How to document cranial nerve examination
Cranial Nerve Examination Nursing | Cranial Nerve Assessment I-XII (1-12)
Timecodes:
this is cereth registered nurse orion
calm and in this video i'm going to be
going over a nursing assessment of the
cranial nerves cranial nerves one
through twelve and if you would like to
watch a complete head-to-toe nursing
assessment you can access this card up
here in the corner or in the youtube
description below to watch that video so
the first thing what you want to do is
you want to provide privacy to the
patient perform hand hygiene and explain
what you will be doing so let's get
started we're going to test the
olfactory cranial nerve one the sense of
smell
so Ben what I'm gonna have you do is I'm
gonna have you close your eyes and I'm
gonna put something in front of your
nose and have you breathe in and smell
and you tell me what you smell and
whenever you do this use something
that's pleasant smelling not something
that's really stinky cuz it could elicit
like a gag reflex or something like that
if the person has a sensitive nose okay
okay and this was vanilla extract and
that's correct
so that cranial nerve is intact to test
cranial nerve to you're going to be
doing two tests number one you're going
to look at the confrontation visual
field and you're going to be looking at
their peripheral vision next you'll be
looking at visual acuity and using a
Snellen chart to assess that first we're
going to test the peripheral vision by
doing the confrontation visual field
test and to do that you're gonna have
the patient's stand in front of you
about arm's length away okay Ben what
I'm gonna have you do is I'm gonna have
you cover up your right eye and I'm also
gonna cover up my left eye so on the
same side and then I want you to look at
this eye and don't look at my fingers
okay and I just want you to tell me how
many fingers you see and you're gonna do
this and the upper and lower visual
fields and about the middle of the
visual field so here we go to correct
dirty very good I'll sit on the opposite
again stare at this eye okay and don't
look at my fingers very good now we're
going to test visual acuity using a
Snellen chart and what you're going to
do is you're going to have
patience and about 20 feet from the
chart so Ben if you'll stand about right
there for me and ask your patient do you
wear glasses okay and if your patient
does wear glasses you'll want them to
wear those for this test okay so what
we're gonna do look at that chart over
there and try to read the lowest line
for me that you can read okay and first
we're gonna cover your right eye then
your left eye and then we'll do both
eyes okay so cover your right eye okay
and what line can you read okay read it
for me okay very good okay now we're
going to cover up your left eye and do
the same thing and again whatever line
you can read let me know eight again
okay the C okay and now read with both
eyes and what line okay okay and he read
from line eight so that means that he
has 20/20 vision and this means that he
can see the same line of letters at 20
feet that a person with normal vision
can see at 20 feet however let's say
that in his left eye he could only read
like line six which is twenty thirty
that would mean that his left eye sees
at twenty feet that a person with normal
vision would see at thirty Nick's what
we're gonna do is we're going to assess
cranial nerve three which is ocular
motor for troch Euler and then six which
is abducens and we're gonna do several
tests to check their function the first
one what we're gonna do is we're going
to be looking for any involuntary
shaking of the eye called nystagmus and
how we're gonna do that was we're gonna
take our pin line we're gonna hold it
about twelve to fourteen inches away
from the patient's nose and then what I
want you to do is keep your head still
don't move your head and just use your
eyes to watch where I move the pin line
and as you
doing this you're going to do you're
going to perform it in the six cardinal
fields of gays and you're just going to
move it you're looking for any
involuntary shaking of the eyes so here
we go
next we're going to see how reactive the
pupils are to lie and to do that we're
going to dim the lights a little bit and
we're gonna have the patients stare off
at a distant object that helps dilate
those pupils and then we're going to
shine using our pin light in at the side
and we're gonna see how that pupil
response is she constrict and then on
the other side it should constrict as
well so say their baseline pupil size
was like three millimeters it should go
down to one milliliter and it should
happen on both sides okay so being stare
off at that object rod on the wall over
there for me okay and that dilates the
pupils and we're just gonna shine light
in at this side okay constrict constrict
okay I'm dilate again and then go over
to the other side do the same again and
they both constricted and equal sighs
next what we're gonna do is we're gonna
check for accomodation and how we do
that is we turn the lights back on we
just previously had them dim but we now
make it light again we're gonna have him
stare off at a distant object that helps
dilate the pupils and we're going to
take a pin light you can use a pin light
finger and you're just gonna slowly move
it inward to the nose and what you're
looking for is that those pupils
constrict they accommodate and the eyes
cross while looking at the pin line so
here we go stare off in the distance
please and I don't want you to move your
head or anything just keep it real still
and just follow this pin light okay
ready
okay so now we can document because we
just checked all of the things with the
eyes we can document that the pupils are
equal round reactive to lie in the
accommodate so that's where that acronym
perrla comes into play I'm going to go
ahead and test cranial nerve 5 which is
the trigeminal nerve and which nerve is
responsible for many things like
massification so what I'm gonna have you
do bian is I'm gonna have you clench
your teeth like bite down for me and I'm
going to feel the masseter muscle which
is right there there should be a nice
firm ball and then feel the temporal
muscle now what I'm going to do to also
test that nervous have him try to open
his mouth against resistance so try to
do that for me okay and he can do that
and while we're here we're gonna go
ahead and look at the facial expressions
and test cranial nerve seven which is
the facial nerve so can you close your
eyes tightly for me and open them up
okay now smile for me frown and puff out
your cheeks okay and he did that with E
so that cranial nerve is entire next
we're gonna test cranial nerve eight
which is the vestibule oh cochlear nerve
and what I'm gonna do is I'm gonna
include one of his ears and then whisper
two words on the other side he needs to
tell me what I said so you ready
okay I'm gonna clued this one okay very
good
CatDog okay and that nerve is intact
next what we're gonna do is we're going
to assess cranial nerve nine the glaucio
pharyngeal and so what I'm going to do
is I'm gonna have you say ah and what
you want is that uvula to move up okay
and then we're just gonna test the gag
reflex I'm sort of just gonna poke a
little bit back there and elicit a gag
reply okay there you go tags really good
and cranial nerve 10 the vagus is intact
because he's able to talk wasn't talked
to me without hoarseness and he's able
to swallow and what we're gonna do is
we're gonna test cranial nerve 11 which
is the accessory nerve so being what I'm
gonna have you do is move your head side
to side up and down okay and then shrug
try to shrug against my resistance and
he does that with ease so that nerve is
intact next what we're gonna do is we're
going to assess cranial nerve 12 which
is the hypoglossal nerve and what I'm
gonna have you do being is I'm gonna
have you stick out your tongue and maybe
it's odd the sod okay and he does that
with ease okay so that wraps up how to
perform a nursing assessment of the
cranial nerves and don't forget to check
out that head to toe nursing assessment
video thank you so much for watching and
don't forget to subscribe to our channel
for more videos
Related queries:
how to document normal cranial nerve assessment
how to document cranial nerve assessment
how to document cranial nerves
how to examine cranial nerves
![[ASMR] Detailed Cranial Nerve Exam](https://img.youtube.com/vi/sCXHdjHqkqQ/mqdefault.jpg)
