Open Resources for Nursing (Open RN) Show
When performing a comprehensive neurological exam, examiners may assess the functioning of the cranial nerves. When performing these tests, examiners compare responses of opposite sides of the face and neck. Instructions for assessing each cranial nerve are provided below. Cranial Nerve I – OlfactoryAsk the patient to identify a common odor, such as coffee or peppermint, with their eyes closed. See Figure 6.11[1] for an image of a nurse performing an olfactory assessment. Figure 6.11 Assessing Cranial Nerve I (Olfactory)Cranial Nerve II – OpticBe sure to provide adequate lighting when performing a vision assessment. Far vision is tested using the Snellen chart. See Figure 6.12[2] for an image of a Snellen chart. The numerator of the fractions on the chart indicate what the individual can see at 20 feet, and the denominator indicates the distance at which someone with normal vision could see this line. For example, a result of 20/40 indicates this individual can see this line at 20 feet but someone with normal vision could see this line at 40 feet. Test far vision by asking the patient to stand 20 feet away from a Snellen chart. Ask the patient to cover one eye and read the letters from the lowest line they can see.[3] Record the corresponding result in the furthermost right-hand column, such as 20/30. Repeat with the other eye. If the patient is wearing glasses or contact lens during this assessment, document the results as “corrected vision.” Repeat with each eye, having the patient cover the opposite eye. Alternative charts are available for children or adults who can’t read letters in English. Figure 6.12 Snellen ChartNear vision is assessed by having a patient read from a prepared card from 14 inches away. See Figure 6.13[4] for a card used to assess near vision. Figure 6.13 Assessing Near VisionCranial Nerve III, IV, and VI – Oculomotor, Trochlear, AbducensCranial nerve III, IV, and VI (oculomotor, trochlear, abducens nerves) are tested together.
Video Review for Assessment of the Cardinal Fields of Gaze[7]Read more details about assessing the Pupillary Light Reflex. Cranial Nerve V – Trigeminal
Cranial Nerve VII – Facial Nerve
Cranial Nerve VIII – Vestibulocochlear
Cranial Nerve IX – GlossopharyngealAsk the patient to open their mouth and say “Ah” and note symmetry of the upper palate. The uvula and tongue should be in a midline position and the uvula should rise symmetrically when the patient says “Ah.” (see Figure 6.22[14]). Figure 6.22 Assessing Glossopharyngeal NerveCranial Nerve X – VagusUse a cotton swab or tongue blade to touch the patient’s posterior pharynx and observe for a gag reflex followed by a swallow. The glossopharyngeal and vagus nerves work together for integration of gag and swallowing. See Figure 6.23[15] for an image of assessing the gag reflex. Figure 6.23 Observing the Gag ReflexCranial Nerve XI – Spinal AccessoryTest the right sternocleidomastoid muscle. Face the patient and place your right palm laterally on the patient’s left cheek. Ask the patient to turn their head to the left while resisting the pressure you are exerting in the opposite direction. At the same time, observe and palpate the right sternocleidomastoid with your left hand. Then reverse the procedure to test the left sternocleidomastoid. Continue to test the sternocleidomastoid by placing your hand on the patient’s forehead and pushing backward as the patient pushes forward. Observe and palpate the sternocleidomastoid muscles. Test the trapezius muscle. Ask the patient to face away from you and observe the shoulder contour for hollowing, displacement, or winging of the scapula and observe for drooping of the shoulder. Place your hands on the patient’s shoulders and press down as the patient elevates or shrugs the shoulders and then retracts the shoulders.[16] See Figure 6.24[17] for an image of assessing the trapezius muscle. Figure 6.24 Assessing Cranial Nerve XICranial Nerve XII – HypoglossalAsk the patient to protrude the tongue. If there is unilateral weakness present, the tongue will point to the affected side due to unopposed action of the normal muscle. An alternative technique is to ask the patient to press their tongue against their cheek while providing resistance with a finger placed on the outside of the cheek. See Figure 6.25[18] for an image of assessing the hypoglossal nerve. Figure 6.25 Assessing the Hypoglossal NerveVideo Review of Cranial Nerve Assessment[19]Expected Versus Unexpected FindingsSee Table 6.5 for a comparison of expected versus unexpected findings when assessing the cranial nerves. Table 6.5 Expected Versus Unexpected Findings of an Adult Cranial Nerve Assessment
Which finding is typical in a patient who has Bell's palsy?The most common symptom is sudden weakness of one side of the face. Other symptoms may include drooping of the mouth, drooling, inability to close eye (causing dryness of the eye), and excessive tearing in one eye.
Which assessment findings would be signs and symptoms of myxedema?Along with the signs and symptoms of severe hypothyroidism, symptoms of myxedema crisis can include:. decreased breathing (respiratory depression). lower than normal blood sodium levels.. hypothermia (low body temperature). confusion or mental slowness.. shock.. low blood oxygen levels.. high blood carbon dioxide levels.. Which signs and symptoms would the nurse find while assessing a patient with Graves disease?Signs and Symptoms of Grave's Disease
Weight loss (burning calories increased) Heat intolerance (feel extremely hot… sweaty) Tachycardia (sympathetic system in overdrive)
Which type of facial assessment would the nurse observe in a patient who has decreased levels of dopamine?A decrease in dopamine level would lead to a masklike face.
|