Health Assessment, part 40: Extremity Assessment & Tests

Hi. I'm Meris. And in this video, I'm going to be talking to you about assessing the extremities and some upper extremity assessment tests. I'm going to be following along using our health assessment flashcards. These are available on our website, leveluprn.com, if you would like to grab a set for yourself. Or if you prefer digital products, I would invite you to check out Flashables, the digital version of all of our flashcards. All right. Without further ado, let's get started.

So first up, I want to talk to you about the basics of assessing the extremities. And what I want to point out to you is that we actually have two separate cards for assessing the upper and the lower extremities. But for the purposes of this video only, I'm going to be talking about them as one. I still would encourage you to look at both of these because there is some slightly different information such as which pulses you should be feeling and which lymph nodes might be present. However, the general assessment is going to be the same. So again, we're going to start by looking with our eyes. We're going to be inspecting for symmetry, edema, color, any sort of deformities or varicosities.

So if we have any sort of varicose veins, for instance, those big dilated obvious veins on the legs especially, but it can be elsewhere, I'm looking for those things as well. And I'm then going to use my sense of touch to assess for temperature and moisture. Again, just like with a skin assessment, I'm going to be using the back of my hand to feel my patient's actual skin, right? We're going to take their actual skin, and we're going to be assessing for temperature and moisture when we do that. I will also then palpate the pulses in the extremities. So it depends on how thorough this assessment is, but for instance, I could assess the radial and the ulnar pulses. I could also assess the brachial pulse. And in the feet, I can assess for dorsalis pedis, posterior tibialis. I can look at popliteal, femoral. There's lots of different pulses that may need to be assessed when you are depending on how in-depth this assessment needs to be. We are also going to be looking at capillary refill, assessing for any sort of lymphadenopathy. And then we're also going to be assessing the range of motion and the strength of our patient's muscles, just like we talked about in musculoskeletal assessment. So that is the basics of assessing your patient's extremities.

But now I want to talk to you about some specific tests that are used to assess the upper extremities. And what I want to point your attention to is the fact that there is a ton of text on this card, and there is some bold red text. And when you see that, you know that that means this is especially important. We only give you the most important information, but if we make it bold and red, that means, "Hey, hey, this is the most important stuff we're telling you on this card." So we're going to pay attention to these things.

The first test I want to talk to you about is something called the modified Allen test. And modified Allen test is used prior to radial artery puncture. And what we are doing is assessing the patency of the arteries that supply the hand. We have what is called collateral flow, meaning that if one artery is not able to provide flow, for some reason, the other artery can perfuse the whole hand. So before I go puncturing the radial artery, because I'm going to hold pressure on that for five minutes afterwards, and because there's the possibility that there could be some sort of an injury from this procedure, I need to make sure that they have collateral flow with the ulnar artery.

So what does this look like? Well, we're going to occlude both the radial artery and the ulnar artery at the same time. It's hard for me to show you on myself because I would use my thumbs to do this in reality. But we're going to include both of these at the same time. And what we're going to do is have the patient, I call it wag off the blood, but they can either kind of flap their arm like this or close and open their fist. And the idea here is we're trying to get the blood out of their hand without letting any more in. It's going to then look pretty pale. And that's good. That's what I want. That's what I expect to see. Once that skin has blanched, I'm going to release pressure from one side, such as the ulnar artery, and I'm going to see and make sure that we have collateral flow. That's modified Allen test because, really, all I'm testing is the ulnar artery. But if we're talking about the full Allen test, we're then going to occlude both again, wag off the blood, and then we're going to let go of the radial artery. That's a true Allen test, but that is not what is being done before you do an ABG of the radial artery. We are doing modified Allen test.

The next test I want to talk to you about is the Phalen test. So the Phalen test is where you're going to have the patient put the dorsal sides of their hands, which are the backs of their hands, together like this. And you're going to have them hold it just like this at this 90-degree angle. Sorry, I didn't mean to cover my face for you there. You're going to have them hold it like that for 30 seconds. And the normal result is that they should be able to do this and report that they have no tingling anywhere. If my patient reports that they have tingling anytime up to that 30-second mark, this means that they might have compression of that median nerve which runs underneath, in that carpal tunnel. And if we have compression of the medial nerve, this may be carpal tunnel syndrome, and this may be something that requires further investigation.

The last one I want to talk to you about is the Tinel test. And the way I remember-- this is not an official cool chicken, but just the way I remember it is Tinel is for tapping. And so what we're going to do is we're going to have our patient put their wrist out, and I'm going to tap over their internal wrist where the median nerve runs. And I'm going to ask my patient, "Do you have any pain, or do you feel any paresthesias, any pins and needles?" And if they do, I am going to again suspect that this could be compression of the median nerve, which again could mean that this patient has carpal tunnel syndrome. This is an abnormal finding, and it needs further investigation. But if I'm doing Tinel's test, and I am tapping here on the medial portion of the inner wrist, the normal and expected finding is that they would report no pain, no paresthesias whatsoever.

All right. I'm so glad you stayed until the end because I've got some quiz questions to test your knowledge of key facts I provided in this video. Which tests should the nurse perform prior to obtaining a radial artery blood gas sample? A modified Allen test. What might a positive Tinel test indicate? Median nerve compression or carpal tunnel syndrome. What is the expected finding when performing the Phalen test? An absence of tingling.

All right. That is it for this video. I hope that you found it useful. I would love it if you would leave me a comment. Let me know something you learned, something you found especially memorable. Or if you have a great way to remember something that I didn't mention, I would love it if you would leave me a comment so we can see it, and I know other learners benefit from that as well. All right. Thanks so much, and happy studying.