EMILIO AGUINALDO COLLEGE

School of Nursing

PERFORMANCE EVALUATION TOOL

PHYSICAL ASSESSMENT

Assessing Reflexes

NAME OF STUDENT:
SECTION/GROUP: Date:

LEGEND:
4 Very Satisfactorily Performed
(Student performs consistently in an effective and efficient manner)
3 Satisfactorily Performed
(Performance is usually effective and efficient but not always)
2 Fairly performed
(Progress in performance is too slow to judge satisfactorily; task performance is not properly for majority of the
time)
1 Poorly performed
(No progress in performance has been demonstrated, and or performance is consistently inefficient)

Assessing Reflexes
Preparation 4 3 2 1 REMARKS
1. Assemble equipment and supplies:
 Reflex hammer
Procedure

1. Introduce yourself; explain to the

client what you are going to do,
why it is necessary, and how she
can cooperate.
2. Wash hands and observe other
appropriate infection control
procedures.
3. Provide for client privacy.

Procedure
5. Test reflexes using a percussion
hammer, comparing one side of the
body with the other to evaluate the
symmetry of response.

0 No Response
+1 Minimal activity (hypoactive)
+2 Normal Response
3+ More active than normal
+4 Maximal Activity(hyoeractive)
6. BICEP REFLEX.
*test the spinal cord level C-5,C-6
 Partially reflex the client’s arm at
the elbow, and rest the forearm
over the thighs, placing the palm
of the hand down.
 Place the thumb of your non
dominant hand horizontally over
the biceps tendon.
 Deliver a blow (slight downward
thrust) with the percussion
hammer to your thumb.
  Observe the normal slight flexion
of the elbow, and feel the bicep’s
contraction through your thumb.
7. TRICEPS REFLEX.
* Test the spinal Cord level C-7,C-8
 Flex the client’s arm at the
elbow, and support it in the palm
of your nondominant hand.
 Palpate the triceos tendon about
2-5 cm (1-2inch) above the
elbow.
 Deliver a blow with the
percussion hammer directly to
the tendon.
 Observe the normal slight
extension of the elbow.
8. BRACHIORADIALIS REFLEX.
*test the spinal cord level C-5,C-6
 Rest the client’s forearm in a
relax position externally rotated
on a firm surface.
 Deliver a blow with percussion
hammer directly on the radius 2
to 5 cm above the wrist or the
styloid process, the bony
prominence on the thumb side of
the wrist.
 Observe the normal flexion and
supination of the forearm. The
fingers of the hand may also
extend slightly.
9. PATELLAR RELFEX.
*tests the spina cord level L-2,L-3,L-
4
 Ask the client to sit on the edge
of the examining table so that the
legs hang freely.
 Locate the patellar tendon
directly below the patella.
 Deliver a blow with the
percussion hammer directly to
the tendon.
 Observe the normal extension or
kicking out of the leg as the
quadriceps muscle contracts.
 If no response occurs and you
suspect the client is not relaxed,
ask the client to interlock the
fingers and pull.
10. ACHILLES REFLEX.
*tests the spinal cord level S-1,S-2.
 With the client in the same
position as for the patellar
refkex, slightly dorsiflex the
client’s ankle by supporting the
ball of the foot lightly in the
hand.
 Deliver a blow with the
percussion hammer directly to
the achilles tendon just above
the heel.
 Observe and feel the normal
plantar flexion (downward jerk)
of the foot.
11. PLANTAR REFLEX.
*this reflex is superfacial. It may be
absent in adults w/out pathology or
overridden by voluntary control.
 Use moderately sharp object,such
as the handle of the percussion
hammer, a key, or an applicator
stick.
  Stroke the lateral border of the
sole of the client’s foot, starting
at the heel, continuing to the ball
of the foot, and then proceeding
across the ball of the foot toward
the big toe.
 Observe the response. Normally,
all five toes end downward; this
reaction is negative Babinski. In
abnormal response (positive)
Babinski response the toes spreas
outward and the big toes move
upward.
14. Document findings in the client
record.
TOTAL

GRADING SYSTEM

Performance Score _________ x 90% = ______

Punctuality and Grooming _________ x 10% = ______

Total = ______

Evaluated by: Conformed by:

____________________________ ______________________________
Signature over printed name Signature over printed name