Name:__________________________ Section/Group:___________________ I.

Cranial Nerve Assessment Skills

Score:________________________________ Clinical Instructor:______________________

Done

Partially done

Not Done

Introduce yourself to the patient Explain the procedure Provide privacy Prepare the equipments Cranial Nerve I (Olfactory) -With eyes closed, patient is asked to identify familiar odors. Each nostril is tested separately Cranial Nerve II (optic) -Assess vision using a snellen chart. Assess visual fields Cranial Nerve III (Occulomotor) -Test for eye movement toward the nose. Evaluate papillary size and reactivity to light. Cranial Nerve IV (Trochlear) -Test for upward eye movement inspect for conjugate movements and nystagmus. Cranial Nerve V (Trigeminal) -Have Patient close the eyes. Touch cotton to forehead, cheeks and jaw. Sensitivity to superficial pain by using sharp and ends of the tongue blade alternate between sharp and dull. Cranial Nerve VI (Abducens) -Test for lateral eye movement inspect for conjugate eye movement Cranial Nerve VII (Facial)- Observe for symmetry while patient performs facial movements (smile, whistle, frown, elevates eye brow, tightly close eyelids against resistance) observe face for flaccid paralysis. Cranial Nerve VIII (acoustic)- Perform whisper or watch tick test. Test for lateralization (weber test). Test for air and bone conduction (Rinne test). Assess standing balance with eyes closed (Rombergs test) Cranial Nerve IX (glossopharyngeal)- Assess patients ability to swallow and discriminate between sugar and salt on posterior third of the tongue Cranial Nerve X (Vagus). Depress a tongue blade on posterior tongue or stimulate posterior pharynx to elisycit gag reflex note any hoarseness in voice. Check ability to swallow have patient say ah.Observe for symmetric rise of uvula and soft

palate Cranial Nerve XI (spinal accessory)-While patient shug shoulder against resistance, palpate and note strength of trapezius muscles. As patient turns head against opposing pressure of the examiners hand, palpate and note strength of each sternocleidomastoid muscle Cranial Nerve XII (Hypoglossal). While patient protrudes the tongue, note any deviation or tremors. Test the strength of the tongue by having patient move the protruded tongue from side to side against a tongue depressor Deep Tendon Reflex: Done Position the patient comfortably Proper positioning of extremity according to selected reflex tested. Proper use of reflex hammer Knowledge of the location of muscles and tendon attachment. Correct grading of the deep tendon reflexes Record the findings after the procedure Partially done Not done

Overall ICU performance: Done Grooming Punctuality Good assessment skills Implementing and evaluating highly specialized nursing care Knowledge on proper usage of ICU equipments Partially Done Not Done Remarks