Health Assessment, part 41: Neurologic Assessment & Tests, Reflex Assessment

Hi, I'm Meris. And in this video, I'm going to be talking to you about how to perform a neurologic assessment, including assessing for stereognosis, graphesthesia, and performing the Romberg test. I'm going to be following along with our health assessment flashcards. These are available on our website, leveluprn.com, if you want to grab a set for yourself. Or if you are more of a fan of digital products, I would invite you to check out Flashables, the digital version of all of our flashcards. All right. Let's go ahead and get started.

So first up, I just want to talk to you about the components of our neurologic assessment. So one of the first things that I perform, whether I mean to or not, is an observation of the patient's gait. How do they walk? Do they walk upright and with good balance, or do they have kind of a bent over, shuffling or festinating gait? What does that gait look like? That's going to tell me a lot about their neurologic status. I'm also going to have them do what's called a tandem walk. And a tandem walk, I always think of this as the field sobriety test, right? This is what they do on the side of the road if you get pulled over, and they think that you have been drinking. You're going to walk heel to toe, meaning that we're going to have you walk in a straight line with your heel immediately in front of the toes of the other foot. Can my patient do that? Are they wobbling? Are they reaching for balance? That's going to give me a lot of information about their neurologic status also. Then I'll perform the Romberg test, and I'll talk to you about that in a minute. We'll assess our patient's coordination with rapid finger movements or rapid coordination, things like finger to finger, finger to nose, or heel to shin movements. I can assess my patient's ability to sense vibration, light touch, and deep touch if we're doing a full in-depth neurologic assessment. I can then assess for stereognosis and graphesthesia, which I'll talk to you about in just a second. And then I will also assess my patient's reflexes. So those are sort of the components of the neurologic assessment, and now I'm going to talk to you about them a little bit more in depth.

All right. So first, I want to talk to you about performing the Romberg test. And the Romberg test is going to tell me about my patient's balance, especially their sense of proprioception. Is the patient able to tell about their own body's position in space and synthesize that information through the cerebellum and hold their balance with their eyes closed? So here's how we're going to do it. I'm going to have my patient stand with their feet together. Normally, we say hips width apart. No, no. We want to make this a narrow base for them to stand on. So feet together, arms by their side, and then we are just going to, "Close your eyes." Just have them stand there and close their eyes. And we are going to watch. Some wobbling is okay. Some swaying back and forth, that's okay. That's considered normal. But if my patient should fall or step forward to catch themselves, that would be considered a positive Romberg test, which is an abnormal finding. We're going to do that for 20 seconds or longer, depending on your facility's policy. And we expect that this patient should be able to hold their balance without stepping forward or falling. And that is the Romberg test.

Next, I'm going to assess my patient's ability to do what's called stereognosis. So stereognosis is basically the person's ability to synthesize three-dimensionality. Let me explain this. If I put something in your hand, something familiar that you know like a coin or a paper clip or a pen, you should, with your eyes closed, be able to feel that item in your palm, in your hand, and describe it to me. That is what stereognosis is, is the ability to reconstruct from touch a three-dimensional object. So that's exactly what we're going to do. We're going to put a familiar item, such as a paperclip, in our patient's hand with their eyes closed and ask them to identify it. It's just that simple. And then we'll move on to graphesthesia. We will assess our patient's graphesthetic ability. And this graphesthesia is similar but different. Graphesthesia has to do with the ability for a person to synthesize written numbers or figures using only their sense of touch. So similarly here, we're going to have the patient close their eyes, present me their palm, and I'm going to draw a number like 4 or 8. We're not going crazy. I'm not 1,700. No, no. Just a single-digit number. And we're going to ask that patient to identify, "Hey, what number did I draw in your palm?" If they can correctly identify it, then that's good. That's the expected finding. If they are unable to identify it or identify a different number, then that is going to be considered an abnormal finding.

All right. Let's move on. And I'm going to talk to you about reflexes and the Babinski reflex. So when we assess for deep tendon reflexes, there are lots of places that we can do this. The most common are going to be the patellar reflex, which you are very familiar with. That's the one where we're going to hit the knee with a reflex hammer. We should see that leg kick out. But there are some others like brachioradialis. There's a bunch of different ones. And what I would tell you is be familiar with whatever your institution or your facility wants you assessing as part of the DTR assessment. Now, how do we grade these reflex movements? I'm so glad you asked. I'm going to tell you. So we grade them from 0, meaning no response whatsoever, there is an absence of a deep tendon reflex, all the way to 4+. And 4+ is considered brisk or even clonus, that twitching. So if I try to elicit a deep tendon reflex, and that patient's knee just-- I mean, they just kick that leg right up, almost kick me in the face, right, that's 4+, really brisk reflex, or if we have clonus, which is that twitching, that beating rhythmic muscle, and this happens a lot in the ankles in certain patient populations, but that is very commonly where we assess for clonus is in the ankles. The normal finding for a deep tendon reflex is 2+. Now, I want you to really hear that because remember, that muscle strength is also graded on a similar scale, but that one, we expect it to be higher. We expect 5 out of 5 to be the strength that you have, but not for deep tendon reflexes. Those are going to be 2+ as the expected or normal value.

And then one of the last things that we will do as we conclude this neurologic assessment, we're going to assess for the patient's Babinski reflex. And the best way I can describe this to you is that you're going to be drawing an upside-down J on your patient's foot, starting with the lateral outside aspect of their foot, like at the bottom, towards their heel. You're going to draw it up and over across their toes towards the big toe in that upside-down J. What we expect here is dependent upon age. So in infants, we do expect to see a positive Babinski reflex. Go watch our videos in maternity or pediatrics about that. And we do expect that in infants. A positive Babinski reflex would be indicated by the toes fanning out in response to that stimulation. However, this is a very ominous sign in somebody who is not an infant. If I go to do the Babinski reflex-- as an ER nurse, this is something that I see done when we have somebody who comes in who is unresponsive. We're trying to figure out what their neurologic status is. If I do a Babinski reflex, and it is positive, and I see their toes fan out, that is an ominous-- a bad sign. That is an abnormal finding and should absolutely be reported to the provider immediately. The expected finding is that I will have downward flexion of the toes. They'll kind of curl down towards the bottom of the foot. And that is the expected finding for anyone who is not an adult is going to be a negative Babinski reflex.

All right. I'm so glad you stayed until the end because I'm going to test your knowledge of key facts provided in this video using some quiz questions. While performing the Romberg test, the nurse notices the patient begin to sway 10 seconds in. How should the nurse describe this finding? This is still considered a negative Romberg test, a normal finding. While assessing deep tendon reflexes, the nurse notes an above-average response without clonus. How should this be described? This would be a 3+ finding. The nurse is testing for the presence of a Babinski reflex in a three-month-old. When performing the test, the toes fan outward. Is this a positive or negative Babinski, and is it an abnormal or normal finding? This is a positive Babinski, which is a normal finding for a three-month-old.

All right. That is it for this video. I hope you learned something new. If you did, I would love it if you would leave me a comment. Let me know something you learned. Or if you have a great way to remember something different from what I said, I would love it if you would leave us a comment with that. I love seeing those comments, and I know it helps other learners as well. All right. I'll see you in the next one. Thanks so much, and happy studying.