NUR C102 : Health Assessment

Ruth I. Gutierrez
movement of • Muscles are fully developed • Muscle atrophy : lower motor
muscles and symmetric in size neurons or muscle disorders.
• No fasciculations, tics, or • Soft, limp, flaccid muscles :
tremors are noted. impaired lower motor neuron

Evaluate • Gait is steady; opposite arm • uneven or unsteady gait is noted

balance swings. with
Romberg test • Client stands erect with • Positive Romberg test: Swaying
minimal swaying with eyes and moving feet apart to
both open and closed prevent fall

stand on one • Bends knee while standing on • Inability to stand or hop on one
foot one foot foot is
• hops on each foot without • seen with muscle weakness
losing balance
 Tandem • Maintains balance • uncoordinated or
walking test • Walks on heels and toes unsteady gait
with little difficulty.
coordination • touches finger to nose • Loss of positional sense
with smooth, accurate and inability to touch
movements tip of nose
rapid • Client touches each finger • Inability to perform
alternating to thumb rapidly rapid alternating
movements • Client rapidly turns movements
palms up and down • Uncoordinated
movements or tremors
are abnormal findings
heel-to-shin • Client is able to run each • Deviation of heel to
test. heel smoothly down each one side orthe other
shin.
 Sensation • correctly identifies light • Inability to perceive
touch sensations : peripheral
• differentiates between neurophaties
dull and sharp • Hyperesthesia : increased
sensations sensitivity
• differentiates hot and • Analgesia : absence of pain
cold temperatures. sensation Light touch Pain Sensation

vibratory • Client correctly • Inability to sense vibrations

sensation identifies sensation
sensitivity to • Client correctly • Inability to identify the
position identifies directions of directions of the movements
movements.
tactile • Client correctly • Inability to correctly identify
discrimination identifies object. objects : astereognosis
Vibratory sensation Position sense
deep tendon Normal reflex scores : • Absent or markedly
reflexes q 1+ : present but decreased decreased deep tendon
q 2+ : normal reflexes
q 3+ : increased or brisk, but Biceps Reflex
not pathologic
Biceps reflex • Elbow flexes and • No response or an
contraction of the biceps exaggerated response
muscle is seen or felt. is abnormal.
• Rangesfrom 1 to 3
brachioradialis • Forearm flexes and
reflex. supinates.
• Ranges from 1 to 3
triceps reflex • Elbow extends, triceps
contracts.
• Ranges from 1 to 3
Triceps Reflex Brachioradialis reflex
 patellar • Knee extends, • No response or an
reflex quadriceps muscle exaggerated response is
contracts. abnormal.
• Ranges from 1 to 3
Achilles • plantar flexion of the
reflex foot. Patellar reflex Ankle clonus
• Ranges from 1 to 3
Test ankle • No rapid contractions • Repeated rapid
clonus of the ankle are elicited contractions
superficial • Flexion of the toes • Except in infancy,
reflexes occurs (plantar • dorsiflexion of the big
response) toe and fanning of all
toes positive (Babinski
response) : lesions of
upper motor neurons.
Achilles reflex Plantar Reflex