Overview
This lecture covers the nursing assessment of cranial nerves I-XII, including key testing steps and normal findings for each nerve.
Preparation Steps
- Provide privacy, perform hand hygiene, and explain procedures to the patient before beginning the assessment.
Cranial Nerve Assessment
Cranial Nerve I: Olfactory
- Test smell by having the patient identify a pleasant scent with eyes closed.
Cranial Nerve II: Optic
- Assess peripheral vision using the confrontation visual field test.
- Evaluate visual acuity with a Snellen chart (record results as 20/20, 20/30, etc.).
Cranial Nerves III, IV, VI: Oculomotor, Trochlear, Abducens
- Assess extraocular movements in six cardinal fields of gaze to check for nystagmus (involuntary eye movement).
- Test pupillary response to light (pupils constrict when exposed to light).
- Check for accommodation by moving an object toward the nose (pupils constrict, eyes cross).
- Document as PERRLA: Pupils Equal, Round, Reactive to Light, and Accommodation.
Cranial Nerve V: Trigeminal
- Palpate masseter and temporalis muscles as patient clenches teeth; check strength against resistance.
Cranial Nerve VII: Facial
- Assess facial symmetry by asking the patient to close eyes tightly, smile, and puff cheeks.
Cranial Nerve VIII: Vestibulocochlear
- Test hearing by occluding one ear and whispering words into the other; patient repeats the words.
Cranial Nerves IX & X: Glossopharyngeal & Vagus
- Ask the patient to say "ah" and observe uvula movement.
- Test gag reflex by gently touching the back of the throat.
- Assess ability to speak and swallow.
Cranial Nerve XI: Accessory
- Have the patient shrug shoulders and turn head against resistance to check muscle strength.
Cranial Nerve XII: Hypoglossal
- Ask the patient to stick out tongue and move it side to side.
Key Terms & Definitions
- PERRLA — Pupils Equal, Round, Reactive to Light, and Accommodation
- Nystagmus — Involuntary, rapid movement of the eyes
- Snellen chart — Tool to measure visual acuity
- Accommodation — Pupillary constriction and eye crossing when focusing on a near object
Action Items / Next Steps
- Watch the head-to-toe nursing assessment video for comprehensive skills review.
- Practice documenting cranial nerve findings accurately after each assessment.