Iskrip

Cranial nerve:
Introduce, verify, explain Good morning maam/sir I am , your student nurse from
Perform hand hygiene university of saint louis, kindly state your name and
Provide for client’s birthdate sir
privacy
For today I will be assessing your 12 cranial nerves, This
is to determine if you are having sign of sensory or motor
dysfunction. I will also perform several test to assess ur
cranial nerve , may i ask your permission if it is okay with
you sir (response), and in order to do that i’ll be needing
your active participation.
CN 1: OLFACTORY First I will assess ur olfactory nerve, in doing this test can
Smell- coffee or kahit ano u close ur eyes and I am gonna put something infront of
your nose, sir can you close your eyes, breath in and
smell and tell me what do u smell?
CN 2: OPTIC Next sir is I will assess ur optic nerve, sir for this I will
Newspaper or visual assess ur visual fields of peripheral vision, in doing this
fields sir I will place the pen in ur side or peripheral vision and
tell me sir if u you can see the pen? (continue)
Both nurse n patient
magcover ng eye and
dapat pantay kayo
CN 3, 4 AND 6: moving on sir, for this i will assess ur oculomotor,

OCULOMOTOR, trochlear and abducens nerves sir. In this assessment sir
TROCHLEAR, AND follow the tip of the pen without moving ur head only ur
ABDUCENS. eyes will move.
-pen
Six cardinal fields
okay sir u were also able to perform the six cardinal
field of gaze test without any difficulties
CN 5: TRIGEMINAL Next is ur trigeminal nerve sir, I will be assessing ur
Magchoose nalang sa ophthalmic branch (both eyes) for this assessment sir I
three branch: opthalmic, will depress ur eyelids, sir kindly gaze into the distance,
maxillary and mandibular using a wisp of cotton touch the cornea gently,
Did u feel anything?

(Gamit cotton here, ibrush sa may maxilla part ganonch)
CN 7: FACIAL I will now assess ur facial nerve sir, can u raise ur

Facial expression n taste eyebrows, smile, Puff your cheeks, and close your eyes
(sweet or sour) tightly. okay sir, ur facial nerve is intact.
CN 8: AUDITORY sir next is ur auditory nerve, in oder to assess ur auditory

Romberg test (balance) sir i will do the romberg test, okay sir so kindly stand with
feet together, arms resting on the side and eyes closed
for atleast 5 secs.
okay negative romberg as you where able to do it while

maintaining balance and without difficulties.
CN 9, 10, 12: For the next test is for ur glossopharyngeal, vagus and
GLOSSOPHARYNGEAL, hypoglossal nerves sir. Sir can u move ur tounge side to
VAGUS AND side, up and down.
HYPOGLOSSAL Okay next is the water test, tell me sir if u have difficulty
swallowing
Move tounge, swallowing
=inom k tapos sagot
CN 11: ACCESSORIES Lastly, I will be assessing ur accessories nerve sir, sir
Shoulder shrug can u shrug ur shoulders
Okay
Document Sir ur cranial nerves are intact, there were no problems
noted and ur were able to do every test without any issue
or difficulties.
okay that’s all for the procedure sir, thank you for your
active cooperation sir
GROSS N FINE MOTOR SKILLS

Introduce, verify, explain Good morning maam/sir I am , your student nurse from
Perform hand hygiene university of saint louis, kindly state your name and
Provide for client’s birthdate sir.
privacy
For today maam/sir i will be assessing for your gross and
fine motor skills, so in this procedure we will determine if
there are any motor difficulties that can lead to
recommendations for support. So may i ask for your
permission if its okay with you maam/sir(), and for that to
happen may i also ask for your active participation.
I will perform several test to assess your gross n fine

motor skills is that okay with u sir/maam?
GROSS
WALKING GAIT For the first one sir, may I ask u to walk across the room
and assess ur gait.
ROMBERG TEST Next is the romberg test,sir kindly stand with feet
together and arms resting at the sides, first with eyes
open for five seconds and then closed for another five
seconds
STANDING ON ONE The next part of the test is the standing one foot with
FOOT WITH EYES eyes closed, sir kindly close ur eyes and stand
CLOSED on one foot for five second, and repeat on the other foot.
HEEL-TOE WALKING For the heel to toe walking sir, kindly walk a straight line,
placing the heel of one foot directly in front of the toes
of the other foot
TOE OR HEEL Lastly, the toe or heel test, in this test sir u will walk on
WALKING several steps on your heel, after that walk on several
steps on your toe
FINE Next ifs fine motor test for ur upper extremities
Sot the first test is the finger to nose test, for this, abduct
FINGER-TO-NOSE and extend the arms at shoulder height and then rapidly
TEST touch the nose alternately with one index finger and then
the other. After doing it for a few seconds, repeat the test
with eyes closed
ALTERNATING For alternating supination and pronation of hands on

SUPINATION AND knees. In here, pat both knees with the palms of both
PRONATION OF hands and then with the backs of the hands alternately at
HANDS ON KNEES an ever-increasing rate.
FINGER-TO-NOSE AND For this test sir, u need to to touch the nose and then
TO your index finger, held at a distance of about 45 cm
THE NURSE’S FINGER (18 in.), at a rapid and increasing rate
FINGERS-TO-FINGERS Sir kindly spread the arms broadly at shoulder height and
then bring the fingers together at the midline, first with
the eyes open and then closed, first slowly and then
rapidly.
FINGERS-TO-THUMB And lastly, sir can u touch each finger of one hand to the
(SAME HAND) thumb of the same hand as
rapidly as possible
Document okay that’s all for the procedure sir, alright thank you for
your active cooperation sir

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Cranial nerve:

CN 3, 4 AND 6: moving on sir, for this i will assess ur oculomotor,

Did u feel anything?

CN 7: FACIAL I will now assess ur facial nerve sir, can u raise ur

CN 8: AUDITORY sir next is ur auditory nerve, in oder to assess ur auditory

okay negative romberg as you where able to do it while

GROSS N FINE MOTOR SKILLS

I will perform several test to assess your gross n fine

ALTERNATING For alternating supination and pronation of hands on

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