As a nurse and nursing student, you will learn how to assess the deep tendon reflexes. In this article, I will discuss how to assess the achilles tendon reflex along with a video demonstration.
The deep tendon reflex examination is part of the neuro assessment for the nursing head to toe assessment. This assessment is usually conducted during the head-to-toe nursing assessment. Nurses do not routinely assess the deep tendon reflexes unless they work in settings such as labor and delivery or neurology or a patient’s condition warrants it (electrolyte imbalances etc.).
Why do nurses assess the deep tendon reflexes?
It helps evaluate the lower motor neurons/fibers at certain levels of the body. For example, the triceps reflex evaluates C7 to C8, and the brachioradialis reflex evaluate C5 to C6.
Grading Scale for Deep Tendon Reflexes
4+ Hyperactive (clonus)
3+ Brisker than normal (hyperreflexive)
2+ NORMAL
1+ Diminished (hyporeflexive)
0 Absent
Demonstration on How to Assess Achilles Deep Tendon Reflex
How to Assess the Achilles Deep Tendon Reflex
Find the achilles tendon.- Locate the heel of the foot and dorsiflex the foot. The achilles is found right above the heel.
- Now have the patient dangle the foot while you dorsiflex it.
- While the foot is dorsiflex, tap with the reflex hammer briskly on the achilles tendon.
Expected Response of the Achilles Deep Tendon Reflex
You will see the foot plantarflex.