Table 5.

5 Glasgow Coma Scale

• Appearance: Neat, clean; clothes appropriate to occasion, season, and sex

• Affect: Attentive, cooperative, pleasant
• Speech : Articulate, fluent, readily answers questions
• Memory: Responds appropriately to questions:
o Immediate: “Why are you here?”
o Recent: “What did you eat for breakfast?”
o Remote: “Where were you born?”
• Orientation :
o Person (self, others)
o Place
o Time
• General knowledge/intellectual level:
o Responds appropriately to general questions like “Who is the president of the Philippines?”

MNEMONICS MNEMONICS

CN 1 OLFACTORY OH SENSORY SOME

CN 2 OPTIC OH SENSORY SAYS

CN3 OCULOMOTOR OH MOTOR MARRY

CN4 TROCHLEAR TO MOTOR MONEY

CN5 TRIGEMINAL TOUCH BOTH BUT

CN6 ABDUCENS AND MOTOR MY

CN7 FACIAL FEEL BOTH BROTHER

CN8 ACOUSTIC A SENSORY SAYS

CN9 GLOSSOPHARYNGEAL GIRLS BOTH BIG

CN10 VAGUS VAGINA BOTH BOOBS

CN11 SPINAL ACCESORY SO MOTOR MATTER

CN12 HYPOGLOSSAL HEAVEN MOTOR MOST

Table 5.6 Cranial Nerves Assessment Tool

I Olfactory Cribiform Plate Special Sensory: Smell
II Optic Optic Canal Special Sensory: Sight Vision
III Oculomotor Superior Orbital Somatic Motor: Superior, Medial, Inferior Rectus,
Fissure Inferior Oblique ; Visceral Motor: Sphincter Pupillae
Pupil Constriction, elevation of upper lid

IV Trochlear Superior Orbital Somatic Motor: Superior Oblique Eye movement

Fissure
V Trigeminal Sup Orbital Somatic Sensory: Face
Fissure Somatic Motor: Mastication, Tensor Tympani, Tensor
V1: Palati Controls muscle of chewing
V2: Foramen
Rotundum
V3: Foramen
Ovale

VI Abducens Superior Orbital Somatic Motor: Lateral Rectus Eye movement,

Fissure
VII Facial Internal Auditory Somatic sensory: Posterior External Ear Canal
Canal Special Sensory: Taste (Anterior 2/3 of Tongue)
Somatic Motor: Muscles Of Facial Expression
Visceral Motor: Salivary Glands, Lacrimal Glands
Controls muscle for facial expression

VIII Acoustic Internal Auditory Special Sensory: Auditory/Balance Maintain equilibrium;

Canal hearing
IX Glossopharyngeal Jugular Foramen Somatic Sensory: Posterior 1/3 Tongue, Middle Ear
Visceral Sensory: Carotid Body/Sinus
Special Sensory: Taste
Somatic Motor: Stylopharyngeus Visceral Motor:
Parotid Controls muscle of throat

X Vagus Jugular Foramen Somatic Sensory: External Ear ; Visceral Sensory:

Aortic Arch/Body ; Special sensory: Taste Over
Epiglottis
Somatic Motor: Soft Palate, Pharynx, Larynx
(Vocalization and Swallowing)
Visceral Motor: Bronchoconstriction, Peristalsis,
Bradycardia, Vomitting Controls muscle of throat,
thoracic and abdominal organs
XI Spinal Jugular Foramen
Accessory
XII Hypoglossal Hypoglossal
Canal
Table 5.7 Cranial Nerve Locations and Functions
Neurologic Assessment Assessment Tool
Motor Function Muscle strength.
assessment of the Flexion and extension.
motor system Muscle tone
involves testing for
muscle size, tone,
and strength
under voluntary
movements
Reflexes Scale Response
0 Absent
+ Present but diminished
++ Normal
+++ Mildly increased but
not pathologic
++++ Markedly hyperactive;
clonus may be
present
Sensory Function Asses for: (done after
symmetric testing of the
arms, legs, and trunk)
Pain: “Sharp or dull?”
Temperature: “Hot or cold?”
Light touch: “Feel touch?”
Vibration: “Feel tuning fork
vibrating against joint?”
Position sense
(proprioception): “Am I
moving your toe up or
down?”
Cerebellar Function Perform Romberg’s test:
o ask the client to
stand
erect, feet together and
arms at side, first with
eyes open, then closed.
The nurse should stand
close to the client to
Somatic Motor: Trapezius, Sternocleidomastoid
Controls neckmuscles
Somatic Motor: Tongue Tongue movement
Normal Findings
• Equal size on both sides
of body
• Usually firm
• Equal strength on both
sides of
the body
• Smooth , coordinated
movements
Blink reflex
Gag and swallow reflex
Plantar response (Babinski
reflex)
Deep tendon reflex
Biceps
Triceps
Brachioradialis
Patellar – NORMAL:
extension of
leg below the knee
Achilles – Normal: plantar
flexion
of feet
Plantar (babinski) –
Normal: bending of toes
downward
Normal sensations
Note the client’s ability to
maintain balance with eyes
open and closed for 20
seconds with minimum
swaying
Significant Findings
NOTE: Tics, tremors,
fasciculations
may suggest neurologic
involvement.
NOTE: Diminished or
absent reflexes may
suggest upper or lower
motor neuron disease;
however, this may also be
found in normal people.
(Reinforcement by
isometric contraction such
as asking patient to push
his or her hands together
while knee reflex is checked
may increase reflex
activity.)
A positive Babinski’s reflex
may be seen in pyramidal
tract disease or in the
unconscious patient
NOTE: Inappropriate
response
indicates neurologic
disorder.
NOTE: Loss of balance is
termed
“positive Romberg test”
(indicates sensory ataxia).
Uncoordinated gait may
suggest cerebral palsy,
parkinsonism, or drug side
effect. Inappropriate
catch the client in the movements suggest
event of a fall cerebellar disease

Table 5.8 Neurologic Assessment Tool and Finding

 Assessment Assessment Normal Significant
Tool Findings Findings
Head Inspection : Normocephalic Hydrocephalic
Size or contour Microcephalic
Asymmetric
Scalp Inspection Smooth, nontender NOTE: Scaling,
masses, tenderness
Head circumference Measuring Tape : Between 5th and Exceeds chest
(measured at largest 95th percentile on circumferenceby 1–2
point above eyebrow standardized growth cm until 18 mo.
and behind occiput) chart.
Anterior fontanel 3–4 cm in length and2– NOTE: Unusually
3 cm in width until large fontanel may
9–12 mo of age. indicate hydrocephaly
Soft, flat; bulges while (faulty circulation or
crying. Closes between absorption of
9 and 18 mo. CSF).
Unusually small
fontanel may indicate
craniosynostosis
(premature closure of
sutures).
Posterior fontanel 0.5–1 cm across. May Delayed closure may
be closed at birth or indicate hydrocephaly.
by 3 months of age.

Table 5.9 Head Assessment

Assessment Assessment Normal Significant

Tool Findings Findings
Face Inspection Symmetric, Asymmetric, weak; involuntary
with relaxed movements; tense or
facial expressions expressionless facies
Sinuses Frontal and Tenderness
maxillary
sinuses nontender
Cranial nerve: Able to smile, puff Unable to purposely and
(CN)VII:facial, cheeks, symmetrically
motor frown, raise use facial muscles
eyebrows,
with symmetry noted
CN V: trigeminal: Bilateral contractions Weak or asymmetric contraction of
Motor of temporal and muscles
masseter
muscles when teeth
are
 clenched

CN V: trigeminal: Able to distinguish Unable to distinguish

sensory touch on type and location of
both sides of touch
face
Table 5.10 Face Assessment