PERFORMANCE CHECKLIST FOR • Cranial Nerve III-Oculomotor and Cranial

CEREBROVASCULAR ACCIDENT NerveIV-Trochlear

Assess six ocular movements and pupil
1. Introduce yourself, and verify the client’s identity. reactions. (Light Reflex) (Six directions)
2. Perform hand hygiene • Cranial Nerve V- Trigeminal
3. Provide client privacy o While the client looks upward, lightly touch
4. We will identify the patient’s priority needs by: the lateral sclera of the eye to elicit the blink
• Determining the client’s history such as reflex.
Presence of pain in the head, back, or o To test light sensation, have the client
extremities close their eyes, and wipe a wisp of cotton
• Any history of loss of consciousness, over the client’s forehead and paranasal
fainting, paralysis, uncontrolled muscle sinuses.
movements, and loss of memory o To test deep sensation, use alternating
blunt and sharp ends of a safety pin over
• Problems with smell, vision, taste, touch, or
the same area.
hearing
• Cranial Nerve VI- Abducens
• Disorientation to time, place, or person (Ask
o Assess directions of gaze. (Pen towards
the client the city and state of residence, time
px)
of day, date, and names of family members.)
• Cranial Nerve VII-Facial
(Where are you now?) (What date is it
o Ask the client to smile, raise the eyebrows,
today?)
frown, puff out cheeks, and close eyes
• Speech disorders (Ask the client to read
tightly.
some words, and to respond to simple verbal • Cranial Nerve VIII-Auditory
and written commands like “point to your o Assess the client’s ability to hear the
toes, “or “Raise your left arm”.) spoken word and the vibrations of a tuning
5. After we identify the priority needs, we will now fork.
assess the client in the emergency room and we • Cranial Nerve IX-Glossopharyngeal
will check for the; o Apply tastes on the posterior tongue for
• chief complaint identification. Ask the client to move their
• vital signs tongue from side to side and up and down.
• for orders to be carried out initially • Cranial Nerve X-Vagus
• and for patient safety and positioning o Assessed with CN IX; assess the client’s
6. Next, we will now demonstrates / performs correct speech for hoarseness
neurologic assessment • Cranial Nerve XI-Accessory
First is the MSE (Mental status exam) o Ask the client to shrug their shoulders
To assess immediate recall: against resistance from your hands and to
o Ask the client to repeat a series of three turn their head to the side against
digits-e.g, 7-4-3-spoken slowly. resistance from your hand. Repeat for the
other side.
To assess recent memory: • Cranial Nerve XII-Hypoglossal
o Ask the client to recall the recent events of o Ask the client to protrude tongue at midline,
the day, such as how he got to the clinic. then move it from side to side.
o Ask the client to recall information given Level of Consciousness
early in the interview-like the name of a • Apply the Glasgow Coma Scale:
doctor or nurse. o Eye response, motor response, and verbal
To assess remote memory: response
Hello sir, Are you okay?
o Ask the client to describe a previous illness Can you show me your tongue?
or surgery. Can you do this? (Thumb)
To test the ability to concentrate or attention span, Assessment of reflexes
have the client to recite the alphabet. Test reflexes using a percussion hammer, comparing
one side of the body with the other to evaluate the
CRANIAL NERVE EXAMINATION symmetry of response
• Cranial Nerve I-Olfactory • Biceps Reflex
o Ask the client to close their eyes and The biceps reflex tests the spinal cord levels
identify different mild aromas such as C-5, C-6. (Inner Elbow)
coffee and vanilla. • Triceps Reflex
• Cranial nerve II-Optic The triceps reflex tests the spinal cord levels
o Ask the client to read Snellen’s chart; C-7, C-8. (Outer elbow)
check visual fields by confrontation, and • Brachioradialis Reflex
conduct an ophthalmoscopic examination. The brachioradialis reflex tests the spinal
(Cover 1 eye and read vv, 40m away) cord levels C-3, C-6. (Side of the wrist)
(Cover r eye patient and left eye nurse. Say • Achilles Reflex
stop when the px see the N finger) The Achilles reflex tests the spinal cord
levels S-1, S-2. (Ankle)
 • Plantar (Babinski’s) Reflex 7. Next, Anticipates diagnostic tests and possible
The plantar or Babinski’s reflex is superficial. outcome. (CT scan, MRI, PET scan, lumbar
It might be absent in adults without pathology puncture, ECG and Skull x-ray)
or overridden by voluntary control. (Hill down 8. We will be monitoring for complications in the ICU.
to fingers) (Change in level of consciousness and
responsiveness. Maintenance of BP)
Motor Function 9. Anticipate drugs to be given and their mechanisms
Gross Motor and Balance Tests of action. (Warfarin- Anticoagulant for long term
• Walking Gait case. Depletes functional vit k reserves and
o Ask the client to walk across the room and reduces the synthesis of active clotting factors.)
back, and assess the client’s gait. 10. We will also Identify possible complications of
• Romberg’s Test CVA (Tissue Ischemia and Cardiac dysrhythmic),
o Ask the client to stand with feet together 11. And lastly, we will formulate nursing care plan for
and arms resting at the sides, first with client with CVA and anticipate expected outcome
eyes open, then closed. of the client in the scenario.
• Standing On One Foot with Eyes Closed
o Ask the client to close their eyes and stand
on one foot, then the other. Stand close to
the client during this test.
• Heel-Toe Walking
o Ask the client to walk a straight line, placing
the heel of one foot directly in front of the
toes of the other foot.
• Toe or Heel Walking
o Ask the client to walk several steps on the
toes and then on the heels
Fine Motor Test for the Upper Extremities
• Finger-to-Nose Test
o Ask the client to abduct and extend arms at
shoulder height and rapidly touch the nose
alternately with one index finger and then
the other. Have the client repeat the test
with eyes closed if the test is performed
easily.
• Alternating Supination and Pronation of
Hands-on Knees
o Ask the client to pat both knees with the
palms of both hands and then with the
backs of hands, alternately, at an ever-
increasing rate.
• Finger to Nose and Nurse’s Finger
o Ask the client to touch your nose and then
your index finger
• Fingers to Fingers
o Ask the client to spread arms broadly at
shoulder height and then bring fingers
together at the midline, first with eyes open
and then closed, first slowly and then
rapidly
• Fingers to Thumb (Same Hand)
o Ask the client to touch each finger of one
hand to the thumb of the same hand as
rapidly as possible.
• Fine Motor tests for the Lower Extremities
o Ask the client to lie supine and to perform
these tests;
• Heel Down Opposite Shin
o Ask the client to place the heel of one foot
just below the opposite knee and run the
heel down the shin to the foot. Repeat with
the other foot. The client may also use a
sitting position for this test.
• Toe or Ball of Foot to the Nurse’s Finger
o Ask the client to touch your finger with the
large toe of each foot.