Cranial Nerves Nursing Assessment

I Olfactory

Sensory -ask patient if can smell a vial of coffee

II Optic

Sensory , test vision, ask patient to read Snellen chart

III Oculomotor

Motor, ask patient to follow pen light in six directions from center outward. Assess pupil reaction to light with pen light

IV Trochlear

Motor, moves eyeball down and laterally, ask patient to follow movement of pen light in six directions.

V Trigeminal

both Sensory and motor, sensation of cornea, nasal mucosa and skin of face. Use cotton ball to lightly touch different places on face when patients eyes are closed. Ask patient to identify location of touch. Use alternating ends of safety pin to test blunt and sharp sensation. Use corner of four by four to lightly touch cornea, patient should blink. Ask patient to clench teeth.

VI Abducens

Motor, lateral eyeball movement, assess directions of gaze.

VII Facial

both motor and sensory, ask patient to smile, raise eyebrows, frown, puff out cheeks, close eyes tightly. Ask pt to identify various tasts on tongue, such as sugar, salt, lemon juice, quinine.

VIII Acoustic

Sensory, Romberg test for balance, equilibrium, tuning fork, whisper to test hearing

IX glossopharyngeal

both motor and sensory, ask pt to move tongue from side to side and up and down, ask pt to swallow.

X Vagus

Both motor and sensory, sensation of pharynx and larynx, swallowing, vocal cord movement. Same tests as glossopharyngeal, plus assess voice for hoarseness"

XI accessory

Motor, head movement, shrugging of shoulders. Sk pt to move head from side to side, touch chin to chest, ear to shoulders or shrug shoulders.

XII Hypoglossal

Motor, ask patient to stick out tongue, move it side to side