Head to Toe Blueprint
Introduction
1. Introduce Self
2. Two patient identifier: look at hospital bracelet to verify.
- What is your name and DOB
3. Explanation of task:
- I’ll be doing a H2T assessment, Asking some questions and then ill start with your head and work
my way down to your feet
4. Hand Hygiene, Gloves
5. Assessment Questions
1. Do you wear any corrective lenses?
2. When was your last eye appointment?
3. Do you wear any hearing aids?
4. Do you have any chest pains right now?
5. Do you do your monthly self-breast exam? Men: Do you do your self-testicular exam?
6. When was your last bowel movement?
7. When was the last time you urinated? Did you have any hesitation, urgency, pain, burning,
sensation, or bleeding? What color was it?
8. Are you up to date with your pneumonia and flu vaccine?
Head/Neck/Eyes/Ears/Mouth
- I’m starting with your head, let me know if you feel any pain or tenderness while I’m doing this
6. Inspect & palpate scalp, hair, and cranium.
- Head is Normocephalic. I don’t feel any lumps or see any infestation
7. Inspects symmetry of face & Palpate around eyes/sinuses:
- Eyes are symmetrical, ears are symmetrical.
8. Pull eyelids down.
- Conjunctiva is Pink and Sclera is white.
9. **use penlight to look in ears & eyes
- no drainage noted in your ears or your eyes
10. Assess vision:
- Can you read my badge/this card? Can you see the clock on the wall?
- Pupils are equally rounded and reactive to light as well as with accommodations
11. Inspect/palpate the nose
- Any pain or tenderness?
- **Penlight: No drainage is noted
12. Assess oral mucous membrane for redness, soreness, bleeding gums, swollen tongue, and
missing teeth
- **penlight: No redness or drainage. Teeth are intact.
13. Have PT swallow
- Can you swallow for me? Any Pain? Trachea Is midline
14. Assess skin turgor. Pinch over clavicle
- Skin is intact.
15. State & Palpate lymph nodes (assess for pain)
- I’m going to check your lymph nodes:
➡ 10 lymph nodes:
1. Pre-Auricular
2. Post Auricular
3. Occipital
4. Jugulodigastric
5. Submandibular
6. Submental
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Head to Toe Blueprint
16.
17.
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7. Deep cervical chain
8. Superficial cervical
9. Posterior cervical
10. **HUNCH SHOULDERS: Supraclavicular
Inspect carotids/ ROM
- Raise head up, down, left and right.
- Any pain or tenderness?
Auscultate/ Palpate carotids
- I’m going to listen to your carotid artery.
Use bell of stethoscope to auscultate
- Have PT hold their breath & release for both
sides.
Palpate both sides individually.
- No bruits noted. Carotid arteries are at a 2+
Heart
- I’m going to listen to your heart
18. Auscultate heart at A, P, T, M with bell
- Im listening to your Aortic, Pulmonic, Tricuspid, and Mitral.
19. Feel and state where to find apical pulse
- I can feel your apical pulse at the left midclavicular line at the
5th ICS
20. Identify heart rhythm as Reg. or Irregular and within normal
limits
- Listen with diaphragm at apex and aortic
- I hear normal S1 and S2 sounds. S3 and S4 sounds are not present.
Thorax/Lungs
- I’m going to listen to your lung sounds, just breathe normally for me
21. Auscultate anterior chest for adventitious sounds in Z formation
22. Inspect posterior chest for spinal curvature/scapulae
- I see that you have a normal curvature of the spine within normal limits and scapula is
symmetrical.
23. Using any accessory muscle (note rate & rhythm)
- I do not see any accessory muscles being used.
24. Auscultate posterior chest for adventitious sounds in Z formation
- Just breathe normally for me. Breath sounds are clear.
25. Assess for CVA tenderness.
- Place hand behind lower ribs and lightly punch the back of your hand.
- Any pain or tenderness?
- I’m going to have you lay back for me
Abdomen
26. Assess for JVD
- Can you turn head to the right for me? Turn to the left? No JVD is noted
27. Inspect the contour
- I’m going to look at your abdomen. Abdomen is flat.
28. Auscultate bowel & arterial sounds.
- Bowel sounds heard in all 4 quadrants.
- Listen to renal and iliac arteries.
- No bruits noted.
29. Percuss 4 quadrants
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Head to Toe Blueprint
- Place hand over quadrant and tap over the back of your hand.
- Normal tympany heard in all 4 quadrants.
30. Lightly palpate 1cm. over 4 quadrants.
- Place hand over quadrant and push down with your other hand.
- No masses felt in any of the 4 quadrants.
Upper/Lower extremities
1. Assess skin temp, color, check for lesions, edema
- Run hands down pt arms
- Your arms are warm and dry, no lesions, redness noted.
2. Palpate & assess radial pulses (rate, rhythm, & force),
- Assess bilaterally.
- Radial pulses are 2+ bilaterally.
3. Capillary Refill.
- Press down on all 10 fingers.
- Capillary refills are less than 3 seconds.
4. Assess skin temp, color, check for lesions, edema
- Run hands down pt legs.
- legs are warm and dry, no lesions, edema or redness noted.
5. Palpate & assess posterior tibial, and dorsalis pedis pulses.
- Assess bilaterally.
- Posterior tibial: ankle area. Dorsalis pedis: Front of
foot
- Posterior tibialis pulses and Dorsalis pedis pulses
are equal bilaterally .
6. Capillary refill.
- Press down on all 10 toes.
- Capillary refill on toes are less than 3 seconds.
7. Assess strength and ROM on arms
- Can you push down? Up? Out? In?
- Muscle strength is a 5/5
- raise arms up and out:
- Full ROM on arms, Any pain or tenderness?
8. Assess Leg strength and ROM
- Can you push down? Up? In? Out?
- Muscle strength is a 5/5
- Lift legs by ankle outward and up.
- Any pain or tenderness? Legs have Full range
of motion.
9. Skin sensation
- Show pt what soft & hard feels like.
- Can you close your eyes for me
- Run soft on one arm and hard on other.
- What did you feel?
- Run soft on one leg and hard on other
- What did you feel?
- Thank you so much for letting me do this head to toe. You have a great day and I will go
ahead and send the doctor in.
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