Module 07: Neuromuscular Assessment (Part 02) Flashcards
How should the nurse perform the Musculo-skeletal examination?
(1) Inspection of muscles, joints, and skin changes
(a) Symmetry
(b) Change in size and shape
(2) Palpate joints, bony prominences, muscles for mass, sensation of pain and tenderness
(3) Feel skin for changes in temperature
What are the normal findings as per inspection during the musculoskeletal examination?
Symmetrical, non-tender, size of muscles and bones equal on lt and rt extremities
What are the abnormal findings as per inspection during the musculoskeletal examination?
(A) Deformity
(B) Atrophy
(C) Contraction
(D) Swelling
(E) Crepitation
(F) Pain and tenderness
(G) Asymmetry/unequal size
How should the nurse perform the range of motion (ROM) and strength of the upper extremities?
(1) Instruct patient to resist your hand during flexion and extension of extremities
(2) Rate the strength using the muscle power scale 5/5 for maximum strength
What are the three (3) positions of the patient when examining the range of motion (ROM) and strength of their upper extremities? Cite the positions along with the following instructions.
(1) Arms outstretched
(2) Arms flexed towards chest
(A) Perform flexion and extension procedures on all extremities as you apply resistance to each extremity
(B) Apply resistance on outstretched arms (superior and inferior) and with arms flexed one at a time. Grade strength 0-5.
(C) Stretch out hands straight
(D) Dorsiflex patient’s wrist with fingers extended
(E) Observe outstretched hands for “tremors” and asterixis
(3) Hand grip test (nurse with crossover hands)
What are the normal findings when assessing the range of motion (ROM) and strength of the upper extremities?
No tremors, muscle strength grade 5
Negative tremors
This condition is also known as the hepatic flap which is a classic sign of liver disease.
Asterixis
What are the abnormal findings when assessing the range of motion (ROM) and strength of the upper extremities?
Limited ROM with pain and crepitation Muscle strength 0 = paralysis + tremors, + asterixis
This scale is often used to probe into the range of motion (ROM) and strength of the upper extremities
MRC Muscle Power Scale
What composes the MRC Muscle Power Scale?
(0) No contraction
(1) Flicker or trace of contraction
(2) Active movement, with gravity eliminated
(3) Active movement against gravity
(4) Active movement against gravity and resistance
(5) Normal Power
How should the nurse perform the range of motion (ROM) and strength of the lower extremities?
Repeat procedure flexion and extension to the lower extremities with resistance:
(1) Knees
(2) Lower legs
(3) Feet: repeat flexion and extension assessment:
What positions should the patient do when assessing the full range of motion (ROM) or rotation of the lower extremities?
Instruct patient to rotate ankle:
(A) Dorsiflexion and plantar flexion
(B) Eversion-inversion of toes
(C) Abduction and adduction of the ankles
What are the normal findings when assessing the range of motion (ROM) and strength of the lower extremities?
(1) Full ROM
(2) Normal strength 5/5
What are the abnormal findings when assessing the range of motion (ROM) and strength of the lower extremities?
(1) Limited ROM with pain and crepitation
(2) Decreased strength below 3/5
What kind of assessment is being performed when assessing the dorsalis pedis pulse?
Vascular Assessment
How should the nurse assess the patient’s dorsalis pedis pulse?
(1) Locate dorsalis pedis using three (3) fingers on both Rt and Lt feet.
(2) Palpate dorsalis pedis pulses at the same time
(3) Compare strength of pulses from Rt and Lt foot
What are the normal findings when assessing the patient’s dorsalis pedis pulse?
(1) Bilateral pulses present; Strong and equal
What are the abnormal findings when assessing the patient’s dorsalis pedis pulse?
(1) Weak in one foot or Absent (ck popliteal)
How should the nurse assess the patient for visible signs of ankle edema?
Procedure:
(1) Press dorsal foot and ankle for 5 seconds; severe edema may require longer firm pressure
(2) Estimate depth of edema using the guide.
This usually performed with assessment of edema on the shin bone bilaterally.
Ankle Edema Assessment
This is a test of cerebellar
coordination; involvement or presence of hemispheric cerebellar lesion.
Heel to shin rub
How should the nurse assist the patient to perform the Heel to shin rub?
Procedure:
(1) Sitting or lying position
(2) Instruct patient to run heel down to opposite shin one at a time
(3) Repeat procedure on the opposite extremities
What are the normal findings as per the heel to shin rub?
Movement of legs smooth and straight
What are the abnormal findings as per the heel to shin rub?
Heel falls off the lower leg or inability to complete the movement.
Uncoordinated movements or tremors are usually seen among patients who have?
Cerebellar disease (dysdiadochokinesia)
This test is usually conducted for disease affecting the corticospinal tract, embolic or thrombotic stroke of the pyramidal tract and upper motor neuron lesion; ETOH intoxication and post seizure
Babinski Reflex:
How should the nurse assess or perform the Babinski Reflex?
Procedure is contraindicated on patient with injury and /or skin disease of the foot
(1) Use the sharp end of the Reflex Hammer.
(2) Start: stroke the sharp end of hammer at the
lower lateral side of the foot.
(3) Scrape upward curving medially
(4) End: under the big toe
(5) Observe movement of the toes
What are the normal findings when assessing or performing the Babinski Reflex among adults?
Plantar flexion (downward) of the toes in adults
What are the normal findings when assessing or performing the Babinski Reflex among infants?
Infants: dorsal flexion (upward of the toes or a
jerk of the legs upwards
What are the abnormal findings when assessing or performing the Babinski Reflex among adults?
Upward movement of the toes Retraction of the
affected foot (severe)
This is used to assess the integrity of the motor system and provides information of the upper and lower motor neurons,
Deep Tendon Reflexes (DTR’s)
This occurs when a component of the lower motor neurons or reflex arc is impaired. This may be seen with spinal cord injuries.
Hyporeflexia
This occurs when deep tendon reflexes (rated +4) is seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.
Hyperactive (hyperreflexia)
This is known as the tendon above the olecranon.
Triceps
This is delineated to be located at the medial elbow joint.
Biceps
This is known as the tendon above the wrist.
Brachioradialis
This is known to be found below or inferior to the patella.
Patellar or knee Jerk
This is known to be found at the tendon above the calcaneus {heel).
Achilles or ankle jerk
What is the muscle of the triceps?
Triceps brachii
What is the muscle of the biceps?
Biceps brachii
What is the muscle of the brachioradialis?
Brachioradialis
What is the muscle of the patellar or knee jerk reflex?
Brachioradialis
What is the muscle of the achilles or ankle jerk reflex?
Gastrocnemius, soleus
What is the nerve supply and innervation of the triceps reflex?
(A) Nerve supply: radial
(B) Innervation C7-C8
What is the nerve supply and innervation of the biceps reflex?
(A) Nerve supply musculocutaneous
(B) Innervation C5-C6
What is the nerve supply and innervation of the brachioradialis reflex?
(A) Nerve supply: radial
(B) Innervation C5-C6
What is the nerve supply and innervation of the patellar or knee jerk reflex?
(A) Nerve supply: radial
(B) Innervation C5-C6
What is the nerve supply and innervation of the achilles or ankle jerk reflex?
(A) Nerve supply: tibial
(B) Innervation SI-52
How should the nurse assess the deep tendon reflexes of the patient?
(1) Instruct patient to be in a relaxed position
(2) Hold the handle of the hammer between your thumb and index finger
(3) If palpable, palpate tendon first
(4) Swing hammer briskly with your wrist and use a rapid wrist movement to strike the tendon.
(5) For arm reflexes, ask the patient to clench jaw or squeeze one thigh of the opposite arm.
(6) For leg reflexes, ask patient to lock the fingers of both hands and pull them against each other.
(7) Compare results between Rt and Lt extremities 8. Perform DTR’s on the following anatomical sites
What are the normal findings when assessing the patient’s deep tendon reflexes?
Range of normal DTR’s =+1, +2, +3
What are the abnormal findings when assessing the patient’s deep tendon reflexes?
Absent Grade = 0
These may suggest injury or disease involving a lower motor neuron (nerve roots or peripheral nerves).
Hypoactive reflex
What is the grade of a hyperactive reflex?
+4
This may suggest injury or lesion of upper motor neuron (brain, brainstem, or spinal cord). In severe cases, clonus is present: seen with MS, spinal cord injury, cerebral palsy and stroke.
Hyperactive reflex
How do you grade reflexes?
4+ = Hyperactive (clonus must be present)
3+ = Brisker than average, not necessarily abnormal
2+ = Average, normal
1+ = Diminished, low normal
0 = No response
Explain the response of infants in the Babinski response.
Extension (dorsiflexion) of the big toe and fanning of all toes are seen with lesions of upper motor neurons.
This is a a test of ability of the CNS to process and recognize spatio-temporal information through hand writing (tactile pressure and direction position of a moving tactile sensory input) on the palms
Cortical and Discriminatory Test
This is a test for cortical and discriminatory sensation, measure of fine tactual discrimination.
Graphesthesia
How should the nurse perform Graphesthesia?
(1) Instruct patient to close eyes
(2) Ask patient to identify number you wrote on his/ her palm (do not use ink)
What are the normal findings under Graphesthesia?
Identifies correct number
What are the abnormal findings under Graphesthesia?
Unable to identify number suggest lesion of the
sensory cortex (dorsal column)
This can be determined on the fingertips, forearm, dorsal hands, back, or thighs. Ask the client to identify the number of points (one or two) felt when touched with the EKG calibers.
Two-point discrimination
How should the nurse measure in Graphesthesia?
(1) Fingertips at 2 to 5 mm apart
(2) Forearm at 40 mm apart
(3) Dorsal hands at 20 to 30 mm apart
(4) Back at 40 mm apart
(5) Thighs at 70 mm apart
This is known as the ability to identify shape/ form of a 3-dimensional object; Test for cortical and discriminatory sensation.
Stereognosis
This suggest lesion of the somatosensory cortex and/or parietal lobe and CVA.
Astereognosis
How should the nurse perform Stereognosis?
(1) Instruct patient to close eyes
(2) Ask patient to identify object placed on his/her palms (e.g. coin, paperclip)
What are the normal findings when performing Stereognosis?
Identifies object correctly
What are the abnormal findings when performing Stereognosis?
Unable to identify object suggests lesion on the
sensory cortex
This is a motor assessment (repeated pronation and supination of hands); cerebellar assessment of coordination.
Rapid alternating movements of hands
This is the inability to perform alternating hand movements
Dysdiadochokinesia
How should the nurse asses the rapid alternating movement of the patient’s hands?
(1) The examiner should demonstrate the procedure to the patient and ask the patient to follow actions and speed
(2) Instruct patient to put palms of both hands down on both thighs, then turn the palms up and then turn the palms down again.
(3) Start slowly and increase speed
(4) Observe hand movements for coordination
What is the normal response when assessing the patient’s rapid alternating movement of the hands?
Rapidly turns palms up and down
What is the abnormal response when assessing the patient’s rapid alternating movement of the hands?
Uncoordinated movement, + tremors, jerky, and incomplete turning of palms
Inability to sense vibrations may be seen in ___________ (e.g., as seen with diabetes or chronic alcohol abuse).
Posterior column disease orb peripheral neuropathy
Identify the following:
(1) Absence of touch sensation
(2) Decreased sensitivity to touch
(3) Increased sensitivity to touch
(4) Absence of pain sensation
(5) Decreased sensitivity to pain
(6) Increased sensitivity to pain
(1) Anesthesia
(2) Hypesthesia
(3) Hyperesthesia
(4) Analgesia
(5) Hypoalgesia
(6) Hyperalgesia
This is delineated as the assessment of cerebellar dysfunction and coordination;
Finger to nose Test
These are delineated as tremors while nearing the target suggested lesion in the cerebellar hemisphere.
“Dysmetria”
How should the nurse assist the patient in performing the finger to nose test?
Instruct patient to close eyes, extend arms outward and then touch tip of the nose with right index fingers and return the arm to extended position. Repeat on the left side, and continue to repeat with alternating movements.
What is the normal finding under he finger to nose test?
Alternating movements are smooth; index finger returns smoothly to nose and arm extension
What is the abnormal finding under he finger to nose test?
Unable to complete movement; clumsy; stops and restarts
Inability to perform rapid alternating movements may be seen with __________.
Cerebellar disease, upper motor neuron weakness, or extrapyramidal disease.
This is often affected by disorders of the motor, sensory, vestibular and
cerebellar systems; cerebellar lesion, depression or organic brain disease.
Gait and Posture Ambulation
Unstable Gait may suggest what?
(1) ETOH intoxication
(2) Hydrocephalus
(3) Cerebellar lesions or abscess
How should the nurse assess the patient’s gait balance and proprioception?
(1) Instruct patient to stand erect for 5 seconds; check posture
(2) Instruct patient to walk naturally 5 steps forwards, turn around and walk back; observe stability, gait, hand swing
What are the normal findings when assessing the patient’s gait and posture ambulation?
(A) Erect posture, relaxed, feel stable, shoulders back
(B) Smooth gait and balance with normal stance and slight arm swing
What are the abnormal findings when assessing the patient’s gait and posture ambulation?
(A) Slumped, tense, and rigid posture
(B) Unsteady gait (stumbles), staggering, shuffles or drags feet or crosses feet
(C) +Titubation
(D) +Cerebellar Ataxia (widened base, unsteady gait, irregular steps and lateral veering)
This is an assessment of Cerebellar dysfunction and (Sensory - vestibulocochlear); positive sign may be seen as if “walking on a tight rope.”
Heel to toe walking (tandem walking)
How should the nurse guide or instruct the patient as per Heel to toe walking (tandem walking)?
(1) Show patient how to walk in a straight line with heel and toe
(2) Normal Findings: Maintained balance; may have very slight swaying of arms
What are the normal findings under Heel to toe walking (tandem walking)?
Maintains balance with tandem walk
What are the abnormal findings under Heel to toe walking (tandem walking)?
Unstable, with arms swaying
This is a test of proprioception; Sensorimotor integration: maintain balance involving visual, vestibular and cerebellum and dorsal column of the spinal cord
Romberg’s Test
How should the nurse guide or instruct the patient as per the Romberg’s Test?
(1) Instruct patient to stand erect with feet together with eyes open for 5 seconds
(2) Repeat with eyes closed for 20 seconds
(3) Caution: surround the patient with your arms to prevent falls
What are the normal findings under the Romberg’s Test?
(A) Stands straight with minimal swaying
(B) Negative “Ataxia”
What are the abnormal findings under the Romberg’s Test?
(A) Disproportionate swaying or falling, moves feet to prevent fall
(B) +Titubation – back and forth swaying while patient is standing
(C) +Cerebellar Ataxia (without coordination of arms and legs suggest damage to part of the cerebellum)
This condition is known as the back and forth swaying of the patient while standing.
Titubation
This condition is often associated with the absence of coordination in the arms and legs that may suggest damage to the part of the cerebellum.
Cerebellar Ataxia
