How to Assess Cranial Nerves? Cranial Nerves Assessment Cheat Sheet

Assessment of the cranial nerves are inevitable in making case studies or family cases analysis.

Cranial nerves assessment can be tedious and sometimes we forget how to do assess a nerve.

With that problem, NursesLabs will give you a “Cranial Nerve Assessment form” to help you document your cranial nerves assessment easily and accurately.

Cranial- Nerves- Assessment- Form

Cranial Nerves Cheat Sheet

Cranial Nerve	Assessment Technique	Normal Response	Client’s Response
I. Olfactory	Ask the client to smell and identify the smell of cologne with each nostril separately and with the eyes closed.	Client is able to identify different smell with each nostril separately and with eyes closed unless such condition like colds is present.	Client was able to describe the odor of the materials used.
II. Optic	Provide adequate lighting and ask client to read from a reading material held at a distance of 36 cm. (14 in.).	The client should be able to read with each eye and both eyes.	Client was able to read with each eye and both eyes.
III. Oculomotor	Reaction to light: Using a penlight and approaching from the side, shine a light on the pupil. Observe the response of the illuminated pupil. Shine the light on the pupil again, and observe the response of the other pupil. Reaction to accommodation: Ask client to look at a near object and then at a distant object. Alternate the gaze from the near to the far object. Next, move an object towards the client’s nose.	Illuminated and non-illuminated pupil should constrict. Pupils constrict when looking at a near object, dilate when looking at a distant object, converge when near object is moved towards the nose.	PERRLA (pupils equally round and reactive to light and accommodation)
IV. Trochlear	Hold a penlight 1 ft. in front of the client’s eyes. Ask the client to follow the movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally.	Client’s eyes should be able to follow the penlight as it moves.	Both eyes are able to move as necessary.
V. Trigeminal	While client looks upward, lightly touch lateral sclera of eye to elicit blink reflex. To test light sensation, have client close eyes, wipe a wisp of cotton over client’s forehead. To test deep sensation, use alternating blunt and sharp ends of an object. Determine sensation to warm and cold object by asking client to identify warmth and coldness.	Client should have a (+) corneal reflex, able to respond to light and deep sensation and able to differentiate hot from cold.	Client was able to elicit corneal reflex, sensitive to pain stimuli and distinguish hot from cold.
VI. Abducens	Hold a penlight 1 ft. in front of the client’s eyes. Ask the client to follow the movements of the penlight with the eyes only. Move the penlight through the six cardinal fields of gaze.	Both eyes coordinated, move in unison with parallel alignment.	Both eyes move in coordination.
VII. Facial	Ask client to smile, raise the eyebrows, frown, and puff out cheeks, close eyes tightly. Ask client to identify various tastes placed on tip and sides of tongue.	Client should be able to smile, raise eyebrows, and puff out cheeks and close eyes without any difficulty. The client should also be able to distinguish different tastes.	Client performed various facial expressions without any difficulty and able to distinguish varied tastes.
VIII. Vestibulocochlear	Have the client occlude one ear. Out of the client’s sight, place a tickling watch 2 to 3 cm. ask what the client can hear and repeat with the other ear. Ask the client to walk across the room and back and assess the client’s gait.	Client should be able to hear the tickling of the watch in both ears. The client should have upright posture and steady gait and able to maintain balance.	Client was able to hear tickling in both ears. The client was able to stand and walk in an upright position and able to maintain balance.
IX. Glossopharyngeal	Ask the client to say “ah” and have the patient yawn to observe upward movement of the soft palate. Elicit gag response. Note ability to swallow.	Client should be able to elicit gag reflex and swallow without any difficulty.	Client was able to elicit gag reflex and able to swallow without difficulty.
X. Vagus	Ask the patient to swallow and speak (note hoarseness)	The client should be able to swallow without difficulty and speak audibly.	Client was able to swallow without difficulty and speak audibly.
XI. Accessory	Ask client to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (repeat for other side).	Client should be able to shrug shoulders and turn head from side to side.	Client was able to shrug his shoulders and turn his head from one side to the other.
XII. Hypoglossal	Ask client to protrude tongue at midline and then move it side to side.	The client should be able to move tongue without any difficulty.	The client was able to move tongue in different directions.

How to Start an Intravenous (IV) Infusion

Deficient Knowledge | Stem Cell Collection NC...

Risk for Infection | Stem Cell Collection Nur...

Deficient Knowledge | Diabetes Insipidus Nurs...

Tags: assessment

cranial nerve assessment, cranial nerves assessment, cranial nerve assessment nursing, intake and output cheat sheet, nursing charting terminology cheat sheet, anatomy and physiology of dengue fever, organ involved for NSVD

4 comments 0 people listening

Comment help
Get Livefyre

Sort: Newest | Oldest

Ralph @ Medical Facts 101

I would just like to recommend reviewing first the anatomy and physiology of eye muscles.

Because cranial nerves 3, 4, and 6 innervate different muscle of the eyes, and each of these muscles have different movements which can be assessed depending on what gaze your penlight is in.

share flag