Page 243 - Critical Care Nursing Demystified

NURSING ALERT

If reflexes tend to be hyperactive, the nurse should test for ankle clonus by supporting

the patient’s knee in a slightly flexed position. With the other hand, the nurse should

dorsiflex the foot and keep it in a flexed position to minimize hyperactivity of the af-

fected area. There should be no movement of the foot.
TABLE 5–5 Commonly Assessed Deep Tendon Reflexes

Reflex Procedure Results
Patellar or Patient should be sitting with the legs The quadriceps mus-
knee jerk hanging downward, knees flexed at cle should contract
90 degrees. Strike the patellar tendon causing extension of
with the pointed tip of the reflex the lower leg.
hammer just below the knee.
Achilles Hold the bottom of the patientʼ s foot The gastrocnemius
tendon reflex in one hand and use the flat end of muscle should con-
the reflex hammer to strike the tract causing plantar
Achilles tendon at the heel or flexion of the foot.
posterior ankle area of the foot.
Triceps reflex The patientʼs relaxed arm should be As the triceps muscle
placed over the nurseʼs arm. The contracts the elbow
patientʼs elbow should be flexed at will extend.
90 degrees and held by the nurse who
strikes the triceps tendon just above 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.
the elbow with the reflex hammer.
Biceps reflex Position with the elbow flexed at 90 The biceps muscle
degrees and the arm relaxed. The should contract caus-
nurse places his or her thumb over ing flexion of the
the biceps tendon in the antecubital elbow.
space and fingers over the biceps
muscle. The nurse uses the pointed
end of the reflex hammer and strikes
his or her own thumb instead of
directly striking the tendon.
Brachioradial The nurse holds the patientʼs slightly The expected
reflex pronated and relaxed arm in his or response is pronation
her hand and strikes the brachioradial of the forearm with
tendon about 1-2 in above the wrist flexion of the elbow.
Babinskiʼs The handle of the reflex hammer can A normal or negative
reflex be used to stroke the side of the sole response should elicit
of the foot from heel to ball, curving plantar flexion of the
across the ball of the foot. toes. Abnormal or
positive response is
evident when the great
toe dorsiflexes and the
remaining toes on the
same foot fan outward
indicating upper motor
tract neuron disease.
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