Hello good morning, how are you?

By the way I’m krysstal geronga your student nurse for today.
And you are? Ms. Chuchu 19 yrs old and your bday is September 28, 2002. I am right?

CRANIAL NERVE

⮚ Assess level of consciousness – Glasgow coma scale/ patient is conscious

and orientation as to time, place and  location – checking mental status

Cranial Nerve III – OCULOMOTOR, CNIV: Trochlear, CNVI: Abducens) ∙ Assess extraocular
movements (EOMs) in all fields of gaze.
- Evaluation the patients extraocular eye movement. Observe each eye for rapid oscillation
(nystagmus), movement not in unison (disconjugate movement), or inability to move certain
directions (ophthalmoplegia), and note complaints of double vision (diplopia)

▪ ABNORMAL FINDINGS- drooping of the patients eyelid or ptosis can result from defect in the
oculomotor nerve. Nystagmus may indicate disorder on the brain stem, drug toxicity such as
anticonvulsant phenytoin.

Cranial Nerve V- TRIGEMINAL  ∙ Touch both sides of the face to determine sensation
- Gently touch the right side and left side of the patients forehead with cotton ball while his eyes
are closed. Instruct him to state the moment the cotton touches the area. Repeat the technique
on the left and right cheek and on the jaw. Repeat the entire procedure using sharp object such
as ballpoint of the pen.
▪ ABNORMAL FINDINGS- probable peripheral nerve damage that causes the lack of sensation, a lesion on
the cervical spine cord may be present

Cranial Nerve VII – FACIAL  - Ask the client/patient to: 

∙ Smile, raise eyebrows, frown, puff out cheeks, close eyes tightly
▪ ABNORMAL FINDINGS may reflect an upper motor neuron problem, such a stroke that has damaged
neurons in the facial control area of the motor strip in the cerebral cortex.

Cranial Nerve IX – GLOSSOPHARYNGEAL 

∙ Have the client speak and swallow. Look into their throat with a  penlight when they say “Ah”
and you should see the uvula rise in  the midline. Place tongue depressor blade on posterior
tongue to elicit gag reflex.
 ABNORMAL FINDINGS may lead to damage of the CN X

REFLEXES
 Test reflexes using a percussion hammer, comparing one side of the body  with the other to
evaluate the symmetry of response

BICEPS REFLEX (Biceps reflex is a reflex test that examines the function of the C5 reflex arc and the
C6 reflex arc)
- Tests the spinal cord levels C-5, C-6
 - Partially flex the client/patient’s arm at the elbow, & rest the  forearm over the thighs,
placing the palm of the hand down 
- Place the thumb of your non-dominant hand horizontally over the  biceps tendon 
- Deliver a blow (slight downward thrust) with the percussion hammer  to your thumb
- Observe the normal slight flexion of the elbow, & feel the bicep’s  contraction through your
thumb

TRICEPS REFLEX  
- Test the spinal cord levels C-7, C-8 
- Flex the arm at the elbow, & support it in the palm of your non dominant hand 
- Palpate the triceps tendon about 2-5 cm (1-2 inches) above the  elbow 
- Deliver a blow with the percussion hammer directly to the tendon ∙ Observe for the normal
slight extension of the elbow

PATELLAR RELFEX   (A stretch reflex is a type of muscle reflex, which protects muscle against
increases in length that can tear and damage muscle fibers. The primary purpose of the patellar
reflex – the stretch reflex of the quadriceps femoris muscle – is to prevent excessive stretching
of the quadriceps.)
- Tests the spinal cord levels L-2, L-3, L-4 
- Ask the client/patient to sit on the edge of the examining table so  that the legs hang freely 
- Locate the patellar tendon directly below the patella 
- Deliver a blow with the percussion hammer directly to the tendon ∙ Observe the normal
extension or kicking out of the leg as the  quadriceps muscle contracts 
- If no response occurs, & you suspect the client is not relaxed, as the   client/patient to interlock
fingers & pull

MOTOR FUNCTION (Reduced motor function can occur as a result of injury to the cerebral cortex,
motor pathway, peripheral nerve or muscle.)

GROSS MOTOR & BALANCE TESTS  

Walking Gait  (A gait analysis measures how your entire body moves and functions, also called
biomechanics. This  affects your mobility, flexibility, stability, and functional strength. If you continue to
use your body — such as while running — with improper gait, you're likely to put more strain on multiple
parts of your body)
- Ask the client/patient to walk across the room & back then assess the  client/patient’s gait

Romberg’s Test   (The Romberg test is used  to demonstrate the effects of posterior column disease
upon human upright postural control.  )
- Ask the client/patient to stand with feet together & arms resting at the  sides, first with eyes
open, then closed

Standing on One Foot with Eyes Closed   (Signals from your eyes play a big role in maintaining your
balance, which helps explain why standing on one leg is significantly harder when you close your eyes.
If you can reach 10 seconds with your eyes closed, you're doing well.)
 - Ask the client/patient to close eyes & stand on one foot, then the other.  Stand close to the
client/patient during this test

Heel-Toe Walking   (is  highly useful in testing for ethanol inebriation)

- Ask the client/patient to walk a straight line, placing the heel of one foot  directly in front of
the toes of the other foot 
Toe or Heel Walking   (This test  gives a rapid overall indication of a patient's lower limbs muscles
power.)
- Ask the client/patient to walk several steps on the toes & then on the heels

Temperature Sensation
- Test skin areas with test tubes filled with hot or cold water 
Have the client/patient respond say, “hot”, “cold”, or “don’t know”