12 Cranial Nerves and Assessment 1)Nerve:Olfactory( I ) Type:Sensory Function:Sense of smell Test: You’ll need three

substances with distinctive but familiar odors; for example, coffee, tobacco, and cloves. Ask your patient to close his or her eyes, and occlude her left nostril with her finger. Hold one of these substances under his / her right nostril, and ask her to identify the odor. Follow the same procedure with the other two substances. Then, repeat the entire test on the other nostril. Normal findings: Patient detects and correctly identifies all three odors. Possible causes of abnormalities: Temporary impairment from common cold; head trauma resulting in Parosmia (perversion of sense of smell); compression of Olfactory bulb by meningiomas or anterior fossa aneurysm; tumor infiltration in frontal lobe; or temporal lobe lesions, resulting in Olfactory hallucinations. 2)Nerve:Optic( II ) Type:Sensory Function:Vision Test: Visual acuity Use Snellen chart or an E chart to test your patient’s visual acuity. Normal Findings:Patient’s vision fields should be approximately the same as your own ( provided your own vision is normal ). Test: Internal eye structure Examine your patient’s eyes with an opthalmoscope. Normal Findings:Optic disc appears yellowish-pink and is round or oval, with clearly defined edges. Fundus appears uniformly orange, with optic disc located one side. Blood vessels extend outward from optic disc along borders of the fundus. Possible causes of abnormalities: Optic neuritis, toxic substances ( fro example, alcohol abuse ), head trauma, chronic nephritis, Diabetes mellitus, anemia, nutritional deficiencies, multiple sclerosis, chronic hypertension, intracranial tumors or aneurysms, or increased intracranial pressure.

(2 ) 3)Nerve/s: Oculomotor( III ) Type: Motor

Trochlear( IV ) Abducens( VI )

Normal Findings:Lower edges of lids meet bottom edges of irises. Test: Direct papillary response Carefully note each pupil’s size. Instruct him or her to focus on a point directly in front of him / her. To do this. and observe the reaction of his or her left pupil. Test: Accommodation and Convergence First. hold the pencil still. Normal Findings:Pupils constrict bilaterally and remain constricted with light. when the pencil’s approximately 24 “ ( 60 cm) from your starting point. as she keeps his / her other eye closed. shine the light directly into one of your patient’s pupils.) in front of your patient’s nose. Then. Test: Extraocular eye movement Begin by familiarizing yourself with the six cardinal fields of gaze. Note the pupil’s reaction. and check your patient’s eyes with a penlight. Observe her ability to focus on one point effectively. First. Check the field separately.Function: Oculomotor:Innervates extrinsic eyemuscles and ciliary muscle Trochlear :Innervates superior oblique muscle Abducens :Innervates external rectus muscle Important:These three (3) nerves operate as a unit and should be tested and evaluated together. Then. Then. then to your left. Position the penlight directly in front of his / her right eye. (3) Normal Findings:Eyes move smoothly and bilaterally in six cardinal fields of gaze. or your patient’s eye movement stops ( in either or both eyes ). checking each vision field separately. Instruct him or her to keep his / her head and eyes stationary . Then. check the other eye. As you know each of these fields corresponds to one of your patient’s extraocular muscles. upper lids cover approximately 2mm of irises. Test: Consensual papillary responses Darken the room. Test: Extrinsic Eye muscles Ask the patient to open his or her eyes. Normal Findings:Pupils constrict and remain constricted with light. check the other eye. hold a pencil approximately 18” ( 45 cm ) in front of your patient’s nose. Note the position of theiris in relation to each eye’s midline. hold a pencil 12” (30 cm. pupils dilate when light is removed. but make sure your patient keeps both eyes open. Ask your patient to hold his / her head still and follow the pencil’s movement with his / her eyes. ask her to watch the pencil as you move it. Repeat this procedure. then. Darken the room. Turn the penlight ON. slowly move the pencil to your right side.

and pterygoid muscles. or lead poisoning. both masseter muscles feel equal in size and strength. both of her pupils constrict and remain constricted. and accommodation power lost. tumor or aneurysm at base of skull. your patient should be able to comfortably hold her gaze. both your patient’s eyes will converge on the pencil at the same level and distance. When the pencil’s 2” to 3” ( 5 to 7. When your patient’s eyes converge. Abnormal findings in Trochlear ( IV ) nerve damage: Inability to turn eye downward or outward. increased intracranial pressure. On palpation. On palpation. diplopia. (4 ) Normal Findings:Patient can clench teeth tightly. pupil dilated and unreactive to light.6 cm. and sensations of face. Abnormal findings in Oculomotor ( III ) nerve damage: Lid ptosis. nystagmus. botulism. paralysis of lateral gaze.throughout the examination. Then. slowly move the pencil toward the bridge of his / her nose. At that point.Compare them. Possible causes of abnormalities: Trauma. If everything’s OK. Test: Temporal muscle strength Instruct your patient to clench his or her teeth tightly. As he or shedoes. Normal Findings:Both eyes converge on pencil at same level and distance. Document all findings in your nurse’s notes.) from the bridge of his / her nose. Patient maintains gaze on pencil when it’s held 2” to 3” ( 5 to 7. multiple sclerosis. Abnormal findings in Abducens ( VI ) nerve damage: Eyeball deviated inward. locate and palpate the temporal muscles at his or her temples. temporal. Sensory Function:Chewing movements by innervation of masseter. temporal muscles feel equal in size and strength. and teeth. 4)Nerve:Trigeminal( V ) Type:Motor. Normal Findings:Patient can clench his / her teeth tightly. expect his / her pupils to constrict and remain constricted. scalp. Compare them.6 cm. As he or she does.locate and palpate the masseter muscle bulges at his / her right andleft jaw joints. Test: Masseter muscle strength Instruct your patient to clench her teeth tightly. Masseter muscles bulge when teeth are clenched. corneal and sneezing reflexes. Test: Pterygoid Muscle strength .) from the bridge of his / her nose. eyeball deviated outward and slightly downward. with inability to completely open eye.

try the entire test ( both ends of pin ) on both sides of your patient’s cheeks and jaw. and tells when and where she feels it. Be sure to document test location. repeat the test. Using the same technique. alternately test his or her other body parts. despite your efforts. when only . Normal Findings:Patient identifies the same sensation bilaterally. Normal Findings:Patient keeps teeth tightly clenched. to do this. Ask him or her to tell you what she feels. fill one test tube ( or bottle ) withhot water and another test tube ( or bottle ) with cold water. test performed. Wait about 2 seconds. then repeat the test on the opposite side of the forehead. (5 ) As you do. menigeal infection. varying test locations. Possible causes of abnormalities: Trauma. and when and where she feels it. her corneal reflexes may be diminished. Gently touch a cotton wisp to her right cornea. touch the one filled with hot water to your patient’s face. tic douloureux ( Trigeminal Neuralgia ). Test: Temperature sensation To test your patient’s hot / cold perception. grasp his or her lower jaw with one hand. using the blunt end of the pin. Then. Test: Facial sensation Instruct your patient to close her eyes. Note any difficulty she has distinguishing hot from cold. and the result. ask your patient to tell you what temperature she feels and where she feels it. Hold it there for about 1 second. touch the cold one to his or her face for about 1 second. and tells when and where she feels it. Next. intracranial aneurysm.Instruct your patient to clench his or her teeth. Then. Ask your patient to resist your efforts to open his or her jaws. Repeat the test on her left cornea. Then. Compare all findings. and pull downward. Gently touch the point of a pin to one side of his or her forehead. Note: if your patient wears contact lenses. intracranial tumor. Normal Findings:Patient blinks and his or her eyes tear when cornea’s touched. Finally. Test: Corneal reflex Instruct your patient to look up. Normal Findings:Patient identifies the same sensation bilaterally.

Instruct him or her to purse his or her lips. salty. herpes zoster. pons lesion produces masticatory muscle paralysis and light touch sensation loss in face. sour. saline ( salty ). and salivary and lacrimal gland innervation. and Bell’s Palsy. temporal bone fracture. Severe continuous pain may result. Normal Findings:Symmetrical facial contours. pelvis. lines. Also. Affected bones becomes thickened and their structure disorganized: X-ray reveal patchy sclerosis. mastoid surgery complication. quinine ( bitter ). taste ( anterior 2/3 of the tongue ). 6)Nerve:Acoustic( VIII ) Type:Sensory .descending tract is affected. back bone. intracranial tumor or aneurysm. meningitis. lemon juice ( sour ). 5)Nerve:Facial( VII ) Type:Motor Function: Facial expression. and long bones. symmetrical facial movement. touch each swab to the front of her tongue. wrinkles. Normal Findings:Patient retains puffed cheeks despite your efforts to collapse them. smile. In turn. Possible causes of abnormalities: Trauma to peripheral nerve branches. Test: Upper portion of the facial nerve Ask your patient to close her eyes and resist your efforts to open them. Medulla lesion affecting descending tract causes pain and produces loss of temperature sensation and corneal reflex. Normal Findings:Patient correctly identifies sweet. Ask your patient to stick out her tongue.). Test: Lower portion of the facial nerve Instruct your patient to puff out his or her cheeks and resist your efforts to collapse them. (6 ) Test: Taste sensation on anterior 2/3 of tongue Wet cotton swabs in each of the following solutions: sugar (sweet). and ask her to identify the taste. Paget’s disease ( a chronic disease of bones occurring in the elderly and most frequently affecting the skull. ability to taste may be inhibited by loss of sense of smell. Normal Findings:Patient resists efforts to open her eyes. Instruct your patient to rinse her mouth with water between tastes. which relieved by a prolonged course of Thyrocalcitonin injections. syringobulbia ( cavities in medulla oblongata ) and multiple sclerosis. Test: Lower portion of the facial nerve Observe your patient’s face at rest and during conversation. Note: Remember. and frown. and bitter tastes.

Touch the base of the tuning fork to your patient’s forehead. Rinne. place the vibrating 256-Hertz fork against his or her right mastoid process. explain the testing procedure to your patient. OR by stroking the prongs upward. If all is well.Before you begin a test. By studying the results of these tests. you should perform each of these tests three separate times with 256-. this may not always be possible.To perform WEBER test. To test your patient’s hearing by bone conduction. Schwabach tests.Next.Then. Ask him or her to tell you when she no longer hears the tone. you’ll perform the RINNE’s test to evaluate your patient’s hearing by both bone and air conduction.You’ll need a tuning fork in the C-Octave. OR you may also get a tone by pinching the fork’s prongs together. 5. 2. First. In that case. Quickly (without re-vibrating the fork). Using a 256-Hertz tuning fork to perform the Weber. ask him or her to point to the ear in which she hears the louder tone. However. Document the result Weber right or Weber left .3 cm. Begin by holding a vibrating 256Hertz tuning fork between your thumb and index finger. you’d document the result as Weber negative (7 ) If your patient hears the tone louder in one ear. Then. Your patient should hear the tone immediately. . and 1. as the nurse is doing here. To ensure accurate results. test his or her hearing by air conduction. 3. ask your patient to mask the hearing in her left ear byrapidly moving his or her left fingertip in and out of his or herleft ear canal.024-Hertz tuning forks.Function:Hearing and sense of balance.) from his or her right external ear canal. ask your patient to describe the tone in each ear. Note the length of time she heard the tone. your patient will hear the same tone ( volume and intensity ) in each ear. Make sure the prongs are in front – but not touching – the ear canal. a trained health-care professional can differentiate between a patient with normal hearing and a patient with a conductive or sensori-neural hearing loss. 4. Then. place the prongs ½ “ ( 1. 512-. You’ll get the most accurate testing tone by gently hitting the fork against your fist. Test: Air and bone conduction 1. practice vibrating the tuning fork.

document the result as +R ( Rinne Positive ). Gag and swallow reflexes. When either you or your patient stops hearing the tone. as well as taste on posterior 1/3 of tongue.You’ll perform the Schwabach test to compare your hearing by bone conduction with your patient’s hearing by bone conduction. If everything’s OK. Repeat the test on your patient’s left mastoid process. Important: these two nerves operate as a unit and should be tested and evaluated together. If all’s well. Quinine. the result. Possible causes of abnormalities: Inflammation. Always document the type of test you performed. lungs. your patient will hear the tone carried by air conduction twice as long as the tone carried by bone conduction. Continue to alternate the tuning fork between your patient’s mastoid process and your mastoid process. and place the fork on your right mastoid process. then. Sensory Function: Swallowing movements and saliva secretion. In this case. 7. in your nurses’ notes. Also. Repeat the same procedure on your patient’s left ear. Listen for the sound. middle fossa skull fracture. and stomach. 7)Nerve/s: Glossopharyngeal( IX ) Vagus( X ) Types:Motor . Test: Throat movement . count the seconds the other continues to hear it. Sensation in the pharynx and larynx. esophagus. Air conducted tone heard twice long in both ears as bone-conducted tone. particularly from Aspirin. (8 ) Normal Findings:Equal hearing in both ears. you’ll stop hearing the tone at the same time. But remember.Ask your patient to tell you when she no longer hears the tone. make sure your hearing is normal before you begin or the test won’t be accurate. If you suspect your patient has a hearing deficit. 6. she should say she hears the sound immediately. drug toxicity.Then. and the kind of tuning fork used. place a vibrating 256-Hertz tuning fork on his or her right mastoid process until she says she hears the sound. recommend she get an audiogram for a more accurate assessment. Note the length of time she heard the tone. intracranial tumor. autonomic innervation of heart. immediately mask the sound in yourleft ear. or Streptomycin. If both of you have normal hearing. Ask your patient to mask the sound in her left ear.

As you depress his or her tongue with a tongue depressor.Instruct your patient to open his or her mouth and say “Ah”. Cough strong. Test: Neck muscle strength Stand facing your patient.. Place your left hand on the right side of your patient’s face. syringobulbia. remember that a weak gag reflex may be normal in an elderly patient. inflammation. Test: Gag reflex Instruct your patient to open his or her mouth. Test: Tongue movement Ask your patient to open his or her mouth. Test: Vocalization Ask your patient to speak or cough. As he or she does. Normal Findings:Patient’s voice clear and strong. Test: . Test: Shoulder movement Stand facing your patient. touch a cotton swab to either side of his or her pharynx. amyotrophic lateral sclerosis. Normal Findings:When patient speaks.. Repeat the procedure on the left side of her face. his or her uvula and soft palate move straight up. Instruct him or her to turn her head toward his or her right side. vascular lesions. syringobulbia. Possible causes of Vagus ( X ) nerve damage: Acute anterior poliomyelitis. against your hand’s pressure. Possible causes of abnormalities: Extrasmedullary tumors.. However. occipital bone necrosis. 9)Nerve:Hypoglossal( XII ) Type:Motor Function:Innervates tongue muscle. Normal Findings:Patient gags. Place your hands on his or her shoulders. multiple sclerosis 8)Nerve:Spinal Accessory( XI ) Type:Motor Function:Innervates sternocliedomastoid and trapezius muscles. Normal Findings:Tongue is motionless and centered on mouth floor. Normal Findings:Firm jaw pressure against your hand. demyelinating diseases of the medulla. Possible causes of Glossopharyngeal ( IX ) nerve damage: Intracranial tumor or infection. and observe his or her tongue at rest. observe his or her uvula and soft palate. intramedullary lesions. Normal Findings:Patient lifts shoulder despite your downward pressure. Ask him or her to lift his or her shoulders as you apply moderate downward pressure. amyotrophic lateral sclerosis.

Test: Tongue strength Instruct your patient to press his or her tongue against one cheekwall. amyotrophic lateral sclerosis. Repeat test on other cheek. Normal Findings:Fast.Tongue Movement Instruct your patient to stick out her tongue. ask him or her to stick his or her tongue out and move it from side to side as quickly as possible. ( 10 ) Test: Tongue Movement Instruct your patient to dart his or her tongue in and out quickly. Apply fingertip pressure to outside of cheek as patient usestongue to resist pressure. Possible causes of abnormalities: Syringobulbia. alcoholism. or CVA . Normal Findings:Protruding tongue appears centered between lips. Normal Findings:Patient exerts firm tongue pressure against your fingertips. Expect slight tongue movement. Then. smooth tongue movement.