College of Health Sciences Document Code CHS-NURS-FRM- 075

Department of Nursing
PERFORMANCE CHECKLIST Revision No. 1 Page 3 of 3
ON CRANIAL NERVE Effectivity Date March 2021
ASSESSMENT

Name: ____________________________________ Date Performed: _____________

Year Level & Section: ________________________

STEPS RATING
BEFORE THE PROCEDURE
1. Explain the procedure to the patient (purpose, nature, time required to
perform the procedure).
2. Perform hand hygiene.
3. Prepare all the materials (CN 1: mild cologne/perfume/coffee, orange/lemon;
CN2 Snellen chart, 2 index card/eye occlude; CN 2,3,4,6: penlight; CN 5: cotton
balls; CN 7: 1 tsp soy, 1 tbsp sugar; CN 8: tuning fork; CN 9: water(potable); CN
10,12: tongue depressor) needed in an organized manner.
4. Positions the patient in a sitting position on the examination table.
5. Performs cranial nerve assessment systematically (head-to-toe/CN 1 to CN 12)
DURING THE PROCEDURE
Cranial Nerve I (Olfactory)
6. Ask patient to close both eyes.
7. Ask patient to occlude one nostril.
8. Ask the patient to smell a scent (Mild Cologne/Perfume or Coffee or
Orange/lemon).
9. Ask the patient to smell and identify another scent.
10. Repeat step 10 on the other nostril.
Cranial Nerve II (Optic)
Visual Acuity
11. Position the patient 20ft from the Snellen chart.
12. Ask the patient to cover one eye with an index card/eye occluder.
13. Ask the patient to read the letters in the Snellen chart starting from the biggest
(topmost) letter down to the smallest letter the patient the can read.
14. Identify the visual acuity of the patient correctly (e.g. 20/20; 20/200)
15. Repeat step 15 on the other eye.
Visual Eye Field Test
16. Face the patient at a distance of 2-3 feet.
17. Ask the patient to cover one eye with an index car/eye occluder.
18. Ask the patient to look directly at the examiner.
19. Cover the eye directly opposite the patient’s eye then looks directly at the
patient.
20. Ask the patient to inform the examiner once object is seen in the field of vision.
21. Move hand holding a penlight from the periphery towards the center.
22. Perform #22 testing all fields by moving penlight from up to down, down to up,
right to left, left to right.
Cranial Nerve III, IV, VI (Oculomotor, Trochlear, Abducens)
23. Stand in front of the patient and place an object (e.g. penlight) about 12 to 14
inches away from the patient’s nose.

Disclaimer: Reproduction of this form is allowed subject

to compliance to the Documented Information
Procedure established by MMSU.
 College of Health Sciences Document Code CHS-NURS-FRM- 075
Department of Nursing
PERFORMANCE CHECKLIST Revision No. 1 Page 3 of 3
ON CRANIAL NERVE Effectivity Date March 2021
ASSESSMENT

24. Ask the patient to follow the object with his/her eyes as it is moved along the
six cardinal fields of gaze.
25. Check all six cardinal fields of gaze by moving the penlight/object starting from
right upper field, left lower field, left upper field, right lower field, then left to
right.
26.
Cranial Nerve V (Trigeminal)
27. Ask the patient to open mouth, clench jaw and chew.
28. Feel for the contraction of the masseter muscles as the patient chew.
29. Ask patient to close eyes and inform the examiner when he feels any stimuli
on his/her face.
30. Brush the cotton ball on patient’s face (forehead both right and left, cheeks
both right and left side, jaw line both right and left side.
31. Lightly touch the cornea of one eye with a wisp of cotton to assess corneal
reflex.
32. Repeat step 29 on the other eye.
Cranial Nerve VII (Facial)
33. Ask the patient to smile, frown, puff-out cheeks and raise and lower eyebrows.
34. Ask the patient to close eyes and stick out tongue.
35. Place the sugar/soy at the anterior two thirds of the tongue.
36. Place sugar/soy at the posterior one third of the tongue.
37. Let the patient taste and identify another flavor in the same manner in step 33
and 34.
Cranial Nerve VIII (Vestibulocochlear/Acoustic)
Voice Whisper Test
38. Ask the patient to occlude one ear with finger on the tragus of the ear.
39. Stand 1-2 feet behind the client directly opposite the unoccluded ear.
40. Whisper 2-3 syllables that is evenly accented.
41. Ask the patient to repeat the word or phrase.
42. Repeat the test on the other ear.
Weber Test
43. Hold the handle of the tuning fork and strike the tines on the ulnar border of
the palm to activate it.
44. Place the stem of the fork firmly against the middle of the patient’s forehead
or on the top of the head at the midline.
45. Ask the patient if the sound is heard centrally or toward one side.
Rinne Test
46. Stand behind or to the side of the patient.
47. Instruct the patient to indicate if the sound is heard (note the length of time
the patient hears the sound).
48. Place the stem of the activated tuning fork against the patient’s right mastoid
process to test bone conduction. Take note of the length of time the patient
hears the sound.
49. Then move the tuning fork, with the tines facing forward, in front of the right
auditory meatus when the patient says the sound has stopped and ask the

Disclaimer: Reproduction of this form is allowed subject

to compliance to the Documented Information
Procedure established by MMSU.
 College of Health Sciences Document Code CHS-NURS-FRM- 075
Department of Nursing
PERFORMANCE CHECKLIST Revision No. 1 Page 3 of 3
ON CRANIAL NERVE Effectivity Date March 2021
ASSESSMENT

patient if the sound is still heard. Take note of the length of time the patient
hears the sound. Compare air conduction and bone conduction.
50. Repeat step 47 on the other ear.
Cranial Nerve IX (Glossopharyngeal)
51. Ask the patient to swallow a sip of water.
Cranial Nerve X (Vagus) and Cranial nerve XII (Hypoglossal)
52. Ask the patient to open mouth wide and say “ahh”, while using a tongue
depressor on the patient’s tongue, then observe for the uvula and soft palate
using a penlight.
53. Ask the patient to stick out tongue to midline and move it from side to side
(Cranial Nerve XII Hypoglossal)
54. Touch the back of the throat on each side lightly using a tongue depressor to
assess gag reflex.
Cranial Nerve XI (Accessory)
55. Ask the patient to tilt head forward, backward and turn the head side to side.
56. Ask the patient to shrug shoulders.
AFTER THE PROCEDURE
57. Perform aftercare.
58. Document findings.
Total Score
Equivalent Grade

Rating Scale:

5- Outstanding
4- Very Satisfactory Clinical Instructor
3- Satisfactory
2- Needs Improvement
1 – Not Observed

Disclaimer: Reproduction of this form is allowed subject

to compliance to the Documented Information
Procedure established by MMSU.