1+ to 4+ reflexes ?? Help !

bagladyrn, RN · Mar 7, 2003

Let's see - 1+ to 2+ is "normal" I use a reflex hammer, the side of my stethescope, or sometimes just the side of my hand for patellar reflex. 1+ - the toe twitches, 2+ the foot moves, 3+ more definite foot/lower leg movement and 4+ - just about kicks you in the nose. When on magnesium, you're watching for the decrease in DTR's to indicate the efficacy of treatment. If you get no reflex after being on magnesium check a mag. level right away and watch respirations/consider lowering mag rate. In the other direction, an increase in DTR's to 4+, especially with clonus (sometimes 4+ is defined as only when clonus is present), the patient may be moving toward seizures.

ShandyLynnRN, BSN, RN · Mar 7, 2003

It is obviously pretty subjective, but I can tell you from experience that the only way you will know is to practice. Once you have seen 4+, you'll know it, as the leg practically flys off!!!

Here's how I define them:

1+ : foot moves

2+ : small bounce, the "general" reflex you will usually get during routine assessment.

3+ : what I call "hyperreflexic", where it is a definite kick

4+ : don't get too close to the leg or you will be kicked in the face

I also notice that when they are 3+ to 4+ is when I can just tap with my fingers and get a huge response in reflex form.

About clonus, I have been in OB (small hospitals, low risk usually) I had NEVER seen TRUE clonus until about a month ago. Two beats, was awesome! (not for the patient, who made me very nervous with BP's of 196/110 and 4+ protein in urine 2 days PP)

I have been told by more experienced OB nurses that there IS "non-true" clonus, where you will get a little bounce afterwords, usually from someone who is very anxious, and has only 2-3+ DTR's....

In time, you will figure it out. What I did when I was learning was to have more experienced nurses, or even the docs, check after me and compare results. And even if I had TWO different people check after me, the results varied. I could have called it 3+, and had another nurse call it 4+ and another one call it 2+...

To expound, the patient that I felt clonus on and 4+ reflexes, the doc came in right after and said she had only 2+ and no clonus... and the nurse working with me agreed with my assessment as well.... (me thinks the doc just didn't want to start mag on her, personally)

passing thru · Mar 7, 2003

Thank you so much. I not going into ob-gyn, simply had a pt in icu with these orders and realized i didn't know/remember the norms. (I was thinking 3+ and 4 + would be better than 1's and 2's ,.... kinda like stars in a movie rating,... LOL ) And I didn't know what DEFINED the 1+ = foot moves a little-toes move, etc. very helpful explanations....(Did we study this in school? )

I'm writing this info in my booklet for future reference and thanks again.

elleRN · Mar 12, 2003

great explanations! really helped me to better understand the difference between them! how often do you check reflexes on your mag pts??? what is the standard? thanks!

ShandyLynnRN, BSN, RN · Mar 12, 2003

Mag patients get hourly vitals, I&O and DTR's in my facility.