Cranial Nerves Assessment

Cranial Nerve Assessment Technique Normal Response Client’s Response

Client is able to identify different smell

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