Understanding Tremor Assessment for Student Nurses
Learn how to observe and describe tremor, recognise changes from a patient's normal baseline and connect abnormal movement with the wider neurological and clinical assessment.
What is a tremor?
Tremor describes a rhythmic, involuntary movement of part of the body. The hands and arms are commonly affected, but tremor can involve other areas. Some tremors are long-standing, while others may appear or change during illness.
The movement is not deliberate
The patient does not intentionally create the repeated movement.
A repeated movement pattern
Tremor typically involves repeated movement rather than a single jerk or isolated muscle contraction.
Not all tremors behave alike
The movement may appear at rest, while holding a position or during purposeful movement.
When does the tremor occur?
One of the most useful observations is whether the tremor appears while the body part is resting, while maintaining a position or during purposeful movement.
Present without purposeful movement
Notice whether tremor is visible while the patient's hands or limbs are relaxed and supported.
Appears during posture
Tremor may become visible when the patient maintains a position, such as holding their arms out.
Changes with purposeful activity
Observe whether tremor appears or becomes more noticeable while the patient reaches for or handles an object.
What should you observe?
Establish the baseline
Ask whether the tremor is normal for the patient, recently changed or completely new.
Identify where it occurs
Note which body part is affected and whether one or both sides are involved.
Observe when it occurs
Is it present at rest, while maintaining posture or during purposeful movement?
Assess functional impact
Consider whether the patient can eat, drink, write, mobilise or perform other usual activities safely.
Several factors may be associated with tremor
Tremor has many possible causes. Student nurses should avoid diagnosing the cause from appearance alone and instead connect the observation with the patient's history, medicines, observations and wider assessment.
The tremor may be established
Some patients have a known long-term neurological or movement disorder associated with tremor.
Medication can matter
Some medicines may contribute to tremor or make an existing tremor more noticeable.
Illness can change movement
Pain, anxiety, fever or acute illness may make shaking or tremor more apparent.
Consider the wider patient
Abnormal glucose or other metabolic disturbances may be associated with shaking or altered neurological function.
History may provide clues
Caffeine, alcohol-related factors and other substances can influence tremor in some circumstances.
Connect other neurological signs
New tremor accompanied by other neurological abnormalities requires appropriate assessment.
Tremor is not the same as clonus
Rhythmic involuntary movement
Tremor may occur spontaneously at rest, during posture or during purposeful movement.
Triggered repetitive response
Clonus is elicited by an appropriate muscle stretch during neurological examination.
Describe what you see
If you are unsure which movement is present, describe its appearance and seek appropriate clinical assessment.
Look beyond the tremor
Is there new weakness?
Compare limb movement and identify any significant new side-to-side difference.
Is movement accurate?
Look for new difficulty reaching, handling objects or performing purposeful movement.
Has communication changed?
New dysarthria or aphasia alongside other neurological changes increases concern.
Any numbness or sensory change?
New sensory abnormalities should be considered within the complete neurological picture.
Is alertness changing?
New abnormal movement with altered consciousness requires urgent clinical assessment.
What else is happening?
Review the patient's vital signs and overall condition rather than treating the tremor as an isolated finding.
A familiar long-standing tremor may have very different significance from a sudden new movement accompanied by neurological or physiological deterioration.
When new symptoms require prompt escalation
- New abnormal movement associated with reduced consciousness.
- New tremor or shaking with significant unilateral weakness.
- New movement abnormality accompanied by facial weakness or speech change.
- New neurological symptoms following a head injury.
- Abnormal movement associated with seizure activity.
- Rapid neurological deterioration or a significant change from baseline.
- Shaking associated with significant physiological deterioration.
- Any new neurological presentation causing immediate concern.
Consider what the tremor means for everyday care
Can the patient manage safely?
Tremor may make handling cups, cutlery or food more difficult.
Has function changed?
If abnormal movement affects the legs or accompanies poor coordination, falls risk may increase.
Can the patient manage usual tasks?
Fine motor difficulty may affect the patient's ability to handle medicines or other equipment safely.
Assess the acutely unwell patient systematically
Airway
Confirm airway patency and respond immediately to any compromise.
Breathing
Assess respiratory rate, oxygen saturation, respiratory pattern and work of breathing.
Circulation
Assess pulse, blood pressure and perfusion within the wider clinical picture.
Disability
Assess consciousness, pupils, speech, strength, sensation, coordination and blood glucose when clinically appropriate.
Exposure
Look for fever, injury and other relevant findings while maintaining patient dignity.
Escalate
Communicate significant deterioration promptly using the appropriate local pathway.
A new tremor during acute illness
Example
You are caring for a patient who normally has no noticeable hand tremor.
During the shift you notice that both hands are shaking and the patient is struggling to hold their drink. They also appear sweaty and less settled than earlier.
Instead of assuming this is primarily a neurological disorder, you recognise that the tremor is new and associated with a wider change in the patient's condition.
You perform an appropriate structured assessment, check relevant observations including blood glucose when clinically indicated and communicate the deterioration promptly.
Describe exactly what has changed
Example escalation
“I'm concerned about Mrs Jones because she has developed a new bilateral hand tremor during the last hour. She normally has no tremor and is now struggling to hold a cup. She also appears sweaty and less settled than earlier.”
This communicates the new symptom, timing, distribution, functional effect and associated clinical change.
Tremor assessment errors to avoid
- Assuming every tremor represents a primary neurological disorder.
- Failing to establish whether the tremor is new or long-standing.
- Not observing whether the tremor occurs at rest or during movement.
- Ignoring whether one or both sides are affected.
- Confusing tremor with clonus, seizure activity or other involuntary movement.
- Ignoring medicines and the wider clinical history.
- Failing to consider the patient's functional safety.
- Focusing on classification while an acutely unwell patient requires escalation.
Observe → compare → connect → escalate
Describe the movement
Identify where the tremor occurs, when it appears and whether it is new.
Use the wider picture
Compare with baseline and connect the tremor with neurological findings, observations, medicines and functional change.
Act on significant deterioration
Describe exactly what has changed and escalate significant new neurological or physiological abnormalities.
Build confidence recognising abnormal neurological movement
Tremor is most useful clinically when you establish whether it is new, describe when it occurs and connect it with the patient's wider neurological and physiological condition.
Explore Clinical Confidence →