A complete head and scalp assessment addresses each of the following as indicated by the patient’s condition and orders, and compares each finding to baseline.
Scalp and hair — lesions, lacerations, scaling or seborrhea, infestation (lice/nits), and overall integrity.
Skull — tenderness, masses, depressions, or step-offs, especially after trauma.
Face (general) — gross symmetry and facial skin; detailed cranial-nerve testing is documented in Neurological.
Head-injury surveillance — after any fall or strike, the mechanism, and the signs of evolving intracranial injury (headache, vomiting, drowsiness, confusion, unequal pupils, focal deficit), with heightened vigilance on anticoagulants.
Headache — onset, severity, quality, triggers, associated symptoms, and any departure from the patient’s usual pattern.
Temporal-artery region — tenderness or a prominent, tender artery in older adults, with associated jaw claudication or visual change.
The anticoagulation and antiplatelet context — current agents and the resulting bleeding risk after any head strike.
Mentation and any neurologic change as a screen that triggers the Cognitive and Neurological pathways.
Relevant devices — a ventricular shunt or a recent cranial-surgery site, where present, for the site and for signs of malfunction.
The home environment and fall context where a head strike has occurred (cross-reference Safety).
