Cranial Nerves Assessment Form

Cranial Nerve I Olfactory Function Method Normal Findings Client should be able to distinguish different smells Clients Responses Smell reception and Ask client to interpretation close eyes and identify different mild aromas such alcohol, powder and vinegar. Visual acuity and Ask client to fields read newsprint and determine objects about 20 ft. away Extraocular eye Assess ocular movements, lid movements elevation, papillary and pupil constrictions lens reaction shape Downward and inward eye movement Sensation of face, scalp, cornea, and oral and nasal mucous membranes. Chewing movements of the jaw

II

Optic

III

Oculomotor

IV

Trochlear

Trigeminal

Client should be able to read newsprint and determine far objects Client should be able to exhibit normal EOM and normal reaction of pupils to light and accommodation Ask client to Client should be move eyeballs able to move obliquely eyeballs obliquely Elicit blink Client blinks reflex by lightly whenever sclera is touching lightly touched; lateral sclera; able to feel the to test wisp of cotton sensation, over the area wipe a wisp of touched; able to cotton over discriminate blunt clients and sharp stimuli forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensation

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Assess skin sensation as of ophthalmic branch above

Client is able to sense and distinguish different stimuli

Ask client to clench teeth Client should be able to clench teeth Client should be able to move eyeballs laterally Client should be able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty and bitter taste

VI

Abducens

Lateral eye movement Taste on anterior 2/3 of the tongue Facial movement, eye closure, labial speech

VII

Facial

VIII Acoustic

Hearing and balance

Ask client to move eyeball laterally Ask client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffee Assess clients ability to hear loud and soft spoken words; do the watch tick test Apply taste on posterior tongue for identification

IX

Glossopharyngeal Taste on posterior 1/3 of tongue, pharyngeal gag reflex, sensation

Client should be able to hear loud and soft spoken words; able to hear ticking of watch on both ears Client should be able to identify different tastes such as sweet,

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from the eardrum and ear canal. Swallowing and phonation muscles of the pharynx

Vagus

Sensation from pharynx, viscera, carotid body and carotid sinus

XI

Spinal accessory

XII

Hypoglossal

Client should be able to swallow without difficulty; has absence of hoarseness in speech Trapezius and Ask client to Client should be sternocledomastoid shrug able to shrug muscle movement shoulders and shoulders and turn turn head from head from side to side to side side against against resistance from resistance nurses hands from nurses hands Tongue movement Ask client to Client should be for speech, sound protrude able to protrude articulation and tongue at tongue at midline swallowing midline, then and move it side to move it side to side side

(sugar, salt and coffee); ask client to move tongue from side to side and up and down; ask client to swallow and elicit gag reflex through sticking a clean tongue depressor into clients mouth Ask client to swallow; assess clients speech for hoarseness

salty and bitter taste; able to move tongue from side to side and up and down; able to swallow without difficulty, with (+) gag reflex

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