Daduya, Reinha Mae DG.

III-BSN

Key Areas of Steps Rationale Weight Score Remarks PICTURES

Responsibility
Cranial Nerves
Management of A. CN I - Olfactory * This test is not 1
Resources and (Sensory) routinely done.
Environment 1. Ensure the paten- However, in
Personal and cy of both nos- cases of head
Professional trils through trauma or
Development inspection or by where the in-
asking the tegrity of CN I
patient to blow is in question
through one it becomes
nostril while the mandatory to
other is occlu- perform the
ded. test.

Fig.1

2. With the client’s * Do not use ir- 1

eyes closed, ritating subs-
occlude one tances
nostril and ask (ex. ammonia,
the patient to vinegar) be-
identify the cause the pain
 odor of at least fibers of the
two common trigeminal
substances. nerve (CN V)
ex. coffee will also be
stimulated.

Management of B. CN II – Optic
Resources and (Sensory)
Environment 1. Testing for visual
Personal and acuity:
Professional a. Informal 1
Development assessment: This is a quick
With one eye way of checking
closed, ask the visual acuity.
the patient to Formally, it
read a news- should be done
paper starting using a Snellen
from the lar- chart which is
ger to the placed 20 feet
smaller away from the
prints. patient.

b. Formal 1
assessment:
Snellen chart
Ask the patient Stop at the line
to read the where the
biggest to the patient fails to
smallest line read at least half.
on the chart.
 Fig.2

Patients with
prescription
glasses
should wear
them during
testing.

Personal and 2. Testing the 1

Professional visual fields:
Development Perform the The patient
confrontation should see the
technique. Stan- examiner’s mo-
ding 2 ft. away ving fingers
from the pa- bilaterally at the
tient, have him same time.
fix his gaze on
you. Bring your
moving fingers
forward begin-
ning from a
point about 6 in.
posterolateral to
 the ear into the
patient’s visual
field.

Fig.3
Do this bilate-
rally and simul-
taneously.
Then repeat
with the fingers
positioned su-
periorly and
inferiorly.

Fig.4

Management of 3. Funduscopic This test may be 1

Resources and exam: reserved for
Environment Using the oph- later when time
Personal and thalmoscope, permits except
Professional examine the when there is
Development fundus. suspected in-
crease in intra-
cranial pressure.
The fundus
 becomes blurred
(papilledema)
with increased
intracranial
pressure.
Fig.5
Personal and C. CN III -
Professional Oculomotor
Development CN IV -
Trochlear
CN VI -
Abducens
(All three:
Motor)
1. Note for ptosis. CN III is respon- 1
sible for eyelid
elevation.

Fig.6

Management of 2. Using a penlight, Pupillary ref- lexes: 1

Resources and examine each 1. direct: when
Environment eye by moving the pupil being
Personal and the light from examined
Professional lateral to me- constricts
Development dial. 2. consensual:
Note for pupil- when the other
lary constric- pupil cons-
tion. tricts as one is
being exa-
mined
 Fig.7

Personal and 3. Ask the patient to CN IV is respon- 1

Professional follow your fin- sible for medial-
Development gers through the ward and down-
six cardinal po- ward eye move-
sitions of gaze. ments.
CN VI is respon-
sible for lateral
movement.
CN III is respon-
Fig.8
sible for all
other eye move-
ments.

Management of D. CN V -
Resources and Trigeminal
Environment (Mixed)
Personal and 1. Testing the sen- The trigeminal
Professional sory component: nerve has 3
Development Using a wisp of branches: 1
cotton, lightly ophthalmic,
stroke the fore- maxillary,
head, cheek, and mandibular.
and jaw on one
side.
 Fig.9
Do this for 1
both sides. Re-
peat the proce-
dure and test for
pain perception
by using the
sharp end of a
safety pin.

Fig.10
You may check
for reliability of
perceived sen-
sation by alter-
nating sharp
and dull
touches.
This will cause 1
For unconscious the patient to
patients, or if blink
preferred: (blink reflex).
Lightly touch the
cornea with a
 wisp of cotton.

Fig.11

Personal and 2. Testing the The trigeminal

Professional motor compo- nerve supplies
Development nent: motor function for
Ask the patient to the jaw and all 1
clench his/her chewing
teeth and feel muscles.
for muscle
movement at
the angle of
the mandible
(temporal and
masseter
muscles).

Fig.12
Alternatively,
you may force
the mouth open
by downward
 pressure on the
chin as the pa-
tient clenches
his/her teeth.

Management of E. CN VII - Facial

Resources and (Mixed)
Environment 1. Testing the sen- The sensory com-
Personal and sory component: ponent controls
Professional Ask the patient to taste on the an- 1
Development identify a sub- terior 2/3 of the
stance placed tongue.
on one side of
the anterior 2/3
of the tongue.
Do the same for
the other side.

Personal and 2. Testing the

Professional motor compo-
Development nent:
Ask the patient to The motor com- 1
smile, frown, ponent is res-
wrinkle the ponsible for the
forehead, open muscles of fa-
the eyes wide, cial expression.
raise the eye-
brows, puff out
cheeks and ob-
serve for sym-
metry.
 Fig.13

Personal and F. CN VIII -

Professional Auditory,
Development Acoustic, or
Vestibulo-
cochlear
(Sensory)
1. Testing the The cochlear
cochlear (hea- division controls
ring) portion: hearing.
a. screening test Alternatively, you 1
Rub your fin- may do the
gers close to voice test and/or
one ear and the watch test.
repeat the
same for the
other ear.

Personal and b. Voice test

Professional Instruct the pa- 1
Development tient to sit in
front of you.
Block one ear
as you whis-
per. Ask him/
her to repeat
 what you
said.

Fig.14

c. Watch test
Management of This is a test for 1
Hold a ticking
Resources and high-frequency
watch about
Environment sounds. A mo-
5 in. away
Personal and dification of the
from one ear
Professional test requires the
and ask the
Development examiner to pull
patient if he/
the watch away
she could
from the ear un-
hear the
til the sound can
sound.
no longer be
heard. The dis-
tance at which
the sound could
no longer be
heard is then
recorded.

Do the Weber
and/or Rinne test
when poor
hearing is
detected.
Management of d. Weber tuning The side where 1
Resources and fork test: the sound is lou-
Environment Place the han- der is suffering
Personal and dle of a vi- from conductive
Professional brating tu- hearing loss;
Development ning fork conversely, the
against the side where the
vertex of the sound is softer is
scalp. suffering from
sensorineural
hearing loss.

Fig.15

Management of e. Rinne tuning The Rinne test 1

Resources and fork test: does not have
Environment Place the han- any predictive
Personal and dle of a vib- value for senso-
Professional rating tuning rineural hearing
Development fork against loss.
the patient’s Normally, the
mastoid area. sound can still
be heard after
the tuning fork
had been re-
moved from the
mastoid and
Fig.16 repositioned
close to the
auricle. This is
because air
 conduction is 2
to 3x longer than
bone connduc-
tion.
Note that a nor-
Fig.17 mal finding
(AC>BC) is
Instruct him/ documented as a
her to note “positive test.”
for the sound.
When the
sound can no
longer be
heard, re-
move the tu-
ning fork
from the
mastoid and
position the
tines close to
the pinna but
not touching
it.

Fig.18
 Fig.19

Ask the
patient if he/
she can still
hear the
sound.

Management of 2. Testing the A thorough and

Resources and vestibular por- more objective
Environment tion: way of testing
Safe and Quality Caloric testing: the cochlear
Nursing Care Examine the ear- portion is to 1
Personal and drums to en- subject the
Professional sure that they patient to
Development are intact. audiometry.
Instill cold
water into one Just like CN I, the
ear and observe vestibular por-
the eyes. tion of CN VIII
Do the same is not routinely 1
for the other tested unless the
ear, this time patient presents
using warm with dizziness
water. (patient is
spinning) and
vertigo (room is
 spinning).

The eyes should

move away from
the ear irrigated
with cold water
Fig.20 after which nys-
tagmus naturally
follows.

The eyes should

move toward the
ear irrigated
with warm water
after which nys-
tagmus naturally
follows.

Presently, the
gold-standard
for diagnosing
ear disorders is
the electronys-
tagmography.
Caloric testing is
just one of four
parts of the
whole ENG.

Management of G. CN IX - Because the

Resources and Glossopha- innervation of
Environment ryngeal both CN IX and
Safe and Quality CN X - Vagus CN X overlap in
Nursing Care (Both mixed) the pharynx
Personal and these 2 nerves
Professional are tested
Development together.

CN IX: CN IX controls 1
Sensory: sensation of the
Using a tongue de- pharyngeal soft
pressor, touch the palate, tonsillar
posterior pharynx mucosa, and
to initiate the gag taste to the
reflex. posterior 1/3 of
the tongue. Its
motor function
concerns saliva
secretion.

Fig.21
CN X is respon- 1
CN X:
sible for sensa-
Motor:
tion behind the
Instruct the patient
ear. Its motor
to swallow.
function is res-
ponsible for
swallowing and
phonation.

Personal and H. CN XI - CN XI controls

Professional Spinal accessory the sternocleido-
Development (Motor) mastoid and the
1. Test the sterno- upper trapezius
cleidomastoid muscles.
muscle:
Place your palm 1
against the
patient’s cheek
then ask him/
her to turn his/
her face
against resis-
tance. Do this
for the other
side.

Fig.22

2. Test the trapezius

muscle:
Place your hands
on the patient’s 1
shoulders and
ask him/her to
shrug his/her
shoulders
against
resistance.
 Fig.23

Personal and I. CN XII - CN XII controls

Professional Hypoglossal tongue move-
Development (Motor) ment.
1. Ask the patient Observe tongue 1
to stick out for symmetry.
his/her Tongue should
tongue; then be at the mid-
move it side line; no tremors/
to side. fasciculations. If
there is a prob-
lem, the tongue
will be deviated
to the affected
side.
Fig.24
1
2. Test tongue
strength:
Ask the patient
to push his/
her tongue
against his/
her cheek as
you apply
resistance.
 3. Sensory Function
Management of 1. Test for pain: There are 5 areas
Resources and With the pa- of sensation:
Environment tient’s eyes * pain
Safe and Quality closed, touch all * light touch
Nursing Care major derma- * vibration
Personal and tomes, first with * position
Professional the sharp end * discrimination 1
Development and then with
the dull end of a 1
safety pin.

Fig.25
Examination
proceeds from
the most distal
going proximal-
ly. If there is
a sensory
deficit, start
from the area
with least sen-
sation and move
toward the area
with the most
sensation.

Proceed in the
 following order:
* fingers
* shoulders
* toes
* thighs
* trunk

Management of 2. Test for light Do not swab the 1

Resources and touch: cotton because
Environment Repeat the pro- you might miss
Personal and cedure above an area of loss.
Professional but use a wisp A patient with
Development of cotton. peripheral neu-
ropathy may be
able to perceive
light touch even
after losing pain
sensation.
Fig.26

Management of 3. Test for Discontinue tes- 1

Resources and vibration: ting proximally
Environment Apply a vibrating when a vibration
Personal and tuning fork over has been felt
Professional bony prominen- because every-
Development ces starting thing above that
from the distal level will be in-
interphalangeal tact.
joints of the If vibratory sense
hands and feet is intact, there
proceeding is no need to
proximally. check for the
 position sense. It
will be normal
because the
same pathway
carries both the
Fig.27 vibratory and
the position
sense.

Personal and 4. Test for position Testing for 1

Professional sense or proprio- position sense
Development ception: requires intact
With the pa- vestibular and
tient’s eyes cerebellar
closed, grasp function.
the great toe
(for the lower
ext.) / index
finger (upper
ext.) and move
it up and down.

Fig.28

Fig.29
 Hold it in one
position and ask
the patient the
position it is in.

Management of 5. Testing for the These tests assess

Resources and sense of discri- the ability of
Environment mination: the cerebral cor-
Personal and A. Stereognosis: tex to interpret 1
Professional With the pa- and integrate
Development tient’s eyes information.
closed, place Tests the ability
an object in to discriminate
his/her open the shape, size,
hand and ask weight, texture,
him/her to and form of an
identify it. object by
touching and
manipulating it.

Fig.30

Total Perfect
Score =

Other tests:
TEST/S RESULT PICTURE

BABINSKI REFLEX

KERNIG SIGN

BRUDZINSKI SIGN