Page 235 - Critical Care Nursing Demystified

220 CRITICAL CARE NURSING DeMYSTIFIED

Best Motor Response
Obeys commands 6
Localizes stimuli 5
Withdrawal from stimulus 4
Abnormal flexion (decorticate) 3
Abnormal extension( decerebrate) 2
No response 1
Best Verbal Response
Oriented 5
Confused and disoriented 4
Inappropriate words 3
Garbled sounds 2
No response 1

Assessing Motor Movements—Strength and Coordination

Each extremity is evaluated and its function compared to the opposite extremity.
Sources describe muscle weakness as a cardinal sign of dysfunction in many Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
neurological disorders.
Categories of motor movement assessments include
Romberg’s test – Have the patient stand with feet together, first with eyes
open and then closed. Observe the patient for signs of swaying or signs of
beginning to fall, and if so, in what direction.
Finger-to-nose test – Have the patient touch one finger to the examiner’s
finger and then touch his or her own nose. The term for overshooting the
mark is known as dysmetria.
RAM (rapid alternating movement) test – Have the patient perform rapid
pronation and supination of each hand on each leg.
Heel-to-shin test – Moving from the knee to the ankle, have the patient
extend the heel of one foot down the front or anterior aspect of the shin.
Pronator drift test – This is a quick test to detect upper extremity weakness.
Have the patient hold his or her arms straight out with eyes closed and palms
outward. The nurse observes for any downward drift or pronation of the
patient’s forearms.
Lower extremity weakness can be tested by having the patient raise one leg
at a time off the bed against the examiner’s resistance.
According to some authors, motor function for each extremity is reported as
a fraction, such as