursing notes, how you record what you found after assessing the sinuses can steer the whole care plan. Think of it as a flashlight for other health team members. The better the notes, the easier it is to spot trouble, track progress, and tailor treatment. And that’s exactly what ATI’s physical assessment materials encourage: precise, patient-centered documentation that makes sense at a glance.

The one thing that really matters (and why it deserves your attention)

Here’s the core rule, plain and simple: document any tenderness or pain the patient reports or shows during palpation. Why is this so critical? Because tenderness isn’t just a momentary discomfort. It can signal underlying issues like sinusitis, infection, or blockages that may need antibiotics, imaging, or other interventions. If you skip over it, you risk losing a key clue about the patient’s current state. And in a busy clinical environment, a well-recorded symptom like tenderness can be the difference between catching a problem early and letting it simmer.

That said, tenderness isn’t the only thing clinicians care about. It’s the starting point, not the end of the story. The rest of the notes help paint a full picture of sinus health and guide next steps.

What else to include (beyond the obvious)

If tenderness is the star, there are a few supporting players you should also capture when you assess the sinuses:

• Symmetry: Are both sides the same in terms of contour and response? Some asymmetry can point to localized inflammation or other issues.

• Fullness or edema: Do the cheeks, forehead, or areas over the sinus regions look swollen or tender to touch even without palpation?

• Nasal discharge: Note color, consistency, and amount if present. A thin, clear discharge is different from a thick, colored discharge—each hinting at different etiologies.

• Facial expression and functional symptoms: Did the patient grimace on palpation? Any reported obstruction, pressure, or headaches?

• Associated symptoms: Fever, malaise, dental pain, or postnasal drip can corroborate a sinus issue.

• Baseline vitals or relevant exam findings: Sometimes sinus concerns pair with upper respiratory signs, so a quick clinical context helps.

The art of phrasing notes: practical templates you can adapt

You don’t need to write a novel. You need clear, usable phrases that others can skim and act on. Here are practical ways to document after a sinus assessment:

• Direct tenderness note

• “Tenderness to palpation over the frontal and maxillary sinuses bilaterally, rated as 3/10 on the patient’s pain scale.”

• “Pain reported with sinus palpation in the left maxillary region; patient describes dull, pressure-like discomfort (2/10).”

• Symmetry and appearance

• “Sinus regions symmetric with mild facial fullness on palpation.”

• “No visible edema around frontal or maxillary areas.”

• Discharge and other clues

• “Nasal discharge present; color yellow-green, thick; no foul odor noted.”

• “No nasal discharge; mucosa pink and moist.”

• Putting it together in a single entry

• “Sinus palpation: bilateral frontal and maxillary tenderness; pain 3/10. Mild facial fullness. Nasal discharge present, thick, yellow-green. No fever reported. Patient reports pressure worsened when bending forward.”

If you want a quick template for your notes, try this structure:

• Assessment headline: what you checked (frontal sinuses, maxillary sinuses)

• Findings: tenderness/pain (location, intensity), symmetry, fullness

• Discharge/other signs: nasal discharge, edema

• Patient-reported factors: pain scale, onset, aggravating factors

• Plan cue: what you’ll monitor or address next (e.g., consider antibiotic for bacterial sinusitis if other signs align)

Why these details matter in real care

Documentation isn’t just paperwork. It’s a living map of a patient’s health. When you record tenderness and its details, you provide:

• A basis for diagnosis: Tenderness can tip the scale toward sinusitis or other sinus pathology when paired with discharge, fever, or facial pain.

• A plan for treatment: Knowing exactly where the patient hurts helps decide whether to pursue antibiotics, decongestants, nasal irrigation, or imaging.

• Clear communication: Other nurses, physicians, and therapists rely on precise notes to coordinate care, avoid delays, and reassess appropriately.

• Legal and professional clarity: Thorough notes protect both patient and provider by documenting what was found and how the team responded.

A few real-world-friendly notes

Let me explain with a tiny scenario. A patient comes in with facial fullness and sinus pressure. Your note might read: “Tenderness to palpation over frontal sinuses bilaterally; forehead tenderness intensifies with palpation. Mild facial fullness. Nasal discharge: scant, clear. No fever. Pain described as pressure-like, 4/10.” This kind entry tells the story: what was found, how it felt to the patient, and what you’re watching next. If symptoms escalate, the chart makes it easier to justify a change in treatment or the need for further testing.

Common slips—and how to avoid them

We’ve all seen notes that miss a beat. Here are the usual culprits and straightforward fixes:

• Sloppy or vague notes: “Sinuses normal.” That line misses a lot. If you didn’t palpate or you found tenderness, say it clearly. If nothing remarkable was found, document “no tenderness on sinus palpation” and supplement with other findings.

• Failing to capture the patient’s experience: It’s not enough to say “no pain.” If the patient reported pain, quote or paraphrase it. A simple “patient reports pain with palpation” signals you’ve listened.

• Overloading with clinical jargon but missing the patient’s perspective: Balance is key. Pair objective findings with patient-reported symptoms.

• Inconsistent terminology: Decide on a couple of terms (e.g., “tenderness to palpation,” “pain on palpation,” “nasal discharge present”) and stick to them so everyone reads notes the same way.

How these notes connect to the bigger picture

Documentation after a sinus assessment has ripple effects. It shapes the initial impression, informs differential diagnoses, and affects what you teach the patient about self-care. When you describe tenderness clearly, you’re also conveying how much the patient is affected day to day. That emotional thread—how the symptoms touch their life—matters. It helps you tailor advice about hydration, humidification, nasal saline rinses, rest, and when to return if symptoms worsen.

A few quick tips you can put into practice today

• Be explicit about pain: include location (frontal, maxillary), intensity on the pain scale, and whether pain changes with movement or position.

• Include a concise set of positive findings: tenderness, fullness, discharge, and symmetry. It’s a small checklist that makes a big difference.

• Use patient quotes when helpful: “It feels like pressure in the forehead,” can be more meaningful than “pain described.”

• Tie findings to potential actions: “Pain persists; consider imaging if symptoms don’t improve in 48-72 hours.”

• Keep notes readable: short sentences, bullet points when possible, and a logical flow from palpation to findings to plan.

Bringing it all together: why this approach matters for ATI’s learning resources

ATI’s physical assessment materials emphasize sound clinical reasoning paired with clear communication. When you document properly, you’re not just ticking boxes—you’re demonstrating the ability to observe, interpret, and respond. The sinuses are a small but telling part of the head-and-neck exam, and they illustrate a core nursing skill: turning sensory impressions into actionable care.

If you’re revisiting sinus assessment, think of tenderness as the anchor. Everything else—symmetry, fullness, discharge, and related symptoms—adds texture to the picture. The goal isn’t to overwhelm your notes with detail; it’s to produce a clean, useful narrative that helps teammates, supports the patient’s comfort, and guides the next steps in care.

Bottom line

When you document after assessing the sinuses, the most important piece is to mention any tenderness or pain experienced. Do that well, and you’ve already communicated a crucial part of the patient’s condition. Then add the rest—the symmetry, fullness, nasal discharge, and any related symptoms—and you’ll create notes that are not only precise but genuinely helpful in shaping thoughtful, timely care.

If you’d like, I can tailor a short, ready-to-use note template based on how you typically chart in your setting. It’ll be simple, clear, and ready to adapt to your electronic health record, so you can keep your focus on patient care where it belongs.