Cranial Nerves Assessment 2009

Sheeba Jacob R.N., B.S.N., Victoria Kim RN B.S.N.

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Goals
Goal: 1 .Students will be able to identify the 12 cranial nerves by name and assess the function of each (knowledge). 2. The student will be able to comprehend the anatomical significance of the assessment. (Comprehension)

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Objectives
1. Objectives, Upon completion of this learning experience the student should be able to:
1. Identify the 12 cranial nerves. 2. Demonstrate the ability to interpret the test of visual acuity using a snellen chart. 3. Assess the visual fields by recognizing correct technique for confrontation. 4. Perform the cover test. 5. Correctly assess PERRLA (Pupils equal, round, reactive to light and accomodation). 6. Comprehend the correct technique for performing the whisper test, Weber and Rhinne test. 7. Perform assessment of neck including the lymph nodes. 8. Use the technique of inspecting and palpating the head and scalp, anterior posterior chest, and sensorimotor functions.
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Identify the 12 cranial nerves.

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The Cranial Nerves

. 1. Video Cranial Nerves
University of Utah (Hyperlinkhttp://www.youtube.com/watch?v=CL1KNziYmzo)

Watch the video and reviewing the different anatomical sections of the brain The nurse, in assessing the 12 cranial nerves, is testing the functions of various parts of the brain
2. .

Anatomy of Brain-

http://www.righthealth.com/search/Picture_Of_Label ed_Brain/overview/google_imagesearch?img=3
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Cranial Nerve Anatomy

There are 12 pairs of cranial nerves CN I Smell CN II Vision CN III, IV, VI Oculomotor CN V Trigeminal Sensorimotor muscles of the Jaw CN VII Sensorimotor of the face CN VIII Hearing CN IX, X, XII Mouth, esophagus, oropharynx CN XI Cervical Spine and shoulder

3. Cranial Nerve
http://www.becomehealthynow.com/images /organs/nervous/cranial_nerves_bh.jpg
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Knowledge Test 1
How many Cranial Nerves are there? 12

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Cranial Nerve V
Temporomandibular joint and Massater Muscle

Cranial Nerve V CN V Trigeminal Sensorimotor muscles of the Jaw The temperomandibular joint is palpated while the patient clenches jaw, opens and closes mouth, moves jaw side to side and forward against pressure CN V, trigeminal Nerve

CN V is further tested with light touch a wisp of cotton in three areas .

Cranial Nerve V http://www.fotosearch.com/L IF155/mm103010/
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Cranial Nerve V
Inspection and Palpation Cranial Nerves are assessed in this order 5,7,2,3,4,6,8,1,9,10, 11,12 Palpate the Temporomandibular Joint CN V
http://images2.wikia.nocookie.net/psychology/images/thumb/9/99/ Gray778_Trigeminal.png/440px-Gray778_Trigeminal.png

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Knowledge Test 1
Q. Which cranial nerve is VI

further tested with light touch a whisp of cotton in three areas .

V
VII III

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Cranial Nerve VII Function

Cranial Nerve VII Definition cranial nerves seven The facial nerve VII (nervus facialis) comes from the pons in the hindbrain. It is a strong motor, sensory and parasympathetic nerve. Its numerous branches connect to the face muscles, the skin around the earlobes and various exocrine glands in the head..
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Cranial Nerve VII, Facial Nerve

1. Cranial Nerve VII Anatomy and Physiology http://www.megasyste msusa.com/app/home /home.aspx

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Cranial Nerve VII Anatomy

Facial Nerve (nervus facialis) Comes from the Pons in the Midbrain Sensory Motor Branches connect to the face muscles, the skin around the earlobes and various exocrine glands in the head..
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Assessment Cranial Nerve VII

Assessment - is tested by observing the presence and symmetry of the patients facial muscle movements

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Smiling Frowning Showing teeth Puffing out cheeks Raising eyebrows Resisting examiners attempt to open the eyes
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Knowledge Test 1
Q. A test of Cranial VII is? Protruding the tongue

Blinking
Flapping hands Smiling

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Cranial Nerve II, Optic Nerve Function of Sight

Definition Cranial Nerve the optic nerve II (vervus opticus), which facilitates sight, http://www.megasystemsusa.com/app/home/ho me.aspx

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Cranial Nerve II, Optic Nerve Anatomy

1. Cranial Nerve II Anatomy and Physiology http://www.megasyste msusa.com/app/home /home.aspx
1.Cranial Nerve II Anatomy and Physiology

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 Assessment Cranial nerve II

Visual Acuity part of cranial nerve to is tested .
Near visual acuity, must be done having patient read a small snellen equivalent Visual fields, part of cranial nerves are tested by confrontation

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Cranial Nerve II, Optic Nerve Visual Acuity

Using a Snellen eye chart
Using the E Snellen Chart hold it out in front of them 14 inches
The chart is usually read while standing at a distance of 20 feet. Acuity is represented as a fraction, with the distance at which you are standing being the numerator (top part of fraction), and the normal maximum legible viewing distance ("Distance" on the chart above) as the denominator (bottom of fraction). So if, at 20 feet, you can read the letters on the row marked "40", this means you have visual acuity of 20/40 or better: 1/2 normal. From 10 feet, if the smallest letters you could read were on the "40" line, this would give you an acuity of 10/40: 1/4 normal. If you are nearsighted, your vision will become more normal the closer you stand to the chart. http://www.isee.org/eyecharts.html

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Patients wearing corrective lenses should be tested with lenses in place . Each eye is tested separately
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Cranial Nerve II, Optic Nerve Confrontation Test

Visual fields, part of cranial nerves are tested by confrontation Examination of the patient's left eye visual fields by confrontation. The patient is asked to identify the number of fingers, which the examiner raises in each quadrant while centering his gaze on the examiner's right eye

ttp://books.google.com/books?id=B4V85KlNZfYC&pg=PA17&lpg=PA17&dq=Cranial+Nerve+II+confrontation&source=bl &ots=uYsPFa_qDC&sig=vqSKzT8LIgYjRoAEiyBzM_JB6No&hl=en&ei=wiKYSqDBCIigsgOd7WzAg&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=Cranial%20Nerve%20II%20confrontation&f=false

Want to see a Video of Confrontation? http://www.youtube.com/watch?v=XiEw7v7OyBw

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Cranial Nerve III, IV, VI Pupillary Function

Part Nine Cranial Nerve III, IV, VI Pupillary Function Definition

The oculomotor nerve III (n. oculomotorius) stretches from the front edge of the pons to the eye socket. There it connects to four external eye muscles (musculi recti superior, inferior et medialis and musculus obliquus inferior). It also carries parasympathetic nerves for closing the pupil (usculus sphincter pupillae) and the accommodation (musculus ciliaris). The trochlear nerve IV (nervus trochlearis) runs from the brain to the tendons on the eye muscles in the orbit. It connects an external motor eye muscle (musculus obliquus superior). The abducens nerve VI (nervus abducens) is a motor nerve which connects to the external optic muscles (musculus rectus lateralis). If this nerve fails, the eyes can become cross-eyed (strabismus convergens).

1. Assessment CN III, IV, VI 2. The cranial nerves of each eye is assessed separately for pupillary reactions to light 3. cranial nerves III, IV and or VI a further tested by evaluating the extra ocular movements through the six cardinal fields of gaze. This examination allows assessment of each muscle in its primary field of action Video link below 4. cranial nerves III, IV and VI are further tested by performing the cover- uncover test

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Part 9--Cranial Nerve III, IV, VI

The cranial nerves of each eye is assessed separately for pupillary reactions to light, Testing is performed twice on each eye Each pupil is evaluated for its direct, and consensual reaction to light Pupils are also examined for accommodation, PERRLA Links to video below http://www.youtube.com/ watch?v=iTncbhfbl6A http://www.youtube.com/ watch?v=E2XzBaOOX8g
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Cranial Nerve III, IV, VI

2. cranial nerves III, IV and or VI a further tested by evaluating the extra ocular movements through the six cardinal fields of gaze. This examination allows assessment of each muscle in its primary field of action Video link below http://www.youtube.com/watc h?v=UDR7B__2sQM right and up right superior rectus and left inferior oblique right lateral rectus and left medial rectus right and down right inferior rectus and left superior oblique . left and up left superior rectus and right inferior oblique left lateral rectus and right medial rectus left and down left inferior rectus and right superior oblique

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Cranial Nerve III, IV, VI

cranial nerves III, IV and VI are further tested by performing the coveruncover test
Link http://www.youtube.com /watch?v=PRa7mPx2XV s

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Part 10-Cranial Nerve VIII Hearing

1. Part TEN Cranial Nerve VIII, Hearing 2. Definition The vestibulocochlear nerve VIII (n. vestibulocochlearis) is a sensory nerve branch which comes from the pons in the brain. It reaches to the inner ear and serves to carry hearing and balance senses.
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Assessment - cranial nerve eight is tested using this screening hearing test or the whisper tests Cranial nerve eight is also tested by performing the Weber and Rinne tests

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Cranial Nerve VIII, Vestibulocochlear nerve VIII

1. Cranial Nerve VII Anatomy and Physiology http://www.megasystemsusa.co m/app/home/home.aspx External Ear --Both outer ears are deliberately and thoroughly inspected and palpated

2.

http://medicalimages.allref er.com/large/medicalfindings-based-on-earanatomy.jpg

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Cranial Nerve VIII, Hearing Anatomy

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Performing the Whisper Test

Check the patients response to your whispered voice one ear at a time Mask the hearing in the other ear by having the patient place a finger in the ear canal and gently move it rapidly up-and-down. Stand to the side of the patient at a consistent distance best for you, about 1 to 2 feet away from the ear being tested, and out of the patients line of vision Whisper a combination of three letters and numbers very softly and ask the patient to repeat the words heard Normal findings .
The patient should hear softly whispered words in each ear at that distance of about 1 to 2 feet, responding correctly more than 50% of the time

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Weber Test of Hearing

Weber and Rinne test is used to compare hearing by bone conduction with that of air conduction Hold the base of the tuning fork with one hand without touching the tines, and stroke or tap the tines gently . With your other hand, setting the tuning fork in vibration

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Performing Weber test

Perform the Weber test by placing the base of the vibrating tuning fork on the midline vertex of the patients head Ask the patient if the sound is heard equally in both ears or is better in one ear Normal finding lateralization of sound. Is their lateralization of sound?
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To test the reliability of the patients response, repeat the procedure while occluding one ear, asking the patient in which hear the sound is best heard. It should be heard best in the occluded ear.

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Rinne Test of Hearing

The Rinne test is performed by placing the base of the vibrating tuning fork against the patients mastoid bone Begin counting or timing the interval with your watch . Ask the patient to tell you when the sound is no longer heard, noting the number of seconds Quickly position the still vibrating tines 1cm to 2 cm from the auditory canal, and again ask the patient to tell you when the sound is no longer heard Continue counting or timing the interval to determine the length of time, the sound is heard by air conduction

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Normal Findings Rinne Test

Compare the number of seconds sound is heard by bone conduction versus air conduction. Normal Findings: The air conducted sound should be heard twice as long as bone conducted sound, after bone conduction stops. For example, if bone conducted sound is heard for 15 seconds, the air conducted sound should be heard for an additional 15 seconds.
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Part 11-Cranial Nerve I, Smell

1. The sense of smell is developed by the mucous membranes in the nose (nasus). Here a small area has a layer of sensory sells, the olfactory epithelium. This picks up smells and sends them to the brain (cerebrum). All information received by the brain from the main sensory organs is called sensory signals. 1. Assessment
1. The nose is inspected and palpated externally . 2. Inspected internally with the light and speculum of an otoscope 3. The patency of the nose is also assessed be occluding each nostril. 4. Test cranial nerve 1 with odor differentiation of each nostril

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Cranial Nerve 1, Olfactory Nerve

Cranial Nerve 1Olfactory

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Cranial Nerve IX and X, Swallowing

1. The glossopharyngeal nerve IX (n. glossopharyngeus) is a motor, sensory and parasympathetic nerve branch which comes from the extended spinal cord (medulla oblongata). Its branches connect to the tongue, the pharyngeal muscles, the ear drum, the lower thorangeal skin and the ear wax glands. The vagus nerve X (n. vagus) comes from the extended spinal cord. It has motor and sensory threads which reachs from the neck to the stomachintestinal tract. On its path, it connects to numerous muscles in the larynx, thorax, gullet and intestinal tract, but also the glands, glandular organs and the ear canal. 1. Assessment Swallowing
1. 2. The entire oral cavity is inspected CN IX and X are tested by
1. 2. 3. 4. Having the patient swallow This can be observed during the thyroid assessment Observing movement of the palate during phonation. A comment about quality of the patients voice should be noted .

2.

Testing the gag reflex, does not need to be assessed and is usually only tested if neurological impairment is suspected . The sense of taste on the posterior third of the tongue does not need these tested

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Cranial Nerve IX and X, Swallowing

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Cranial Nerve IX, X

Cranial Nerve 1Olfactory

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The thyroid gland

The thyroid gland (glandula thyroidea) The two oval side lobes (lobus dexter, lobus sinister) of the thyroid gland are located at the front of the neck to the right and left of the windpipe (trachea) underneath the larynx (larynx). The two lobes are joined by a narrow bridge of tissue, the isthumus, on a level with the 2nd to 4th tracheal cartilages. It has a plentiful supply of blood. Mutations in the form of hard patches and considerable enlargements (goiter, struma) are not rare and indicate malfunctions of the gland.

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The thyroid gland

The thyroid gland is inspected and palpated before and during swallowing . The patient is provided a couple water to facilitate swallowing during this part of the assessment

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Cranial Nerve XII

The hypoglossal nerve XII (nervus hypoglossus) comes from the extended spinal cord. This motor nerve connects to the muscles of the tongue.

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Cranial Nerve XII

Cranial nerve XII assessed by observing
The movement of the tongue laterally medially Including a statement about patients ability to articulate

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Part 13-Range of Motion of the Cervical Spine

The Cervical Vertebrae (Vertebrae cervicales) The cervical vertebral column is the one most capable of movement. The first cervical vertebrae (atlas) and the second cervical vertebrae (axis) deviate significantly from the basic form of the cervical vertebrae. For instance, the atlas does not have the body of the vertebrae or spine of the vertebrae. Instead of that, it has two arches with joint surfaces for the axis and the occipital bone (os occipitale). The second cervical vertebra has a tooth-like process (dens axis), which connects the front surface of the joint of the atlas and axis. The cervical vertebrae 3-6 are very similar to one another.

The range of motion of the cervical spine is evaluated by having the patient . - put his or her chin on the chest . - lift chin to ceiling -turn chin toward each shoulder - touch each ear toward corresponding shoulder

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Cervical Vertebrae Anatomy

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Cranial Nerve XI
Cranial nerve 11 is tested by having the patients .
Shrugged the their shoulders against resistance . By turning their head against the examiner hand bilaterally Observe the Sternocleidomastoid and trapeze muscles for equal size General examination of the patients anterior neck

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Assessment of Neck Observe the Sternocleidomastoid and trapeze used muscles for equal size

The sternomastoid muscle (M. sternocleidomastoideus) goes at an incline on the neck from the upper edge of the breastbone (sternum) and collarbone (clavicula) to the mastoid process of the temporal bone (os temporale). It can be used one-sided and two-sided. On one side, it bends the cervical vertebral column to the same side and rotates the head to the opposite side while raising the chin. It raises the chin on both sides, bends the cervical vertebral column forwards and it raises and supports the thorax.
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Neck
All lymph nodes in the head, posterior and anterior neck, and supraclavicular regions are palpated The specific lymph nodes are named while examining the specific areas

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Lymph Nodes (must be named)

1. 2. 3. 4. 5. 6. 7. 8. 9. Occipital Postauricular Preauricular Posterior Cervical Supraclavicular Submandibular Submental Superficial Anterior Cervical Inferior anterior cervical

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Trachea
The position of the trachea is palpated

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Auscultate the Carotids

The carotids are also auscultated bilaterally using the belle of the stethescope while the patient is holding his breath Note the thyroid is also auscultated only if it is enlarged The carotid arteries, which each extend towards the head on either side, branch off in the so-called carotid bifurcation on the level of the upper edge of the larynx into an inner and outer carotid artery (arteria carotis externa et interna). The outer carotid artery supplies blood to the thyroid gland (glandula thyreoidea), larynx (larynx), oral cavity (cavum oris), masticatory muscles and the face; the inner carotid artery supplies blood to the eye (oculus) and to most of the brain (cerebrum).

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Carotids Anatomy

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Summary Part 1
The cranial nerves The appearance of the sternoclidomastoid muscle and the trapezius muscle Lymph Nodes of the head and neck Position of the trachea Start Part 2

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References
1. 2. Video Cranial Nerves , The University of Utah, Videohttp://www.youtube.com/watch?v=CL1KNziYmzo Brain Anatomy http://craig.f12network.com/microbiology/Ch26_BL/homep age_BL.htm Cranial Nerve http://www.becomehealthynow.com/images/organs/nervous /cranial_nerves_bh.jpg Foto search Stock Photography and Stock Footage Royalty Free Images, Publitek, Inc. dba Fotosearch 21155 Watertown Road, Waukesha, WI 53186-1898 USA http://www.fotosearch.com/illustration/brain_5.html
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