Page 242 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 227

Palpation

The critical care nurse should gently palpate areas of the patient’s body that
have created pain and distress for signs of fractures, deformities, lack of func-
tioning capabilities, and dislocations.

Percussion—Deep Tendon Reflexes

Critical care nurses must develop delicate and refined methods of assessing
individual responses to various stimuli in an effort to determine a person’s level
of neurological functioning or deficits that could identify specific injuries. Such
examinations consist of the nurse testing deep tendon or stretch reflexes for
degrees of muscle contraction in response to direct or indirect percussion of a
tendon. Reflexes generally occur without conscious thought and are responses
to sensory impulses placed on tendons and muscle groups. Sensory impulses
consist of sensory, CNS, and motor neuron components that comprise the
three-neuron reflex arc. An example of the three-neuron reflex arc is the with-
drawal reflex where a body part will withdraw from painful stimuli. 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.

H ? How to Do It —Deep Tendon

o I
o D
w t
o
t —De
Reflexes (DTRs)
Reflexes (DTRs)
1 . G e n t ly suppor t t h e t en d on an d a ll ow i t t
1. Gently support the tendon and allow it to relax.
se
a
e
the wrist when tapping th
f
f
lick o
U
2.
2. Use a flick of the wrist when tapping the tendon.
3. Note that the muscle group should co
3. Note that the muscle group should contract when tapping with the reflex
hammer
hammer.
4. Compare the muscle groups bilaterally. Commonly elicited groups are shown in
Table 5–5.
5. Record your responses by writing in the chart or making a stick man with num-
bers by each group.
6. Grades include the following: 0 = no response; 1+ = hypoactive, a sluggish or di-
minished response; 2+ = normal or an expected active response; 3+ = a slightly
hyperactive or very brisk, more than normal response, however, not necessarily
pathologic; 4+ = an abnormal, intermittent clonus or repetitive and brisk hyperac-
tive reflex action usually associated with neurological disease.