Head-To-Toe Assessment (S. Extremities)
Inspection
- Observe for size, contour, bilateral symmetry, and involuntary movement.
- Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration.
- Always compare both extremities.
Palpation
- Feel for evenness of temperature. Normally it should be even for all the extremities.
- Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting for equality of contraction).
- Perform range of motion.
- 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.
Complete Head to Toe Assessment with Videos
