PROCEDURAL GUIDELINES (to accompany Chapter 65)

Assessing Cranial Nerve Function

Equipment •  Watch •  Ophthalmoscope

•  Tongue depressor •  Cotton-tipped swab •  Samples of familiar odors
•  Flashlight •  Cotton swabs •  Tuning fork
•  Sugar and salt samples •  Snellen chart •  Tubes of hot and cold water

Implementation
Nursing Actions Rationale

1. Explain procedure to patient. 1. Knowledge increases patient comfort and cooperation.

2. Perform hand hygiene. 2. Asepsis is essential to prevent infection.
3. Assess cranial nerve (CN) I (olfactory). With eyes closed, 3. The significant finding is anosmia (loss of sense of smell).
patient is asked to identify familiar odors (coffee, tobacco).
Each nostril is tested separately.
4. Assess CN II (optic). Assess vision using a Snellen eye chart. 4. Significant findings include hemianopias (visual field defects)
Assess visual fields. Perform ophthalmoscopic examination. and decreased visual acuity or blindness.
5. Assess CN III (oculomotor). Test for eye movement toward 5. Significant findings include dysconjugate gaze; gaze
the nose; inspect for conjugate movements and nystagmus. weakness or paralysis; double vision; dilated pupil, with or
Evaluate papillary size, and test for pupillary reactivity to light; without impaired pupillary reaction to light; and inability to
inspect ability to open eyelids. open the affected eyelid.
6. Assess CN IV (trochlear). Test for upward eye movement; 6. Significant findings include dysconjugate gaze, gaze
inspect for conjugate movements and nystagmus. weakness or paralysis, and double vision.
7. Assess CN V (trigeminal). Have patient close the eyes. Touch 7. Significant findings include impaired or absent corneal reflex,
cotton to forehead, cheeks, and jaw. Sensitivity to superficial facial numbness, and jaw weakness.
pain is tested in these same three areas by using the sharp and
dull ends of a broken tongue blade. Alternate between the sharp
point and the dull end. Patient reports “sharp” or “dull” with
each movement. If responses are incorrect, test for temperature
sensation. Test tubes of cold and hot water are used alternately.
While patient looks up, lightly touch a wisp of cotton against
the temporal surface of each cornea. A blink and tearing are
normal responses.
Have patient clench and move the jaw from side to side. Palpate
the masseter and temporal muscles, noting strength and equality.
8. Assess CN VI (abducens). Test for lateral eye movement; 8. Significant findings include dysconjugate gaze, gaze
inspect for conjugate movement. weakness or paralysis, and double vision.
9. Assess CN VII (facial). Observe for symmetry while patient 9. Significant findings include facial weakness, inability to
performs facial movements: smiles, whistles, elevates completely close the eyelid, and impaired taste.
eyebrows, frowns, tightly closes eyelids against resistance
(examiner attempts to open them). Observe face for flaccid
paralysis (shallow nasolabial folds). Have patient extend
tongue. Test ability to discriminate between sugar and salt.
10. Assess CN VIII (acoustic). Perform whisper or watch-tick test. 10. Significant findings include decreased hearing or deafness
Test for lateralization (Weber test). Test for air and bone con- and impaired balance.
duction (Rinne test). Assess balance with eyes open and then
closed for 20 seconds (Romberg test).
11. Assess CN IX (glossopharyngeal). Assess patient’s ability to 11. Significant findings include dysphagia (difficulty swallowing)
swallow and discriminate between sugar and salt on posterior and impaired taste.
third of the tongue.
12. Assess CN X (vagus). Depress a tongue blade on posterior 12. Significant findings include weak or absent gag reflex,
tongue, or stimulate posterior pharynx to elicit gag reflex. Note dysphagia, aspiration, hoarseness, and dysarthria (slurred
any hoarseness in voice. Check ability to swallow. Have patient speech).
say “ah.” Observe for symmetric rise of uvula and soft palate.
13. Assess CN XI (spinal accessory). While patient shrugs 13. Significant findings include weak or absent shoulder shrug
shoulders against resistance, palpate and note strength of and inability to turn the head to the side.
trapezius muscles. As patient turns head against opposing
pressure of the examiner’s hand, palpate and note strength of
each sternocleidomastoid muscle.
14. Assess CN XII (hypoglossal). While patient protrudes the 14. Significant findings include dysphagia and dysarthria.
tongue, note any deviation or tremors. Test the strength of the
tongue by having patient move the protruded tongue from side
to side against a tongue depressor.

Adapted from Bader, M., Littlejohns, L. R., & Olson, D. (2016). AANN core curriculum for neuroscience nursing (6th ed.). Chicago, IL: American Association
of Neuroscience Nurses; Weber, J., & Kelley, J. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

From Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 14th Edition. All Rights Reserved.

LWBK1592-CH65_online-01.indd 1 7/25/17 5:54 PM