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    Assessing Cranial Nerve Function

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    SITTIE JOBAISAH TOMINAMAN ALI
    This document outlines procedural guidelines for assessing the 14 cranial nerves. It lists the necessary equipment and provides instructions for testing each cranial nerve, including which movements, sensations or reflexes to observe. Significant clinical findings that may indicate a cranial nerve impairment are described for each nerve assessment. The goal is to perform a thorough cranial nerve exam and identify any abnormalities that could indicate an underlying neurological problem.

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    Assessing Cranial Nerve Function

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    SITTIE JOBAISAH TOMINAMAN ALI
    34 views1 page
    This document outlines procedural guidelines for assessing the 14 cranial nerves. It lists the necessary equipment and provides instructions for testing each cranial nerve, including which movements, sensations or reflexes to observe. Significant clinical findings that may indicate a cranial nerve impairment are described for each nerve assessment. The goal is to perform a thorough cranial nerve exam and identify any abnormalities that could indicate an underlying neurological problem.

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    This document outlines procedural guidelines for assessing the 14 cranial nerves. It lists the necessary equipment and provides instructions for testing each cranial nerve, including which movements, sensations or reflexes to observe. Significant clinical findings that may indicate a cranial nerve impairment are described for each nerve assessment. The goal is to perform a thorough cranial nerve exam and identify any abnormalities that could indicate an underlying neurological problem.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views1 page

    Assessing Cranial Nerve Function

    Uploaded by

    SITTIE JOBAISAH TOMINAMAN ALI
    This document outlines procedural guidelines for assessing the 14 cranial nerves. It lists the necessary equipment and provides instructions for testing each cranial nerve, including which movements, sensations or reflexes to observe. Significant clinical findings that may indicate a cranial nerve impairment are described for each nerve assessment. The goal is to perform a thorough cranial nerve exam and identify any abnormalities that could indicate an underlying neurological problem.

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    © All Rights Reserved
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    Download as pdf or txt
    of 1

    PROCEDURAL GUIDELINES (to accompany Chapter 65)

    Assessing Cranial Nerve Function

    Equipment •  Watch •  Ophthalmoscope


    •  Tongue depressor •  Cotton-tipped swab •  Samples of familiar odors
    •  Flashlight •  Cotton swabs •  Tuning fork
    •  Sugar and salt samples •  Snellen chart •  Tubes of hot and cold water

    Implementation
    Nursing Actions Rationale

    1. Explain procedure to patient. 1. Knowledge increases patient comfort and cooperation.


    2. Perform hand hygiene. 2. Asepsis is essential to prevent infection.
    3. Assess cranial nerve (CN) I (olfactory). With eyes closed, 3. The significant finding is anosmia (loss of sense of smell).
    patient is asked to identify familiar odors (coffee, tobacco).
    Each nostril is tested separately.
    4. Assess CN II (optic). Assess vision using a Snellen eye chart. 4. Significant findings include hemianopias (visual field defects)
    Assess visual fields. Perform ophthalmoscopic examination. and decreased visual acuity or blindness.
    5. Assess CN III (oculomotor). Test for eye movement toward 5. Significant findings include dysconjugate gaze; gaze
    the nose; inspect for conjugate movements and nystagmus. weakness or paralysis; double vision; dilated pupil, with or
    Evaluate papillary size, and test for pupillary reactivity to light; without impaired pupillary reaction to light; and inability to
    inspect ability to open eyelids. open the affected eyelid.
    6. Assess CN IV (trochlear). Test for upward eye movement; 6. Significant findings include dysconjugate gaze, gaze
    inspect for conjugate movements and nystagmus. weakness or paralysis, and double vision.
    7. Assess CN V (trigeminal). Have patient close the eyes. Touch 7. Significant findings include impaired or absent corneal reflex,
    cotton to forehead, cheeks, and jaw. Sensitivity to superficial facial numbness, and jaw weakness.
    pain is tested in these same three areas by using the sharp and
    dull ends of a broken tongue blade. Alternate between the sharp
    point and the dull end. Patient reports “sharp” or “dull” with
    each movement. If responses are incorrect, test for temperature
    sensation. Test tubes of cold and hot water are used alternately.
    While patient looks up, lightly touch a wisp of cotton against
    the temporal surface of each cornea. A blink and tearing are
    normal responses.
    Have patient clench and move the jaw from side to side. Palpate
    the masseter and temporal muscles, noting strength and equality.
    8. Assess CN VI (abducens). Test for lateral eye movement; 8. Significant findings include dysconjugate gaze, gaze
    inspect for conjugate movement. weakness or paralysis, and double vision.
    9. Assess CN VII (facial). Observe for symmetry while patient 9. Significant findings include facial weakness, inability to
    performs facial movements: smiles, whistles, elevates completely close the eyelid, and impaired taste.
    eyebrows, frowns, tightly closes eyelids against resistance
    (examiner attempts to open them). Observe face for flaccid
    paralysis (shallow nasolabial folds). Have patient extend
    tongue. Test ability to discriminate between sugar and salt.
    10. Assess CN VIII (acoustic). Perform whisper or watch-tick test. 10. Significant findings include decreased hearing or deafness
    Test for lateralization (Weber test). Test for air and bone con- and impaired balance.
    duction (Rinne test). Assess balance with eyes open and then
    closed for 20 seconds (Romberg test).
    11. Assess CN IX (glossopharyngeal). Assess patient’s ability to 11. Significant findings include dysphagia (difficulty swallowing)
    swallow and discriminate between sugar and salt on posterior and impaired taste.
    third of the tongue.
    12. Assess CN X (vagus). Depress a tongue blade on posterior 12. Significant findings include weak or absent gag reflex,
    tongue, or stimulate posterior pharynx to elicit gag reflex. Note dysphagia, aspiration, hoarseness, and dysarthria (slurred
    any hoarseness in voice. Check ability to swallow. Have patient speech).
    say “ah.” Observe for symmetric rise of uvula and soft palate.
    13. Assess CN XI (spinal accessory). While patient shrugs 13. Significant findings include weak or absent shoulder shrug
    shoulders against resistance, palpate and note strength of and inability to turn the head to the side.
    trapezius muscles. As patient turns head against opposing
    pressure of the examiner’s hand, palpate and note strength of
    each sternocleidomastoid muscle.
    14. Assess CN XII (hypoglossal). While patient protrudes the 14. Significant findings include dysphagia and dysarthria.
    tongue, note any deviation or tremors. Test the strength of the
    tongue by having patient move the protruded tongue from side
    to side against a tongue depressor.

    Adapted from Bader, M., Littlejohns, L. R., & Olson, D. (2016). AANN core curriculum for neuroscience nursing (6th ed.). Chicago, IL: American Association
    of Neuroscience Nurses; Weber, J., & Kelley, J. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

    From Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 14th Edition. All Rights Reserved.

    LWBK1592-CH65_online-01.indd 1 7/25/17 5:54 PM

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