Head-To-Toe Assessment (S. Extremities)

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Inspection

1. Observe for size, contour, bilateral symmetry, and involuntary movement.
2. Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration.
3. Always compare both extremities.

Palpation

1. Feel for evenness of temperature. Normally it should be even for all the extremities.
2. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting for equality of contraction).
3. Perform range of motion.
4. Test for muscle strength. (performed against gravity and against resistance)

Table showing the Lovett scale for grading for muscle strength and functional level

Functional level	Lovett Scale	Grade	Percentage of normal
No evidence of contractility	Zero (Z)	0	0
Evidence of slight contractility	Trace (T)	1	10
Complete ROM without gravity	Poor (P)	2	25
Complete ROM with gravity	Fair (F)	3	50
Complete range of motion against gravity with some resistance	Good (G)	4	75
Complete range of motion against gravity with full resistance	Normal (N)	5	100

Normal Findings:

• Both extremities are equal in size.
• Have the same contour with prominences of joints.
• No involuntary movements.
• No edema
• Color is even.
• Temperature is warm and even.
• Has equal contraction and even.
• Can perform complete range of motion.
• No crepitus must be noted on joints.
• Can counter act gravity and resistance on ROM.

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