Assessment

of
Cranial
Nerves
PURPOSE:
To assess the function of cranial nerves and detect
any abnormalities.
ASSESSMENT:
Inquire if the client has history of the following:
trauma, tingling or numbness, tremors or tics, limping,
paralysis, uncontrolled muscle movements, or
problems with smell, vision, taste, touch, or hearing.
MATERIALS:
Coffee or vanilla granules
Snellen’s Chart
Tongue depressor
Salt
Sugar
Sterile gauze
Pin
Cotton
Tuning fork
 5. Assessment of the Cranial Nerves:
Cranial Nerve Test
Cranial Nerve I: Olfactory ▪ Have the client close the eyes and occlude
▪ Sensory 1 nostril with a finger
▪ Controls the sense of smell ▪ Ask the client to identify nonirritating and
familiar odors (e.g., coffee, tea, cloves, soap,
chewing gum peppermint)
▪ Repeat the test on the other nostril

Cranial Nerve II: Optic ▪ Assess visual acuity with a Snellen chart
▪ Sensory and perform an ophthalmoscopic exam
▪ Controls vision ▪ Check peripheral vision by confrontation
▪ Check color vision

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Cranial Nerve
Cranial Nerves III, IV, and VI
Cranial Nerve III: Oculomotor
▪ Motor
▪ Controls pupillary
constriction, upper eyelid
elevation, and most eye
movement
Cranial Nerve IV: Trochlear
▪ Motor
▪ Controls downward and
inward eye movement
Test
• Assess six ocular movements and pupil reaction.
▪ The motor functions of cranial nerves III, IV,
and VI overlap; therefore, they should be
tested together
▪ Inspect the eyelids for ptosis (drooping);
then assess ocular movements and note
any eye deviation
▪ Test accommodation and direct and consensual
light reflexes
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Cranial nerves
Cranial Nerve VI: Abducens
▪ Motor
▪ Controls lateral eye movement
Cranial Nerve V: Trigeminal
▪ Sensory and motor
▪ Controls sensation in the cornea,
nasal and oral mucosa, and facial
skin, as well as mastication
Test
Assess direction of gaze. ( can be observed during assessment of
CN III and CN IV)
▪ To test motor function, ask the client to clench the teeth
and assess the muscles of mastication; then try to
open the client’s jaws after asking the client to keep
them tightly closed
▪ The corneal reflex may be tested by the health care
provider; this is done by lightly touching the client’s
cornea with a cotton wisp (this test may be omitted if
the client is alert and blinking normally)
▪ Check sensory function by asking the client to close
the eyes; lightly touch forehead, cheeks, and chin,
noting whether the touch is felt equally on the 2 sides
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Cranial Nerve
Cranial Nerve VII: Facial
▪ Sensory and motor
▪ Controls movement of the face
and taste sensation
Cranial Nerve VIII: Acoustic or
Vestibulocochlear
▪ Sensory
▪ Controls hearing and vestibular
function
Test
▪ Test taste perception on the anterior two thirds of the
tongue; the client should be able to taste salty and
sweet tastes
▪ Have the client smile, frown, and show the teeth
▪ Ask the client to puff out the cheeks
▪ Attempt to close the client’s eyes against resistance
 Assessing the client’s ability to hear tests the cochlear
portion
▪ Assessing the client’s sense of equilibrium tests the
vestibular portion
▪ Check the client’s hearing, using acuity tests
▪ Observe the client’s balance and watch for swaying
when he or she is walking or standing
▪ Assessment of sensorineural hearing loss may
be done with the Weber or Rinne test
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Cranial Nerve Test
Cranial Nerves IX and X ▪ Usually cranial nerves IX and X are tested
Cranial Nerve IX: Glossopharyngeal together
▪ Sensory and motor
▪ Controls swallowing ability, sensation ▪ Test taste perception on the posterior one third of
in the pharyngeal soft palate and the tongue or pharynx; the client should be able
tonsillar mucosa, taste perception on to taste bitter and sour tastes
the posterior third of the tongue, and
salivation
Cranial Nerve X: Vagus
▪ Sensory and motor ▪ Inspect the soft palate and watch for symmetrical
▪ Controls swallowing and phonation, elevation when the client says “aaah”
sensation in the exterior ear’s
posterior wall, and sensation behind ▪ Touch the posterior pharyngeal wall with a
the ear tongue depressor to elicit the gag reflex
▪ Controls sensation in the thoracic and
abdominal viscera

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4
Cranial Nerve Test
Cranial Nerve XI: Spinal ▪ The nurse palpates and inspects the
Accessory sternocleidomastoid muscle as the client pushes the
▪ Motor chin against the nurse’s hand
▪ Controls strength of neck and
shoulder muscles ▪ The nurse palpates and inspects the trapezius
muscle as the client shrugs the shoulders against the
nurse’s resistance

Cranial Nerve XII: Hypoglossal ▪ Observe the tongue for asymmetry, atrophy, deviation
▪ Motor to 1 side, and fasciculations (uncontrollable twitching);
▪ Controls tongue movements ask the client to stick out the tongue (tongue should be
involved in swallowing and speech midline)

▪ Ask the client to push the tongue against a tongue

depressor, and then have the client move the tongue
rapidly in and out and from side to side

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DEMONSTRATION VIDEO:
CRANIAL NERVES ASSESSMENT

https://www.youtube.com/watch?v=
Q8jzYRQf_oc
Assessment
of
Deep
Tendon
Reflexes
• Biceps
• Triceps
• Brachioradialis
• Patellar
• Achilles
Biceps Reflex
Purpose:
To examine the function of the spinal cord level c5 and c6.
Assessment:
Inquire if the client has history of presence of pain and numbness
in the lower extremities, as well as onset and aggravating and
alleviating factors.

Material
Percussion hammer
Procedures
1. Partially flex the client’s arm at the elbow, and
rest the forearm over the thighs, placing the
palm of the hand down.
2. Place the thumb of your non dominant hand
horizontally over the biceps tendon
3. Deliver a blow (slight downward thrust) with
the percussion hammer to your thumb
4. Observe the normal slight flexion of the
elbow, and feel the bicep’s contraction
through your thumb.
Triceps Reflex
Purpose:
To examine the function of spinal cord level C7 and
C8.

Procedures
1. Flex the client’s arm at the elbow and support it
in the palm of your non dominant hand
2. Palpate the triceps tendon about 2- 5 cm above
the elbow.
3. Deliver a blow with the percussion hammer
directly to the tendon.
4. Observe for the normal slight extension of the
elbow.
Brachioradialis Reflex
Purpose:
To examine the function of spinal cord level C3 and
C6.

Procedures
1. Rest the client’s arm in a relaxed position on your
forearm or on the client’s own leg.
2. Deliver a blow with the percussion hammer directly on
the radius 2 – 5 cm above the wrist or the styloid
process, the bony prominences on the thumb side of the
wrist.
3. Observe the normal flexion and supination of the
forearm.
4. The fingers of the hand may also extend slightly.
Patellar Reflex
Purpose:
To examine the function of the spinal cord level L2,
L3, and L4

Procedures
1. Ask the client to sit on the edge of the examining table
so that his legs hang freely
2. Locate the patellar tendon directly below the patella.
3. Deliver a blow with the percussion hammer directly to
the tendon.
4. Observe the normal extension or kicking out of the leg
as the Quadriceps muscle contracts.
5. If no response occurs, and you suspect the client is not
relaxed. Ask the client to interlock the fingers and pull.
Achilles Reflex
Purpose:
To examine the function of the spinal cord level S1
and S2.

Procedures
1. Ask the client to sit on the edge of the examining
table so that his legs hang freely.
2. Slightly dorsiflex the client’s ankle by supporting
the foot lightly in the hand
3. Deliver a blow with the percussion hammer
directly to the Achilles tendon just above the heel.
4. Observe and feel the normal plantar flexion
(downward jerk) of the foot.
DEMONSTRATION VIDEO:
REFLEXES

https://www.youtube.com/watch?v=
dW8ZQCBWwxw&ab_channel=CONA
MSTeam
Babinski Reflex
Purpose:
To determine the presence or absence of Plantar or
Babinski Reflex

Procedures
1. Use a moderately sharp object such as percussion hammer, key
or dull end of the pin or applicator stick.
2. Stroke the lateral border of the sole of the client’s foot, starting
at the heel, continuing to the ball of the foot.
3. Proceed across the ball of the foot toward the big toe.
4. Observe the response, Normally all 5 toes bend down which if
negative Babinski’s
5. In an abnormal response, the toes spread outward and the big
toe moves upward.
DEMONSTRATION VIDEO:
BABINSKI REFLEX

https://www.youtube.com/watch?v=
XaPiaQhFUHg&ab_channel=CONAM
STeam
GROSS MOTOR AND BALANCE TESTS
Purpose:
To examine proprioception and cerebellar function

Assessment:
Inquire if the client has history of loss of consciousness, or fainting.

Procedures:
1. Walking Gait
2. Romberg’s Test
3. Standing On One Foot w/ Eyes Closed
4. Heel – Toe Walking
5. Toe or Heel Walking
DEMONSTRATION VIDEO:
GROSS MOTOR AND BALANCE TEST

https://www.youtube.com/watch?v=
DmL4n8ln6AY&ab_channel=CONAM
STeam
FINE MOTOR TESTS FOR UPPER EXTREMITIES
Purpose:
To examine proprioception and cerebellar function

Assessment:
Inquire if the client has history of presence of pain in the upper extremities, as well as onset
and aggravating and alleviating factors, tingling or numbness, tremors or tics, and paralysis.

Procedures:
1. Finger to Nose Test
2. Alternating Supination and Pronation of Hands on
3. Finger to Nose and to the Nurse’s Finger
4. Fingers to Fingers
5. Fingers to Thumb (Same Hand)
DEMONSTRATION VIDEO:
FINE MOTOR TEST

https://www.youtube.com/watch?v=
jZmC90RPN5k&ab_channel=omnipot
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