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

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A quick and easy way to organize the head to toe assessment for anyone who, like me, has ever struggled with it!

Specializes in Emergency Nursing. Has 1 years experience.

What is Head to Toe Assessment?

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

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:

  1. Introduction
  2. Wash hands
  3. ID band check

Orientation:

  1. Person
  2. Place
  3. Time

Face:

  1. Eyes
  2. Mouth
  3. Skin

Heart:

  1. Inspect upper chest
  2. Auscultate w/diaphragm
  3. Auscultate w/bell

Lungs:

  1. Inspect lower chest
  2. Auscultate on front
  3. Auscultate on back

Abdomen:

  1. Inspect
  2. Auscultate
  3. Palpate

Legs:

  1. Skin
  2. Appearance (Edema? Abnormalities?)
  3. Temp

Feet:

  1. Pulse
  2. Capillary Refill
  3. Strength (dorsiflex, plantarflex)

Arms:

  1. Skin
  2. Appearance
  3. Temp

Hands:

  1. Pulse
  2. Capillary Refill
  3. Strength (grips)

IV/drains:

  1. Rate
  2. Infiltration?
  3. Patency (flush with saline)

Back (assess for):

  1. Skin
  2. Appearance/Muscles
  3. Temp

Back (3 landmarks for skin breakdown):

  1. Occipital
  2. Sacral
  3. Heels

Closing:

  1. Recap (Okay so I've finished your head to toe assessment...)
  2. Questions/Concerns (Do you have any questions or concerns?)
  3. 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

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7 Comment(s)

Yeah... I like the original format the first time you presented it to us, was easier to read and grasp.

Thanks for sharing it herebthough!

What's funny is, for some reason... I think I know who you are!!! :woot:

HermioneG, BSN, RN

Specializes in Emergency Nursing. Has 1 years experience.

Ben_Dover said:
Yeah... I like the original format the first time you presented it to us, was easier to read and grasp.

Thanks for sharing it herebthough!

What's funny is, for some reason... I think I know who you are!!! :woot:

how fun!!! I figured someone might recognize it or me... it's an awfully small world!! 🙂 🙂

Do we "know of" each other or are we on a first name basis?

tnbutterfly - Mary, BSN, RN

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

I'm not sure how the formatting got changed, but I changed it back to the original format.

HermioneG, BSN, RN

Specializes in Emergency Nursing. Has 1 years experience.

tnbutterfly said:
I'm not sure how the formatting got changed, but I changed it back to the original format.

Thank you so much!! 🙂

Akay1717

Specializes in Anesthesia, Trauma, Palliative, Tele. Has 9 years experience.

Thanks for posting! Want to use this idea to help nurses anesthetists perform thorough pre op assessments! Great idea and observation.

HermioneG, BSN, RN

Specializes in Emergency Nursing. Has 1 years experience.

Akay1717 said:
Thanks for posting! Want to use this idea to help nurses anesthetists perform thorough pre op assessments! Great idea and observation.

Oh wow, that makes me so happy thank you for sharing!! It means so much to me when people share how they plan to use it! That's wonderful and I'm excited that people are using it, thanks! 🙂