Upper and lower extremities nursing assessment during a head-to-toe assessment: Nurses assess the extremities so that they can identify potential diseases or disorders in the arms, hands, legs, and feet.
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The upper extremities examination (arms and hands) involves assessing things such as arm strength, arm drift, skin turgor (tenting), assessing the hands for deformities (such as Bouchard's or Herbeden's Nodes), assessing capillary refill, the joints, and any central lines or IVs.
The lower extremities examination involves assessing things such as color from legs to toes, normal hair growth (peripheral vascular disease: leg may be hairless, shiny, thin), are the legs warm (good blood flow)?
You'll also want to check for edema/swelling by pressing down firmly over the tibia to check for pitting. Look for any redness, swelling DVT (deep vein thrombosis), capillary refill less than 2 seconds in toes?
Also, check the following:
-How do the toe nails look (fungal or normal)?
-Are there sores on the feet? (Note: with diabetics, foot care is important. They don’t have good sensation on their feet. Therefore, inspect the feet for damage because they may not be aware of it.)
-Is there any breakdown on the heels?
-Assess joints of the toes and knees (any crepitus, redness, swelling, pain)
-Palpate pulses bilaterally: popliteal (behind the knee), dorsalis pedis (top of foot), posterior tibial (at the ankle) and grade them
-Palpate muscle strength: have patient push against resistance with feet and lift legs
-Test Babinski reflex: curling toes is a negative normal response
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