Nursing Care Management 101

HEALTH ASSESSMENT
Procedural Checklist in Assessment Of Neurological System

Name: _____ Date: ______Year/Sec: ___ Rating:

General Objectives: To administer neurological exam and assess cranial nerve status
with maximum comfort and safety for the patient and nurse.

Specific Objectives:
1. To know the basic anatomy and function of cranial nerves

2. Obtain an accurate nursing history of a client neurological status.

3. Perform assessment of the cranial nerves using the correct techniques.

4. To be able to understand and carry out a bedside assessment of cranial nerve

function.

5. Differentiate between normal and abnormal findings of the nervous system.

6. Analyze the data gathered to formulate valid nursing diagnosis.

CRITERIA:
Item Descriptors Verbal Interpretation
Weight
1 Excellent Performed the procedure with great ease and confidence,
observing work ethics (prudent, accepts criticisms and
suggestions), able to rationalize scientifically and shows
diligence in documenting observations at all times .
0.75 Very Performed the procedure with less confidence, observing
Satisfactory work ethics (prudent, accepts criticisms and suggestions),
able to rationalize scientifically and shows minimal
diligence in documenting observations.
0.5 Satisfactory Performed the procedure but requires close supervision
and shows potential for improvement.
0.25 Needs Failed to perform the procedure, unable to function well
Improvement and needs repeated specific/ detailed guidance or
direction.
I. Skills 1 0.75 0.5 0.25 Remarks

1. BASIC NURSING SKILLS

 Prepare necessary equipment
 Introduce self.
 Check patients identity
 Explain procedures
 Secure informed consent.
 Maintain privacy
 Position the patient appropriately
 Wear adequate PPE
 Perform hand hygiene.
2. CN I- Olfactory
 Using familiar scent test one nostril at
a time by occluding the other nostril
3. CNII- Optic
 Inspection of pupil size, shape,
equality or any defects or foreign
bodies
 Assess pupillary reflexes by asking
patient to look at distant object using
penlight shine from the side bringing
into the eye
 Test for accommodation by using a
pen asking patient to focus and bring
10cm apart from the face
 Test for visual acuity by asking
patient to read Snelen Chart.Cover
one eye and allow to read, do the
same on the other eye
 Test visual field by tesing peripheral
vision. Cover one eye, ask client to
focus on your nose and by using
 white pen test the visual quadrants at
arms length. Do the same on the
other eye

4. CN III,IV,VI- Occulomotor,
Trochlear, Abducens
 Hold a pen 50 cm from patient in the
midline and on level with the eye. Ask
the patient to follow the object with
eyes only keeping the head still,
create a double H, move the object
slowly side to side, up and down
centrally, then at a extreme lateral
gaze. The pen held vertically for
horizontal movement and horizontally
for vertical movements.
5. CN V- Trigeminal
 Test for sensory by light touch- use a
wisp of cotton and pain- use the sharp
end of the neuro tip, use blunt end as
discriminator. Test both sides and
compare
 Test for corneal reflex- use cotton
wisp tp touch the lateral cornea. Do
on both eyes
 To test motor reflex- ask patient to
clenched teeth and feel the
temporalis and maseter muscle
 Jaw jerk- ask patient to open mouth.
Place your finger on chin and percuss
your finger. Mandible jerk upward
6. CNVII- Facial
 Test for motor- Ask patient to show
teeth, purse lips, blow out cheeks,
 close eyes tightly and open wide eyes
as they can.
 Assess against resistance: While
patient’s eyes tightly shut pull eyelids
apart. With eyebrows raised, pull
eyebrows downward, with lips pursed
tightly attempt to pull lips apart, with
the cheek blown out press against the
cheek. Document weakness.
7. CNVIII- Acoustic/Vestibulocochlear
 Test for auditory function- position on
clients side and whisper on the side
of the ear while blocking the opposite
side, do it twice at varied distance. Do
the same on the other side of the ear.
 Test for gait by asking patient to walk
heel to toe
8. CNIX, X, XII Glossopharyngeal,
Vagus, Hypoglossal
 Test patient gag reflex by using
tongue depressor
 Ask the patient to say Ahhhh and
note for uvula for deviation
 Ask patient to open mouth and
examine tongue inside, then ask to
stick out tongue and observe for
deviation
 Test power of the tongue by asking
the patient to push tongue against the
inside of the cheek. Examine both
sides
9. CNXII- Accessory Spinal
 Ask patient to turn head to side, place
your hand on the patient’s cheek and
 attempt to turn the head to midline
( Ask patient to resist turning). Do on
both sides
 Ask the patient to shrug shoulder and
attempt to push down. (Ask patient to
resist)
10. End the procedure by
 Keep patient informed
 Clean all the equipment
 Wash hands.
 Document Findings
 Refer

Comments: (Strengths & Weaknesses)

Conforme: Evaluated by:

___________________ ____________________________________
Student’s Signature CI’s Signature over Printed Name
Date: Date: