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CRANIAL NERVE ASSESSMENT

Name of Student: ___________________________ ___________________________ Year & Section: ____________________________ ____________________________ Date: C.I.:

Procedure

A !e to "erfor m

A !e to "erform #it$ a%%i%tance

&na !e to "erform

1. Introduce self and verify clients identity. 2. Explain the procedure to the patient and his/her ability to participate in the assessment procedure. 3. Gather necessary equipment. . !ash hands and start the assessment. ". #$ I%chec&s patency of nostrils' chec&s one nostril at a time for clients ability to identify the smell of common substances. (. #$ II%tests a. acuity is easily tested )ith *nellen #hart' b. #olour vision is tested usin+ Ishihara plates c. ,isual fields % patient to loo& directly at you )hilst you )i++le one of your fin+ers in each of the four quadrants. -s& the patient to identify )hich fin+er is movin+. d. .. #$ III' I,' and ,I% a. /ests E01s by havin+ the client move the eyes throu+h the ( cardinal fields of +a2e )ith the head held steady. b. ,isual reflexes 3 4lace one hand vertically alon+ the patients nose to bloc& any li+ht from enterin+ the eye )hich is not bein+ tested. *hine a pen torch into one eye and chec& that the pupils on both sides constrict. /his should be tested on both sides 5. #$ ,' motor function%has client move his 6a) from side to side' clenchin+ his 6a)' and bitin+ do)n on a ton+ue blade. 7. #$ ,' sensory function%has the client close his eyes and identify )hen nurse is touchin+ his face at the forehead' chee&s' and chin bilaterally8first )ith the fin+er and then )ith a toothpic&. 19. /ests corneal reflex by touchin+ the cornea )ith a )isp of cotton or puffin+ air from a syrin+e over the cornea. /his should cause the patient to shut their eyelids. 11. #$ ,II' motor function%has the client ma&e faces' such as raisin+ eyebro)s' smile' fro)n' close their eyes and &eep them closed a+ainst resistance' puff out their chee&s and reveal their teeth. 12. #$ ,II' taste%tests taste on the anterior portion of the ton+ue by placin+ s)eet :su+ar;' salty :salt;' or sour :lemon;

substance on tip of ton+ue. 13. #$ ,III%<ses= a. !atch3tic& test for hearin+. b. /o carry out the >inne test' place a soundin+ tunin+ for& on the patients mastoid process and then next to their ear and as& )hich is louder. - normal patient )ill find the second position louder. c. /o carry out the !ebers test' place the tunin+ for& base do)n in the centre of the patients forehead and as& if it is louder in either ear. $ormally it should be heard equally in both ears. d. >omber+ test for balance. 1 . #$ I? and ?%observes ability to tal&' s)allo)' and cou+h. 1". #$ I? and ?' motor function%as&s client to say @ahA )hile depressin+ ton+ue )ith a ton+ue blade and observin+ the soft palate and uvula to rise. 1(. #$ I? and ?' sensory function%touches bac& of pharynx )ith ton+ue blade to induce a +a+ reflex. 1.. #$ I? and ?' taste :s)eet' salty' sour;% tests on posterior portion of ton+ue. 15. #$ ?I a. 4laces hands on clients shoulders and has client shru+ his shoulders a+ainst resistance. b. Bave client turn his head from side to side a+ainst resistance. 17. #$ ?II%have the client= a. *ay @d' l' n' t.A b. 4rotrude the ton+ue and move it from side to side. c. as& the patient to push ton+ue a+ainst chee& 29. !ash Bands 21. Cocument findin+s T'TAL SC'RE (INAL RATIN)
De+end= 2 % -ble to perform 1 % -ble to perform )ith assistance 9 % <nable to perform EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE *IG$-/<>E 0F */<CE$/ 0,E> 4>I$/EC $-1E

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