Cranial Nerve Assessment Tests PDF

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cranial nerves assessment test...

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CRANIAL NERVE ASSESSMENT TESTS Cranial Nerve (CN) CN I: Olfactory CN II: Optic CN III, IV, and VI: Oculomotor, trochlear, abducens

CN V: Trigeminal

CN VII: Facial

CN VII: Acoustic

CN IX and X (glossopharyngeal and vagus)

Assessment Assess ability to identify common odors Use Snellen chart to assess vision Extraocular eye movement (EOM): Have client follow finger through 6 cardinal fields of vision Ptosis (III) Droopy eyelid PERRLA: Assess pupils equal, round, and reactive to light and accommodation Nystagmus: Pupil movement is choppy Doll’s eyes: In comatose client, doll’s eyes is present when eyes stay center while head moves left and right, absent when eyes move with head Jaw clench: Palpate masseter and temporal muscles when client’s jaw if clenched; note difference on left or right Compare light, dull, and sharp sensations on both sides of face Corneal reflex: On an unconscious client, a wisp of cotton is touched to cornea; normal response is to blink lids (V, VII); stroke each lid to elicit a blink response Facial symmetry: Note droopiness of nasal labia fold, lower eyelid, or corner of mouth when asking client to grin, raise eyebrows, and sniff; assess accuracy of tasting sweet, sour, and salty items on anterior 2/3 of tongue Assess hearing in each ear with a ticking watch or whisper voice test Cold caloric testing: Irrigating ear in cold water causes slow movement of eyes toward irrigated side with a rapid return to midline; this is called oculovestibular reflex and indicates an intact brain stem Swallow reflex: Assess whether client can swallow water or has dysphagia Gag reflex: Assess gag by touching back of both sides of throat; unilateral loss may be noted Hoarseness: Assess client’s voice for

hoarseness Cough reflex: Assess whether client’s cough is strong, weak, or absent Assess sweet, salty, and sour taste on posterior 1/3 of tongue...