Cranial Nerves Assessment
2009
Sheeba Jacob R.N., B.S.N.,
Victoria Kim RN B.S.N.
3/19/2016
1
Goals
Goal:
1 .Students will be able to identify the 12 cranial
nerves by name and assess the function of each
(knowledge).
2. The student will be able to comprehend the
anatomical significance of the assessment.
(Comprehension)
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Objectives
1. Objectives, Upon completion of this learning experience the
student should be able to:
1. Identify the 12 cranial nerves.
2. Demonstrate the ability to interpret the test of visual acuity using a
snellen chart.
3. Assess the visual fields by recognizing correct technique for
confrontation.
4. Perform the cover test.
5. Correctly assess PERRLA (Pupils equal, round, reactive to light and
accomodation).
6. Comprehend the correct technique for performing the whisper test,
Weber and Rhinne test.
7. Perform assessment of neck including the lymph nodes.
8. Use the technique of inspecting and palpating the head and scalp,
anterior posterior chest, and sensorimotor functions.
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Identify the 12 cranial nerves.
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The Cranial Nerves
. 1. Video Cranial Nerves
University of Utah (Hyperlinkhttp://www.youtube.com/watch?v=CL1KNziYmzo)
 Watch the video and
reviewing the different
anatomical sections of
the brain
 The nurse, in assessing
the 12 cranial nerves, is
testing the functions of
various parts of the brain
2. .
Anatomy of Brain-
http://www.righthealth.com/search/Picture_Of_Label
ed_Brain/overview/google_imagesearch?img=3
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Cranial Nerve Anatomy
•
•
•
•
•
•
•
•
•
There are 12 pairs of cranial nerves
CN I Smell
CN II Vision
CN III, IV, VI Oculomotor
CN V Trigeminal Sensorimotor
muscles of the Jaw
CN VII Sensorimotor of the face
CN VIII Hearing
CN IX, X, XII Mouth, esophagus,
oropharynx
CN XI Cervical Spine and shoulder
3. Cranial Nerve
http://www.becomehealthynow.com/images
/organs/nervous/cranial_nerves_bh.jpg
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Knowledge Test 1
• How many Cranial
Nerves are there?
12
6
3
10
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Cranial Nerve V
Temporomandibular joint and
Massater Muscle
• Cranial Nerve V
• CN V Trigeminal Sensorimotor
muscles of the Jaw
• The temperomandibular joint is
palpated while the patient clenches
jaw, opens and closes mouth,
moves jaw side to side and forward
against pressure CN V, trigeminal
Nerve
• CN V is further tested with
light touch a wisp of cotton
in three areas .
Cranial Nerve V http://www.fotosearch.com/L
IF155/mm103010/
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Cranial Nerve V
Inspection and Palpation
Cranial Nerves are assessed
in this order
5,7,2,3,4,6,8,1,9,10,
11,12
Palpate the
Temporomandibular
Joint– CN V
http://images2.wikia.nocookie.net/psychology/images/thumb/9/99/
Gray778_Trigeminal.png/440px-Gray778_Trigeminal.png
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Knowledge Test 1
Q. Which cranial nerve is
further tested with
light touch a whisp of
cotton in three areas .
VI
V
VII
III
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Cranial Nerve VII Function
Cranial Nerve VII
• Definition cranial nerves seven
• The facial nerve VII (nervus facialis) comes
from the pons in the hindbrain. It is a strong
motor, sensory and parasympathetic nerve. Its
numerous branches connect to the face
muscles, the skin around the earlobes and
various exocrine glands in the head..
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Cranial Nerve VII, Facial Nerve
1. Cranial Nerve VII
Anatomy and
Physiology
http://www.megasyste
msusa.com/app/home
/home.aspx
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Cranial Nerve VII Anatomy
•
•
•
•
•
Facial Nerve (nervus
facialis)
Comes from the Pons in
the Midbrain
Sensory
Motor
Branches connect to the
face muscles, the skin
around the earlobes and
various exocrine glands in
the head..
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Assessment Cranial Nerve VII
• Assessment - is tested by observing the
presence and symmetry of the patients facial
muscle movements
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–
–
–
–
–
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Smiling
Frowning
Showing teeth
Puffing out cheeks
Raising eyebrows
Resisting examiners attempt to open the eyes
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Knowledge Test 1
Q. A test of Cranial VII is?
Protruding the tongue
Blinking
Flapping hands
Smiling
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Cranial Nerve II, Optic Nerve
Function of Sight
Definition Cranial Nerve the optic nerve II (vervus
opticus), which facilitates sight,
http://www.megasystemsusa.com/app/home/ho
me.aspx
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Cranial Nerve II, Optic Nerve
Anatomy
1. Cranial Nerve II
Anatomy and
Physiology
http://www.megasyste
msusa.com/app/home
/home.aspx
3/19/2016
1.Cranial Nerve II Anatomy and Physiology
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• Assessment Cranial nerve II
– Visual Acuity – part of cranial nerve to is tested .
• Near visual acuity, must be done having patient read a
small snellen equivalent
• Visual fields, part of cranial nerves are tested by
confrontation
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Cranial Nerve II, Optic Nerve
Visual Acuity
•
Using a Snellen eye chart
•
Using the E Snellen Chart hold it out in front of them 14
inches
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•
•
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The chart is usually read while standing at a distance of 20 feet. Acuity
is represented as a fraction, with the distance at which you are
standing being the numerator (top part of fraction), and the normal
maximum legible viewing distance ("Distance" on the chart above) as
the denominator (bottom of fraction). So if, at 20 feet, you can read
the letters on the row marked "40", this means you have visual acuity
of 20/40 or better: 1/2 normal. From 10 feet, if the smallest letters
you could read were on the "40" line, this would give you an acuity of
10/40: 1/4 normal. If you are nearsighted, your vision will become
more normal the closer you stand to the chart. http://www.isee.org/eyecharts.html
Patients wearing corrective lenses should be tested with lenses in
place .
Each eye is tested separately
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Cranial Nerve II, Optic Nerve
Confrontation Test
• Visual fields, part of cranial nerves are tested by
confrontation
• Examination of the patient's left eye visual fields
by confrontation. The patient is asked to identify
the number of fingers, which the examiner raises
in each quadrant while centering his gaze on the
examiner's right eye
ttp://books.google.com/books?id=B4V85KlNZfYC&pg=PA17&lpg=PA17&dq=Cranial+Nerve+II+confrontation&source=bl
&ots=uYsPFa_qDC&sig=vqSKzT8LIgYjRoAEiyBzM_JB6No&hl=en&ei=wiKYSqDBCIigsgOd7WzAg&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=Cranial%20Nerve%20II%20confrontation&f=false
• Want to see a Video of Confrontation?
http://www.youtube.com/watch?v=XiEw7v7OyBw
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Cranial Nerve III, IV, VI
Pupillary Function
•
•
Part Nine –Cranial Nerve III, IV, VI Pupillary Function
Definition
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–
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The oculomotor nerve III (n. oculomotorius)
stretches from the front edge of the pons
to the eye socket. There it connects to
four external eye muscles (musculi recti
superior, inferior et medialis and musculus
obliquus inferior). It also carries
parasympathetic nerves for closing the
pupil (usculus sphincter pupillae) and the
accommodation (musculus ciliaris).
The trochlear nerve IV (nervus trochlearis)
runs from the brain to the tendons on the
eye muscles in the orbit. It connects an
external motor eye muscle (musculus
obliquus superior).
The abducens nerve VI (nervus abducens) is
a motor nerve which connects to the
external optic muscles (musculus rectus
lateralis). If this nerve fails, the eyes can
become cross-eyed (strabismus convergens).
1. Assessment – CN III, IV, VI
2. The cranial nerves of each eye is
assessed separately for pupillary
reactions to light
3. cranial nerves III, IV and or VI a
further tested by evaluating the
extra ocular movements through
the six cardinal fields of gaze. This
examination allows assessment of
each muscle in its primary field of
action Video link below
4. cranial nerves III, IV and VI are
further tested by performing the
cover- uncover test
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Part 9--Cranial Nerve III, IV, VI
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–
–
–
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The cranial nerves of each eye is
assessed separately for pupillary
reactions to light,
Testing is performed twice on
each eye
Each pupil is evaluated for its
direct, and consensual reaction
to light
Pupils are also examined for
accommodation, PERRLA Links
to video below
• http://www.youtube.com/
watch?v=iTncbhfbl6A
• http://www.youtube.com/
watch?v=E2XzBaOOX8g
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Cranial Nerve III, IV, VI
•
2. cranial nerves III, IV and or VI a
further tested by evaluating the extra
ocular movements through the six
cardinal fields of gaze. This
examination allows assessment of
each muscle in its primary field of
action Video link below
– http://www.youtube.com/watc
h?v=UDR7B__2sQM
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– right and up right superior rectus
and left inferior oblique
– right lateral rectus and left medial
rectus
– right and down right inferior
rectus and left superior oblique
– . left and up left superior rectus
and right inferior oblique
– left lateral rectus and right medial
rectus
– left and down left inferior rectus
and right superior oblique
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Cranial Nerve III, IV, VI
• cranial nerves III, IV and
VI are further tested by
performing the coveruncover test
– Link
http://www.youtube.com
/watch?v=PRa7mPx2XV
s
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Part 10-Cranial Nerve VIII Hearing
1. Part TEN –Cranial
Nerve VIII, Hearing
2. Definition The
vestibulocochlear nerve
VIII (n.
vestibulocochlearis) is a
sensory nerve branch
which comes from the
pons in the brain. It
reaches to the inner ear
and serves to carry
hearing and balance
senses.
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•
•
Assessment - cranial
nerve eight is tested
using this screening
hearing test or the
whisper tests
Cranial nerve eight is
also tested by
performing the Weber
and Rinne tests
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Cranial Nerve VIII, Vestibulocochlear nerve VIII
1.
2.
Cranial Nerve VII Anatomy and
Physiology
http://www.megasystemsusa.co
m/app/home/home.aspx
External Ear --Both outer ears
are deliberately and thoroughly
inspected and palpated
http://medicalimages.allref
er.com/large/medicalfindings-based-on-earanatomy.jpg
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Cranial Nerve VIII, Hearing
Anatomy
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Performing the Whisper Test
• Check the patients response to
your whispered voice one ear at a
time
• Mask the hearing in the other ear
by having the patient place a finger
in the ear canal and gently move it
rapidly up-and-down.
• Stand to the side of the patient at a
consistent distance best for you,
about 1 to 2 feet away from the ear
being tested, and out of the
patients line of vision
• Whisper a combination of three
letters and numbers very softly and
ask the patient to repeat the words
heard
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• Normal findings .
– The patient should hear softly
whispered words in each ear at
that distance of about 1 to 2 feet,
responding correctly more than
50% of the time
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Weber Test of Hearing
• Weber and Rinne test is used
to compare hearing by bone
conduction with that of air
conduction
• Hold the base of the tuning
fork with one hand without
touching the tines, and stroke
or tap the tines gently . With
your other hand, setting the
tuning fork in vibration
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Performing Weber test
• Perform the Weber test by
placing the base of the
vibrating tuning fork on the
midline vertex of the patients
head
• Ask the patient if the sound
is heard equally in both ears
or is better in one ear
• Normal finding lateralization
of sound. Is their
lateralization of sound?
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• To test the reliability of
the patient’s response,
repeat the procedure
while occluding one ear,
asking the patient in
which hear the sound is
best heard. It should be
heard best in the
occluded ear.
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Rinne Test of Hearing
• The Rinne test is performed
by placing the base of the
vibrating tuning fork against
the patient’s mastoid bone
• Begin counting or timing the
interval with your watch .
• Ask the patient to tell you
when the sound is no longer
heard, noting the number of
seconds
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• Quickly position the still
vibrating tines 1cm to 2 cm
from the auditory canal, and
again ask the patient to tell
you when the sound is no
longer heard
• Continue counting or timing
the interval to determine the
length of time, the sound is
heard by air conduction
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Normal Findings Rinne Test
• Compare the number of seconds sound is heard
by bone conduction versus air conduction.
• Normal Findings: The air conducted sound
should be heard twice as long as bone
conducted sound, after bone conduction stops.
For example, if bone conducted sound is heard
for 15 seconds, the air conducted sound should
be heard for an additional 15 seconds.
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Part 11-Cranial Nerve I, Smell
1.
The sense of smell is
developed by the mucous
membranes in the nose
(nasus). Here a small area
has a layer of sensory sells,
the olfactory epithelium.
This picks up smells and
sends them to the brain
(cerebrum). All information
received by the brain from
the main sensory organs is
called sensory signals.
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1. Assessment
1. The nose is inspected and
palpated externally .
2. Inspected internally with the
light and speculum of an
otoscope
3. The patency of the nose is also
assessed be occluding each
nostril.
4. Test cranial nerve 1 with odor
differentiation of each nostril
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Cranial Nerve 1, Olfactory Nerve
Cranial Nerve 1Olfactory
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Cranial Nerve IX and X, Swallowing
1.
2.
The glossopharyngeal nerve IX (n.
glossopharyngeus) is a motor, sensory
and parasympathetic nerve branch
which comes from the extended
spinal cord (medulla oblongata). Its
branches connect to the tongue, the
pharyngeal muscles, the ear drum,
the lower thorangeal skin and the ear
wax glands.
The vagus nerve X (n. vagus) comes
from the extended spinal cord. It
has motor and sensory threads which
reachs from the neck to the stomachintestinal tract. On its path, it
connects to numerous muscles in the
larynx, thorax, gullet and intestinal
tract, but also the glands, glandular
organs and the ear canal.
1. Assessment Swallowing
1.
2.
The entire oral cavity is inspected
CN IX and X are tested by
1.
2.
3.
4.
Having the patient swallow
This can be observed during the
thyroid assessment
Observing movement of the palate
during phonation.
A comment about quality of the
patients voice should be noted .
Testing the gag reflex, does not
need to be assessed and is
usually only tested if
neurological impairment is
suspected .
The sense of taste on the
posterior third of the tongue
does not need these tested
•
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Cranial Nerve IX and X, Swallowing
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Cranial Nerve IX, X
Cranial Nerve 1Olfactory
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The thyroid gland
•
•
•
The thyroid gland (glandula
thyroidea)
The two oval side lobes (lobus
dexter, lobus sinister) of the thyroid
gland are located at the front of the
neck to the right and left of the
windpipe (trachea) underneath the
larynx (larynx). The two lobes are
joined by a narrow bridge of tissue,
the isthumus, on a level with the
2nd to 4th tracheal cartilages.
It has a plentiful supply of blood.
Mutations in the form of hard
patches and considerable
enlargements (goiter, struma) are
not rare and indicate malfunctions
of the gland.
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The thyroid gland
The thyroid gland is
inspected and palpated
before and during
swallowing .
The patient is provided a
couple water to
facilitate swallowing
during this part of the
assessment
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Cranial Nerve XII
• The hypoglossal nerve
XII (nervus hypoglossus)
comes from the
extended spinal cord.
This motor nerve
connects to the muscles
of the tongue.
•
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Cranial Nerve XII
• Cranial nerve XII
assessed by observing
– The movement of the
tongue laterally medially
– Including a statement
about patients ability to
articulate
•
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Part 13-Range of Motion of the
Cervical Spine
•
•
•
•
The Cervical Vertebrae (Vertebrae
cervicales)
The cervical vertebral column is the one
most capable of movement. The first
cervical vertebrae (atlas) and the second
cervical vertebrae (axis) deviate significantly
from the basic form of the cervical
vertebrae. For instance, the atlas does not
have the body of the vertebrae or spine of
the vertebrae. Instead of that, it has two
arches with joint surfaces for the axis and
the occipital bone (os occipitale).
The second cervical vertebra has a tooth-like
process (dens axis), which connects the front
surface of the joint of the atlas and axis. The
cervical vertebrae 3-6 are very similar to one
another.
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• The range of motion of the
cervical spine is evaluated by
having the patient .
- put his or her chin on the
chest .
- lift chin to ceiling
-turn chin toward each
shoulder
- touch each ear toward
corresponding shoulder
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Cervical Vertebrae Anatomy
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Cranial Nerve XI
• Cranial nerve 11 is tested by
having the patients .
– Shrugged the their shoulders
against resistance .
– By turning their head against
the examiner hand bilaterally
– Observe the
Sternocleidomastoid and
trapeze muscles for equal size
– General examination of the
patients anterior neck
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Assessment of Neck
Observe the Sternocleidomastoid and trapeze used muscles for equal size
• The sternomastoid muscle (M.
sternocleidomastoideus) goes at an
incline on the neck from the upper
edge of the breastbone (sternum)
and collarbone (clavicula) to the
mastoid process of the temporal
bone (os temporale). It can be used
one-sided and two-sided. On one
side, it bends the cervical vertebral
column to the same side and
rotates the head to the opposite
side while raising the chin. It raises
the chin on both sides, bends the
cervical vertebral column forwards
and it raises and supports the
thorax.
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Neck
• All lymph nodes in the
head, posterior and
anterior neck, and
supraclavicular regions
are palpated
• The specific lymph
nodes are named while
examining the specific
areas
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Lymph Nodes (must be named)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Occipital
Postauricular
Preauricular
Posterior Cervical
Supraclavicular
Submandibular
Submental
Superficial Anterior Cervical
Inferior anterior cervical
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Trachea
• The position of the
trachea is palpated
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Auscultate the Carotids
• The carotids are also auscultated
bilaterally using the belle of the
stethescope while the patient is
holding his breath
• Note – the thyroid is also
auscultated only if it is enlarged
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• The carotid arteries, which each
extend towards the head on either
side, branch off in the so-called
carotid bifurcation on the level of the
upper edge of the larynx into an
inner and outer carotid artery
(arteria carotis externa et interna). The
outer carotid artery supplies blood
to the thyroid gland (glandula
thyreoidea), larynx (larynx), oral
cavity (cavum oris), masticatory
muscles and the face; the inner
carotid artery supplies blood to the
eye (oculus) and to most of the brain
(cerebrum).
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Carotids Anatomy
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Summary Part 1
• The cranial nerves
• The appearance of the
sternoclidomastoid
muscle and the trapezius
muscle
• Lymph Nodes of the
head and neck
• Position of the trachea
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• Start Part 2
51
References
1.
2.
3.
4.
Video Cranial Nerves , The University of Utah,
Videohttp://www.youtube.com/watch?v=CL1KNziYmzo
Brain Anatomy
http://craig.f12network.com/microbiology/Ch26_BL/homep
age_BL.htm
Cranial Nerve
http://www.becomehealthynow.com/images/organs/nervous
/cranial_nerves_bh.jpg
Foto search Stock Photography and Stock Footage
Royalty Free Images, Publitek, Inc. dba Fotosearch
21155 Watertown Road, Waukesha, WI 53186-1898 USA
http://www.fotosearch.com/illustration/brain_5.html
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