Nurs405 Teaching and Learning Guide: Spine, Sensation, Coordination and Reflexes

Not
es
1. Wash hands
2. Introduce self to patient and gains consent

Gait
3. Observe patient’s posture while walking away from you, turning & walking back to you

4. Note fluidity and smoothness of gait, posture steadiness, any hesitancy, and swinging/
position of arms

Inspection of Spine
5. Inspect skin condition on posterior back - note any lesions, scars, muscle wasting,
deformity, atrophy, fasciculations.

6. Assess cervical, thoracic and lumbar curves for increased/ decreased concavity.
7. Verbalize spine curvature as lordosis, scoliosis, kyphosis or normal

8. With patient standing erect and then in flexion, inspect for alignment & symmetry of
patient’s iliac crests & creases below gluteal folds.

Palpation
9. Palpate the spinous processes of each vertebra for tenderness or pain.
10. Inspect & palpate the lower lumbar area for a vertebral step-off (unusual prominence or
recession)

11. Palpate paravertebral muscles for tenderness or spasm.

12. Palpate over the sacroiliac joints for tenderness or pain.

ROM – Standing

13. Assess spine flexion and extension, Lateral bending (right and left), rotation, for
coordinated motion, pain, impaired movement/ fluidity.
14. Assess neck flexion, extension, rotation, lateral (ear to shoulder)

Extra neurological tests (if indicated)

15. Romberg test (position sense) - Patient stands

with feet together, eyes open. Then without
support, closes eyes for 20-30 seconds- notes
patient’s ability to maintain upright posture

16. Pronator drift (weakness) - Patient stands for 20-30 seconds with arms straight forward,
palms up, eyes closed. Inspect for a sideway or upward drift of the hand.
Sensation (Broad Screen)
17. Ask patient to close eyes & using cotton wool and broken spatula (or paper clip) show them
what is sharp and what is dull

18. Test light and sharp sensation over both shoulders & compare both limbs.

19. Test light and sharp sensation over lateral and medial aspect of forearm & compare both
limbs

20. Test light and sharp sensation over anterior thigh & compare both limbs.

21. Test light and sharp sensation over lateral and

medial calves & compare both limbs.
 22. Test light and sharp sensation over
lateral dorsum of foot & compare both
limbs.

Reflexes – both limbs - Grade each reflex using a scale of 1 + 2+ 3+ 4+ (2+ is normal)

23. Assess and grade brachioradialis reflex, biceps, triceps, patellar, plantar reflex (stroke
lateral aspect of sole from heel to ball of foot and note movement of toes)
Mention dorsiflexion of big toe and fanning of other toes as abnormal (Babinski response)
Coordination

24. Tap the patient’s ball of foot briskly with your hand to assess for clonus.

25. Ask patient to place their heel on opposite shin and run heel down shin (both limbs).
Observe speed, rhythm, smoothness of movement, accuracy.

26. Ask patient to do rapid alternating movements on both thighs.

 27. Ask patient to do rapid alternating movements on both hands.

28. Ask patient to touch their index finger & then their nose alternatively several times.

29. Using 128 HZ tuning fork, assess vibration over 1 st MTP & compare both limbs.

Notes

Equipment – Tuning fork, cotton wool, spatula

Ankle Reflex
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