University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2021
Views:

145

Pages:

1
Author:

Marin Mason

Cranial Nerve Assessment Cheat-Sheet Senses • “Do you have any blurred vision, change in vision, smell, taste, hearing, or balance?” CN1, CN2, CN8 Olfactory, Optic, and Vestibulocochlear Nerve Perform visual acuity or auditory testing if needed Visual Fields • Cover one eye and hold up numbers in their peripheral 4 quadrants. Repeat for the other eye. vision in all CN2 Optic Nerve Pupillary Light Reflex • Shine light into the right eye and observe both pupils. Then remove light and observe both pupils. Repeat for the left. Ensure both direct and consensual CN2 and CN3 Optic and Oculomotor Nerves constriction in response to light Eye Movements • Hold pen midline and ask patient to focus on it. • “Follow my finger with your eyes only, keep your head still” • Move pen slowly to the left, then to the right, back to midline, then up, then down, back to midline, then down-left, then down-right. CN3, CN4, CN6 Oculomotor, Trochlear, and Abducens Nerves Observe for conjugate gaze palsy (inability for both eyes to look in a certain direction) or nystagmus (fast beats) at the extremities Facial Sensation and Movement • Lightly stroke both sides of forehead, cheek, and chin equally CN5 “Does this feel the same on each side?” • Ask the patient to close eyes, then open, raise their eyebrows smile, then frown Trigeminal Nerve , then CN7 Facial Nerve Assess for asymmetry in forehead wrinkles, eyebrows, eyes, nasolabial folds, and mouth • Assess patient for dysarthria throughout interview • “Stick out tongue, now move it side to side rapidly” Assess for tongue deviation and/or weakness • “Open mouth and say “ahhhhh” or yawn Observe for symmetric palatal movement. Can do gag reflex is abnormal CN9 and CN12 Glossopharyngeal and Hypoglossal Nerves Shoulder Shrug / Head Turn • Ask the patient to shrug their shoulders against resistance • Ask the patient to turn their head against resistance There is no direct way to test the CN10 (Vagus Nerve) except via gag reflex, but this should not be done routinely CN11 Accessory Nerve