When Nurses Check Reflexes
Registered nurses (RNs) do not typically perform a full deep tendon reflex (DTR) check as part of a routine adult physical assessment. This is a common misconception, as reflex testing is more often associated with physicians or advanced practice nurses (APRNs). However, the scope of a nurse's practice is dynamic and depends heavily on the care setting and patient population. Nurses check reflexes frequently in specialized environments where neurological monitoring is critical for patient safety and condition management.
In Specialized Adult Care
Nurses working in specialty units have different responsibilities that require detailed neurological assessments, including reflex testing. In these cases, checking reflexes is an essential, often frequent, task:
- Neuroscience Units: For patients with conditions like spinal cord injuries, stroke, or traumatic brain injury, frequent neurological checks are vital for monitoring changes in condition. Nurses compare reflex responses to the patient's baseline to detect new or worsening deficits.
- Critical Care (ICU): In intensive care units, nurses monitor patients on specific medications or with severe conditions. For example, a nurse administering magnesium sulfate to an obstetric patient with pre-eclampsia must monitor deep tendon reflexes closely, as an absent reflex can indicate drug toxicity.
- Advanced Practice Nursing (APRNs): Nurse practitioners and other APRNs perform comprehensive neurological exams that routinely include DTRs, similar to physicians. Their advanced training equips them to interpret reflex findings for diagnostic purposes.
In Neonatal and Pediatric Care
Reflex checks are a cornerstone of newborn assessment and are regularly performed by nurses. Neonatal reflexes are involuntary movements that indicate the healthy development of the nervous system.
- Common Neonatal Reflexes: Nurses assess for several key reflexes in newborns, including:
- Moro (Startle) Reflex: The infant is startled by a noise or movement, causing them to throw back their head and extend their arms and legs.
- Rooting Reflex: Stroking the infant's cheek causes them to turn their head and open their mouth, helping them find food.
- Grasp Reflex: The infant's fingers curl around an object placed in their palm.
- Babinski Reflex: Stroking the sole of the foot causes the toes to fan out.
These reflex assessments are crucial for identifying potential neurological or developmental issues in infants and are a routine part of a neonatal nurse's role.
Components of a Nursing Neurological Exam
For a standard adult patient, a routine nursing neurological assessment, often called a "neuro check," focuses on the following key areas, with DTRs typically reserved for more comprehensive evaluations:
- Mental Status: Nurses evaluate a patient's level of consciousness, orientation (person, place, time), and ability to follow commands.
- Pupillary Response: Checking that pupils are equal, round, and reactive to light is a vital part of every neuro check.
- Motor Strength and Sensation: Assessment includes evaluating motor strength in all four limbs by asking the patient to push and pull against resistance, as well as checking for symmetrical sensation.
- Cerebellar Function and Gait: Nurses may observe a patient's balance and coordination while they walk.
Performing a Deep Tendon Reflex Check
When a DTR check is necessary, the nurse uses a reflex hammer to elicit an involuntary response. This is often done by tapping a tendon, which causes a quick stretch of the attached muscle. The reflex is then graded on a scale, with 2+ considered normal.
Interpretation of Reflex Findings
Interpreting reflex findings is critical for detecting neurological abnormalities. Asymmetry in responses between the right and left sides of the body is often more significant than a general increase or decrease. Alterations in reflexes can be linked to conditions such as:
- Hyperreflexia: Overly brisk reflexes can signal issues with upper motor neurons.
- Hyporeflexia: Diminished or absent reflexes may indicate lower motor neuron problems or neuromuscular disease.
- Clonus: Rhythmic, involuntary muscle contractions can be a sign of increased reflexes.
The Difference Between Routine and Comprehensive Neurological Exams
| Feature | Routine Nursing Neurological Exam | Comprehensive Neurological Exam |
|---|---|---|
| Primary Goal | Rapidly assess key neurological functions and monitor for changes in condition | Thoroughly evaluate the entire nervous system to identify and diagnose specific issues |
| Assessor | Registered Nurse (RN) | Advanced Practice Nurse (APRN), Physician, or Neurologist |
| Reflex Check | Generally excluded for stable adults; included in specialty units (e.g., neonatal) | Routinely includes deep tendon reflex (DTR) testing |
| Components | Level of consciousness, pupillary response, motor strength, sensation | All of the above, plus cranial nerve assessment, cerebellar function, detailed DTRs |
| Patient Focus | All hospitalized patients, particularly those with a risk of neurological decline | Patients presenting with neurological symptoms or a known neurological disease |
| Tools | Penlight for pupil check; observations | Penlight, reflex hammer, tuning fork, cotton swabs |
Reporting and Documentation
Nurses are critical in observing and documenting subtle changes in a patient's neurological status. Accurate documentation of reflex findings, including the specific reflex tested and its grade, is crucial for effective communication among the healthcare team. In many cases, a nurse's observation of a reflex change triggers a more extensive workup by an advanced practitioner or physician. Therefore, understanding when and how to perform these checks is a core competency, especially for those in specialized or advanced roles.
Conclusion
Ultimately, whether a nurse checks reflexes depends on the clinical context. While it's not part of the standard, basic neuro check for every adult, it is an essential skill and responsibility in specific patient populations, including infants, neuroscience patients, and those in critical care. Advanced practice nurses incorporate reflex testing into their routine comprehensive exams. A nurse's keen observational skills and ability to accurately assess neurological function are invaluable for patient safety and outcome. To learn more about neurological assessments, you can review this overview from Stanford Medicine 25.
