Check out this cranial nerves chart for assessment in nursing! Assessment of the cranial nerves provides insightful and vital information about the patient’s nervous system. There are 12 cranial nerves that are often forgotten by nurses, so with that in mind, here’s a free assessment form that you can use!
Cranial Nerves Chart
Listed below is a chart of the 12 cranial nerves, the assessment technique used, if the response elicited is normal, and how to document it.
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Ask the client to smell and identify the smell of cologne with each nostril separately and with the eyes closed.
Client is able to identify different smell with each nostril separately and with eyes closed unless such condition like colds is present.
Client was able to describe the odor of the materials used.
II: Optic
Assessment Technique
Normal Response
Documentation
Provide adequate lighting and ask client to read from a reading material held at a distance of 36 cm. (14 in.).
The client should be able to read with each eye and both eyes.
Client was able to read with each eye and both eyes.
III: Oculomotor
Cranial Nerve Assessment
Normal Response
Documentation
Reaction to light:
Using a penlight and approaching from the side, shine a light on the pupil. Observe the response of the illuminated pupil. Shine the light on the pupil again, and observe the response of the other pupil.
Illuminated and non-illuminated pupil should constrict.
Reaction to accommodation: Ask client to look at a near object and then at a distant object. Alternate the gaze from the near to the far object. Next, move an object towards the client’s nose.
Pupils constrict when looking at a near object, dilate when looking at a distant object, converge when near object is moved towards the nose.
PERRLA (pupils equally round and reactive to light and accommodation)
IV: Trochlear
Cranial Nerve Assessment
Normal Response
Documentation
Hold a penlight 1 ft. in front of the client’s eyes. Ask the client to follow the movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally.
Client’s eyes should be able to follow the penlight as it moves.
Both eyes are able to move as necessary.
V: Trigeminal
Cranial Nerve Assessment
Normal Response
Documentation
While the client looks upward, lightly touch the lateral sclera of eye to elicit blink reflex.
Client should have a (+) corneal reflex, able to respond to light and deep sensation and able to differentiate hot from cold.
Client was able to elicit corneal reflex, sensitive to pain stimuli and distinguish hot from cold.
To test light sensation, have client close eyes, wipe a wisp of cotton over client’s forehead.
(same as above)
(same as above)
To test deep sensation, use alternating blunt and sharp ends of an object. Determine sensation to warm and cold object by asking client to identify warmth and coldness.
(same as above)
(same as above)
VI: Abducens
Cranial Nerve Assessment
Normal Response
Documentation
Hold a penlight 1 ft. in front of the client’s eyes. Ask the client to follow the movements of the penlight with the eyes only. Move the penlight through the six cardinal fields of gaze.
Both eyes coordinated, move in unison with parallel alignment.
Both eyes move in coordination.
VII: Facial
Assessment Technique
Normal Response
Documentation
Ask client to smile, raise the eyebrows, frown, and puff out cheeks, close eyes tightly. Ask client to identify various tastes placed on the tip and sides of tongue.
Client should be able to smile, raise eyebrows, and puff out cheeks and close eyes without any difficulty. The client should also be able to distinguish different tastes.
Client performed various facial expressions without any difficulty and able to distinguish varied tastes.
VIII: Vestibulocochlear
Cranial Nerve Assessment
Normal Response
Documentation
Have the client occlude one ear. Out of the client’s sight, place a tickling watch 2 to 3 cm. ask what the client can hear and repeat with the other ear.
Client should be able to hear the tickling of the watch in both ears.
Client was able to hear tickling in both ears.
Ask the client to walk across the room and back and assess the client’s gait.
The client should have upright posture and steady gait and able to maintain balance.
The client was able to stand and walk in an upright position and able to maintain balance.
IX: Glossopharyngeal
Cranial Nerve Assessment
Normal Response
Documentation
Ask the client to say “ah” and have the patient yawn to observe upward movement of the soft palate.
Client should be able to elicit gag reflex and swallow without any difficulty.
Client was able to elicit gag reflex and able to swallow without difficulty.
Elicit gag response.
(same as above)
(same as above)
Note ability to swallow.
(same as above)
(same as above)
X: Vagus
Cranial Nerve Assessment
Normal Response
Documentation
Ask the patient to swallow and speak (note hoarseness)
The client should be able to swallow without difficulty and speak audibly.
Client was able to swallow without difficulty and speak audibly.
XI: Accessory
Cranial Nerve Assessment
Normal Response
Documentation
Ask client to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (repeat for other side).
Client should be able to shrug shoulders and turn head from side to side.
Client was able to shrug his shoulders and turn his head from one side to the other.
XII: Hypoglossal
Cranial Nerve Assessment
Normal Response
Documentation
Ask client to protrude tongue at midline and then move it side to side.
The client should be able to move tongue without any difficulty.
The client was able to move tongue in different directions.
Cranial Nerves Cheat Sheet Download
In this section, you can download the cranial nerves cheat sheet. To download, simply click on the image and save. Please feel free to use and share!
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