College of Nursing

ASSESSMENT OF THE CRANIAL NERVES

Instruction: Check on the column as to what level is the performance of the student in the
following procedure. Be guided in the scoring with the legend below.

4 Very satisfactory (Performed all the procedures correctly)

3 Satisfactory (Needs minimal assistance in performing the procedure)
2 Good (Needs more practice in performing the procedure)
1 Fair (inappropriate in the performance of the procedure)
PROCEDURE 4 3 2 1
Considers the following:
1. Adequate lighting, comfortable room temperature
2. Assembles needed equipment/ materials.
3. Introduces self and verify client’s identity. Explain the procedure, its purpose and
how the client can cooperate.
4. Provides privacy and ask if they prefer to have a family or significant other with
them during the procedure.
5. Have client sit in a comfortable position at your eye level.
6. Performs hand hygiene.
CRANIAL NERVE I - OLFACTORY
7. Ask the client to clear the nose to remove any mucus, then to close eyes, occlude
one nostril, and identify a scented object that you are holding (such as soap,
coffee, or vanilla). Repeat procedure for the other nostril.
CRANIAL NERVE II – OPTIC
8. Provide adequate lighting and ask client to read from a reading material held at
a distance of 36 cm. (14 in.) to assess near vision.
Use a Snellen chart to assess vision in each eye.
Assess visual fields of each eye by confrontation.
CRANIAL NERVE III – OCULOMOTOR
9. 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: Asks 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.
CRANIAL NERVE IV – TROCHLEAR
10. Hold a penlight 1 ft. in front of the client’s eyes. Asks the client to follow the
movements of the penlight with the eyes only. Move the penlight upward,
downward, sideward and diagonally.
CRANIAL NERVE V – TRIGEMINAL
11. 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.

CRANIAL NERVE VI – ABDUCENS

12. 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.

CRANIAL NERVE VII – FACIAL

 13. 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.
CRANIAL NERVE VIII – ACOUSTIC/ VESTIBULOCOCHLEAR
14. Have the client occlude one ear. Out of the client’s sight, place a ticking 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.
CRANIAL NERVE IX – GLOSSOPHARYNGEAL
15. Assess taste and gag reflex
Elicit gag response. Note ability to swallow
Ask client to identify lemon and salt
CRANIAL NERVE X – VAGUS
16. Ask the client to say “ah” and have the patient yawn to observe upward
movement of the soft palate.
Ask the patient to swallow and speak (note hoarseness )
CRANIAL NERVE XI – SPINAL ACCESSORY
17. Ask client to shrug shoulders against resistance from your hands and turn head to
side against resistance from your hand (repeat for other side).
CRANIAL NERVE XII – HYPOGLOSSAL
18. Ask client to protrude tongue at midline and then move it side to side.
Total Score
Perfect Score 68

Remarks:

Name / Signature of Student Name / Signature of RD Instructor