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11.9: Assessing Reflexes

Last updated

Jul 28, 2021
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- 11.8: Assessing Cerebellar Function
- 11.10: Neurological Assessment

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Assessment of reflexes is not typically performed by registered nurses as part of a routine nursing neurological assessment of adult patients, but it is used in nursing specialty units and in advanced practice. Spinal cord injuries, neuromuscular diseases, or diseases of the lower motor neuron tract can cause weak or absent reflexes. To perform deep reflex tendon testing, place the patient in a seated position. Use a reflex hammer in a quick striking motion by the wrist on various tendons to produce an involuntary response. Before classifying a reflex as absent or weak, the test should be repeated after the patient is encouraged to relax because voluntary tensing of the muscles can prevent an involuntary reflexive action.

Reflexes are graded from 0 to 4+, with “2+” considered normal:

0: Absent
1+: Hypoactive
2+: Normal
3+: Hyperactive without clonus
4+: Hyperactive with clonus (involuntary muscle contraction)

To observe assessment of deep tendon reflexes, view the following video.

View Stanford Medicine’s Assessment of Deep Tendon Reflexes Video.^{^[1]}

Brachioradialis Reflex

The brachioradialis reflex is used to assess the cervical spine nerves C5 and C6. Ask the patient to support their arm on their thigh or on your hand. Identify the insertion of the brachioradialis tendon on the radius and briskly tap it with the reflex hammer. The reflex consists of flexion and supination of the forearm. See Figure $\PageIndex{1}$ ^{^[2]} for an image of obtaining the brachioradialis reflex.

Photo of nurse testing reflex of patient's forearm — Figure $\PageIndex{1}$ : Brachioradialis Reflex

Triceps Reflex

The triceps reflex assesses cervical spine nerves C6 and C7. Support the patient’s arm underneath their bicep to maintain a position midway between flexion and extension. Ask the patient to relax their arm and allow it to fully be supported by your hand. Identify the triceps tendon posteriorly just above its insertion on the olecranon. Tap briskly on the tendon with the reflex hammer. Note extension of the forearm. See Figure $\PageIndex{2}$ ^{^[3]} for an image of the triceps reflex exam.

Photo showing nurse testing reflex on patient's tricep — Figure $\PageIndex{2}$ : Triceps Reflex

Patella (Knee Jerk) Reflex

The patellar reflex, commonly referred to as the knee jerk test, assesses lumbar spine nerves L2, L3, and L4. Ask the patient to relax the leg and allow it to swing freely at the knee. Tap the patella tendon briskly, looking for extension of the lower leg. See Figure $\PageIndex{3}$ ^{^[4]} for an image of assessing a patellar reflex.

Photo showing a nurse testing the patellar reflex — Figure $\PageIndex{3}$ : Patellar Reflex

Plantar Reflex

The plantar reflex assesses lumbar spine L5 and sacral spine S1. Ask the patient to extend their lower leg, and then stabilize their foot in the air with your hand. Stroke the lateral surface of the sole of the foot toward the toes. Many patients are ticklish and withdraw their foot, so it is sufficient to elicit the reflex by using your thumb to stroke lightly from the sole of the foot toward the toes. If there is no response, use a blunt object such as a key or pen. The expected reflex is flexion (i.e., bending) of the great toe. An abnormal response is toe extension (i.e., straightening), also known as the Babinski reflex, which is considered abnormal after 2 years of age. See Figures $\PageIndex{4}$ – $\PageIndex{7}$ ^{^[5],^[6],^[7],^[8]} for images of assessing the plantar reflex.

Illustration showing plantar reflex and babinski sign — Figure $\PageIndex{5}$ : Plantar Reflex and Babinski Sign

Photo showing closeup of an adult's splayed toes — Figure $\PageIndex{6}$ : The Babinski Sign in an Adult

Photo showing closeup of an infant's splayed toes — Figure $\PageIndex{7}$ : The Normal Babinski Reflex in a Newborn

Video Reviews for Assessment of Deep Tendon Reflexes^{^[9]}

Thumbnail for the embedded element "Deep Tendon Reflex Examination for Nursing Head to Toe Assessment of Neuro System"

Babinski-Plantar Reflex^{^[10]}

Thumbnail for the embedded element "Babinski Reflex | Plantar Reflex Test | Nursing Head to Toe Assessment"

"Deep Reflex Exam Image 4.png" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
"Deep Reflex Exam Image 2.png" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0^↵
"Deep Reflex Exam Image 3.jpg" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0↵
"Neuro Exam Image 23.png" and "Neuro Exam Image 21.png" by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0↵
“Lawrence 1960 20.4.png” by Earl Lawrence House & Ben Pansky is in the Public Domain↵
“BabinskiSign.jpg” by Medicus of Borg is in the Public Domain↵
“Babinski-newborn.jpg” by Medicus of Borg is licensed under CC BY-SA 3.0↵
RegisteredNurseRN (2016, April 1). Deep tendon reflex examination for nursing head to toe assessment of neuro system. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/eqOpNQH09pA↵
RegisteredNurseRN (2016, March 29). Babinski reflex | Plantar reflex test | Nursing head to toe assessment. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/dcJgxuLtHdg↵

Brachioradialis Reflex

Triceps Reflex

Patella (Knee Jerk) Reflex

Plantar Reflex

Video Reviews for Assessment of Deep Tendon Reflexes[9]

Babinski-Plantar Reflex[10]

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Video Reviews for Assessment of Deep Tendon Reflexes^{^[9]}

Babinski-Plantar Reflex^{^[10]}