Comprehensive Head-to-Toe Assessment Notes

Introduction:
- Nurse introduces herself (Sarah) and explains the purpose of the assessment.
- Obtains patient's consent.
Armband Verification:
- Confirms patient identity using armband.
- Verifies name (Ben Dover) and date of birth (08/28/82).
Neuro Status Assessment (Alert and Oriented x4):
- Asks orientation questions:
  - Current location (hospital).
  - Purpose of the assessment (head-to-toe assessment).
  - Identity of the US President (Donald Trump).
- Determines the patient is alert and oriented to person, place, time, and situation (A&O x4).

Vital Signs:
- Collects heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and pain rating.
- Asks about pain level on a scale of 0-10.
- Patient reports no pain (0/10).
Height, Weight, and BMI:
- Collects height and weight to calculate Body Mass Index (BMI).
- BMI ranges:
  - Underweight: $BMI \le 18.5$
  - Obese: $BMI \ge 30$
General Survey (Ongoing Observation):
- Patient's response and emotional status (calm, agitated, drowsy).
- Apparent age compared to stated age.
- Skin color in relation to ethnicity.
- Ability to understand questions.
- Response time and appropriateness.
- Outward abnormalities (amputations, masses, lesions).
- Skin condition (sweaty, cold, clammy, cyanosis).
- Hygiene and posture.
- Presence of abnormal smells.

Inspection:
- Skin color (pink).
- Head size proportionate to the body.
- Abnormal facial movements or twitching.
- Facial symmetry (no drooping).
- Eyes and ears at the same level.
Cranial Nerve VII (Facial Nerve):
- Tests facial expressions:
  - Close eyes tightly and open them.
  - Smile.
  - Frown.
  - Puff out cheeks.
- Confirms that cranial nerve VII is intact.
Palpation:
- Uses gloves to palpate the head and cranium.
- Checks for masses, indentations, and skin breakdown.
- Pays special attention to the back of the head in immobile patients.
Hair Assessment:
- Looks for skin breakdown and infestations (lice).
- Checks for abrupt baldness (alopecia).
Beard Assessment (if applicable):
- Checks for lesions and infestations in the beard.
Hand Hygiene:
- Removes gloves and performs hand hygiene.

Temporal Artery:
- Palpates temporal arteries bilaterally.
- Notes pulse strength (2+).
Cranial Nerve V (Trigeminal Nerve):
- Motor Function:
  - Patient clenches teeth to assess the masseter and temporal muscles.
  - Patient tries to open mouth against resistance.
- Temporomandibular Joint (TMJ):
  - Palpates TMJ while patient opens and closes mouth.
  - Checks for clicking or grating sensations.
Sinuses:
- Palpates maxillary and frontal sinuses.
- Asks about pain or tenderness.

Inspection:
- Eyelids (swelling).
- Sclera (white, shiny, no yellowness indicating jaundice).
- Iris.
- Pupils.
- Conjunctiva (pink, no redness or drainage).
- Eye alignment in the eye socket.
- Assesses for strabismus (cross-eye).
Pupil Size and Equality:
- Assesses for anisocoria (unequal pupil size).
- Normal pupil size: 3-5 mm.
Cranial Nerves III, IV, VI (Oculomotor, Trochlear, Abducens):
- Nystagmus Assessment:
  - Checks for involuntary eye shaking.
  - Uses a penlight held 12-14 inches from the patient's nose.
  - Asks patient to follow the light through the six cardinal fields of gaze.
- Pupillary Reaction to Light:
  - Dims the lights and has the patient stare at a distant object.
  - Shines light from the side of each eye and observe for constriction.
  - Expected response: Pupils constrict from 3 mm to 1 mm bilaterally.
- Accommodation:
  - Turns lights back on.
  - Asks patient to stare at a distant object.
  - Moves a penlight slowly inward toward the nose.
  - Expected response: Pupils constrict and eyes converge.
Documentation:
- Documents pupils are equal, round, reactive to light, and accommodate (PERRLA).

Inspection:
- External ear abnormalities, redness, or drainage.
- Asks about ear pain.
- Checks for tophi (uric acid crystal accumulation) on the helix in patients with gout.
Palpation:
- Moves the ear and tragus to check for tenderness or masses.
Mastoid Process:
- Palpates the mastoid process for swelling, redness, and tenderness.
Otoscopic Examination:
- Inspects the tympanic membrane (pearly gray, translucent, shiny).
- Adult: Pulls the pinna up and back.
- Identifies the cone of light (right ear at 5 o'clock, left ear at 7 o'clock).
Cranial Nerve VIII (Vestibulocochlear Nerve):
- Whisper test (occlude one ear and whisper two words into the other ear).

Inspection:
- Nose midline on the face.
- Septum for deviation.
- Asks about nasal issues or drainage.
Patency:
- Checks patency by having the patient occlude one nostril and breathe out the other.
Internal Inspection:
- Uses a penlight to look for drainage, redness, or polyps.
Cranial Nerve I (Olfactory Nerve):
- Sense of smell test (uses a pleasant scent like vanilla).

Inspection:
- Lips (pink, not chapped, no sores).
  - Inspect color, should be pink not dusky or blue.
Cranial Nerve XII (Hypoglossal Nerve):
- Patient sticks out tongue and moves it side to side.
Internal Inspection:
- Uses gloves and a tongue blade.
- Inside of cheeks (pink, no sores).
- Tongue (moist, pink, not beefy red or dry/cracked).
- Underneath the tongue (for lesions).
- Gums (cavities, loose or broken teeth).
- Soft and hard palate.
- Uvula (midline).
Cranial Nerve IX (Glossopharyngeal Nerve):
- Patient says