Deep Tendon Reflex Examination for Nursing Head to Toe Assessment of Neuro System

Summary

In this educational video, Sales Ready Turner teaches how to assess deep tendon reflexes, crucial for evaluating lower motor neuron function. Key reflexes covered include bicep, triceps, brachioradialis, patellar, and Achilles. Turner explains the importance of reflex assessment in nursing, particularly in neuro and labor & delivery settings, and provides a grading scale for reflexes. Practical tips for eliciting responses and the correct technique for each reflex are demonstrated.

Takeaways

• 🔍 The video provides an overview on how to assess deep tendon reflexes, crucial for evaluating lower motor neuron function.
• 🏥 A reflex hammer is required to perform these assessments, which are part of a standard neurologic examination.
• 👩‍⚕️ Nursing students and nurses are taught to assess deep tendon reflexes, though frequency of use varies by specialty.
• 🤰 In labor and delivery, deep tendon reflexes are checked frequently due to risks associated with conditions like preeclampsia.
• 🩺 Checking deep tendon reflexes is important in med-surg units to monitor electrolyte imbalances that can affect reflexes.
• 📊 Reflexes are graded on a scale from zero (absent) to four plus (hyperactive or clonus), with a normal response being a two plus.
• 📝 Documentation of deep tendon reflexes is essential for medical records and tracking patient conditions.
• 💪 Practice is necessary to accurately assess reflexes, as the skill is subjective and requires experience.
• 🤲 Tips for eliciting responses include swinging the hammer briskly and ensuring the tendon is correctly located.
• 🦵 Demonstrations are provided for assessing the bicep, tricep, brachioradialis, patellar, and Achilles reflexes.

Q & A

What is the purpose of assessing deep tendon reflexes?

Deep tendon reflexes help evaluate the lower motor neuron/v or fibers at specific levels in the body, providing insights into the functionality of the spinal nerve roots.

What tools are required to assess deep tendon reflexes?

A reflex hammer is required to assess deep tendon reflexes.

Why are deep tendon reflexes particularly important in labor and delivery settings?

In labor and delivery, pregnant women are at risk for conditions like preeclampsia, which can cause hyperactive deep tendon reflexes. Checking these reflexes can help monitor the health of the mother and the baby.

How often should deep tendon reflexes be assessed in different nursing specialties?

The frequency of assessing deep tendon reflexes varies by specialty. For instance, nurses in neurology and labor and delivery might check them more routinely compared to those in other areas like cardiology.

What is the significance of grading scales in documenting deep tendon reflexes?

Grading scales are used to document the level of response during deep tendon reflex assessments, helping to identify hyperactive, normal, or diminished reflexes.

What does a score of 'four plus' indicate on the deep tendon reflex grading scale?

A score of 'four plus' indicates hyperactive or clonus reflexes, which is the highest score and suggests an overly active response.

How can one improve their ability to elicit responses during deep tendon reflex assessments?

Practicing the skill repeatedly helps to understand the difference between hyperactive and hypoactive reflexes, as it's a subjective skill that requires experience.

What is the correct technique for hitting the tendon with a reflex hammer?

The correct technique involves swinging the hammer briskly, not too slowly or too fast, and ensuring the hammer does not rest on the tendon after hitting.

How can one find the tendon for the bicep reflex assessment?

To find the bicep tendon, have the patient flex their arm and bicep, revealing a cord-like area where the tendon is located.

What response is expected when assessing the patellar reflex?

When assessing the patellar reflex, one should look for extension of the lower leg, indicating a normal response.

Why is it important to check deep tendon reflexes in patients with electrolyte imbalances?

Electrolyte imbalances can cause diminished or hyperactive deep tendon reflexes. Checking these reflexes provides a baseline to monitor changes in a patient's condition.