Organizing the Head to Toe Assessment using the "Rule of 3s"

HermioneG, BSN, RN

Towards the end of nursing school, I spent a week in the lab helping medsurg nursing students with their head to toe assessments. I noticed right away that many students struggled with organizing their head to toe assessment. I, myself, would frequently forget something important and have to double back during the assessment.

It wasn't until I was helping what was probably my thirteenth student that I started to see patterns in the assessment. What I discovered was that, if organized in a very specific way, the head to toe assessment could be broken up into threes. At the most basic level, each important body system has just three things to assess! It is in this way that I developed what I now call the "Rule of 3s"

Head to Toe "Rule of 3's"

Intro:

Introduction
Wash hands
ID band check

Orientation:

Person
Place
Time

Face:

Eyes
Mouth
Skin

Heart:

Inspect upper chest
Auscultate w/diaphragm
Auscultate w/bell

Lungs:

Inspect lower chest
Auscultate on front
Auscultate on back

Abdomen:

Inspect
Auscultate
Palpate

Legs:

Skin
Appearance (Edema? Abnormalities?)
Temp

Feet:

Pulse
Capillary Refill
Strength (dorsiflex, plantarflex)

Arms:

Skin
Appearance
Temp

Hands:

Pulse
Capillary Refill
Strength (grips)

IV/drains:

Rate
Infiltration?
Patency (flush with saline)

Back (assess for):

Skin
Appearance/Muscles
Temp

Back (3 landmarks for skin breakdown):

Occipital
Sacral
Heels

Closing:

Recap (Okay so I've finished your head to toe assessment...)
Questions/Concerns (Do you have any questions or concerns?)
Need Anything (Is there anything that I can get for you such as another blanket or some water?)

My advice to anyone wanting to use the Rule of 3s is to practice it in the same order every single time. I always go: Intro, Orientation, Face, Heart, Lungs, Abdomen, Feet... then up to Arms, Hands, IV site. I then roll the patient on their side and assess the entire back from head to feet and the three landmarks for skin breakdown, and finally "closing"

Some students preferred moving to the arms after abdomen, and then to the legs. Others preferred to split it up in a different way that made sense to them. No matter how you decide to move down the body, make sure to do it in the exact same sequence every single time. This can help you lay down a strong foundation to add onto later.

I also noticed that it helped the students significantly when I sat across from them and pointed each area of my body and had them verbalize the Rule of 3s to me. For example, I would point to my arm from my shoulder to my wrist and have them state the three things to assess for (skin, appearance, temp). I would then continue down the assessment sequence to my hand from my wrist to my fingers. As the students got better, they would immediately say "pulse, capillary refill, strength." It was so rewarding to see them get their assessments organized, and it helped me a lot too!

I have posted about this method in allnurses already and people have mentioned how it was helpful. I wanted to submit it as an article so that it can hopefully reach and help more people. Like I've said before, I do realize that posting this here comes with some risk. I've already shared this method with my classmates in school, a professor, and the educators in my department. I realize that this may "out" me to some people, but I think that risk is worth it!

-HermioneG

Organizing the Head to Toe Assessment using the "Rule of 3s"

Head to Toe "Rule of 3's"

About HermioneG, BSN, RN

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