Neurovascular

Assessment,
Pupillary
RLE 5F

Assessment,
Glasgow Coma
Scale, Cranial
Nerve Assessment
Group A - 5
 GROUP
MEMBERS

CENITA, ANTHONETTE ZEN CORDENO, HAZEKIAH JOHANN CORTES, MARIA YSABEL

CORTEZ, PAULA KHRYSTELLE DACLAN, JUBILEEN ANNE DANAQUE, CHRISANNE JOY

 COURSE LEARNING
CLO#1: Define the key OUTCOMES
terms in Neurovascular Assessment, Pupillary
Assessment, Glasgow Coma Scale, Cranial Nerve Assessment.

CLO#2: Discuss the importance and indications of Neurovascular Assessment,

Pupillary Assessment, Glasgow Coma Scale, Cranial Nerve Assessment

CLO #3: Explain the parameters and method of exam and interpretation of
results in Neurovascular Assessment, Pupillary Assessment, Glasgow Coma
Scale, Cranial Nerve Assessment.

CLO #4: Identify the guidelines in using the tools for Neurovascular
Assessment, Pupillary Assessment, Glasgow Coma Scale, Cranial Nerve
Assessment.

CLO #5: Distinguish between the normal and abnormal findings.

 COURSE LEARNING
CLO#6: discuss briefly the physiology of pupillaryOUTCOMES
reactions and the different
levels of consciousness.

CLO#7: Compare and contrast the Adult and Pediatric Glasgow Coma Scales.

CLO#8: Examine the nursing responsibilities before, during and after using
the different assessment tools.

CLO #9: Demonstrate beginning skills in evaluating a client’s health status

using the various assessment tools.
 1
DEFINITION OF
TERMS
Mr. Hazekiah Johann G. Cordeño
 NEUROVASCULA
R ASSESSMENT
Is an assessment procedure performed to
detect early signs and symptoms of
musculoskeletal disorders (especially for
those with fractures). Neurovascular
assessment requires a thorough
assessment of the tissue and nerve
damage on fingers or toes of the affected
limb. This assessment involves checking
the 5 Ps:
1. Pain
2. Pulse
3. Pallor
4. Paresthesia
5. Paralysis
 COMPARTMENT
SYNDROME
Occurs when pressure rises in and around the muscles.
Compartment syndrome can limit the flow of blood,
oxygen, and nutrients to muscles and nerves. It can
cause serious damage and possible death.
PARESTHESIA

Refers to a burning or prickling sensation that

is usually felt in the hands, arms, legs, or feet,
but can also occur in other parts of the body.
This sensation often occurs without warning
and is usually painless (described as tingling or
numbness).
DIRECT LIGHT
REFLEX
Is a pupillary response to light that enters the
ipsilateral (same) eye.
CONSENSUAL
LIGHT REFLEX
Is the response of a pupil to light that enters
the contralateral (opposite) eye
ANISOCORIA

Is a condition characterized by unequal pupil

sizes. It is relatively common and causes vary
from benign physiologic anisocoria to
potentially life-threatening emergencies.
APHASIA
Is a condition that causes inabilities in
communication. It can affect the ability
to speak, write, and understand
language, both verbal and written.
Aphasia typically occurs suddenly after
a stroke or a head injury.
APRAXIA
Is a neurological disorder characterised
by the inability to perform learned
(familiar) movements on command,
even though the command is
understood and there is a willingness to
perform the movement. Both the desire
and the capacity to move are present,
but the person simply cannot execute
the act.
DECEREBRATE
Decerebrate posture is an abnormal
posture that involves the arms and legs
being held straight out, the toes being
pointed downward, and the head and
neck being arched backward. The
muscles are tightened and held rigidly.
This type of posturing usually means
there has been severe damage to the
brain.
DECORTICATE

Decorticate posture is an abnormal posture in

which a person is stiff with bent arms, clenched
fists, and legs held out straight. The arms are
bent in toward the body and the wrists and
fingers are bent and held on the chest. This
type of posturing is a sign of severe damage in
the brain.
HYPOSMIA

Is a decreased sense of smell, or a decreased

ability to detect odors through your nose.
GNOSIA

The faculty of perceiving and recognizing. The

ability to identify an object through a particular
sensory system.
STEREOGNOSIS

Refers to the ability to identify an object (its

shape and form) with tactile manipulation
(touch).
PTOSIS

Also known as “blepharoptosis”, is a drooping

or falling of the upper eyelid. The dropping may
be worse after being awake longer when the
individual’s muscles are tired.
NYSTAGMUS

Is an involuntary rhythmic side-to-side, up and down

or circular motion of the eyes that occurs with a
variety of conditions.
 2
IMPORTANCE &
INDICATIONS OF
ASSESSMENT
Mr. Hazekiah Johann G. Cordeño
 3
CLO #3: Explain the parameters and method
of exam and interpretation of results in
Neurovascular Assessment, Pupillary
Assessment, Glasgow Coma Scale, Cranial
Nerve Assessment.
CENITA, ANTHONETTE ZEN E.
 I. NEUROVASCULAR
ASSESSMENT
A. Parameters and method of exam and interpretation of results

Assessment Approach:

● Always perform bilateral assessment as it is needed for comparison of findings

and documentation.
● Include the parents/guardians in the assessment process for children as they are
more familiar with the child’s responses to pain.
● Inform the physician whenever alterations in the assessment occur.
● Neurovascular assessment is in addition to the preexisting initial assessment and
reassessment forms and will be properly filled up based on the medical condition
of the patient and if neurovascular impairment is suspected.
Materials:

1. Clean gloves
2. Watch with second hand
3. Doppler and marker

Procedure:

4. Explain the procedure to the patient and obtain consent.

5. Provide privacy while doing the procedure.
6. Wash hands thoroughly and don clean gloves.
7. Assess the patient’s level of pain using an appropriate pain scale
8. Palpate the peripheral pulse distal to the injury and/or restriction on the
unaffected side, repeat on the affected side and note the presence of the pulse
and any inconsistencies between sides in rate and quality of the pulse. Use
Doppler if necessary.
9. Perform capillary refill test, if the pulse is inaccessible or cannot be felt and note
the speed of return in seconds on Neurovascular Assessment Form. Normal
capillary refill is <2 seconds.
7. An assessment of sensation should be made by asking first the patient if he or she
feels any altered sensation on the affected limb (paresthesia) - consider any nerve
blocks or epidurals.

8. Ask the patient to flex and extend each toe, finger, ankle, and wrist, where possible.

● Active movement - ability to extend/flex extremity or digits voluntarily.

● Passive movement - staff assessing is able to flex and extend extremity/digits.
9. Observe the color of the limb in comparison with the affected side noting any
pale, cyanotic, pinky, or dusky appearance.

10.Feel the warmth of the limb above and below the site of injury using the back of
the hand and compare with the other side.

11.Inspect the limb for swelling and compare with the unaffected side.

Documentation:

● A baseline neurovascular assessment of both limbs is essential in recognising

neurovascular compromise and should be documented on admission
● Neurovascular observations for both upper and lower limbs can be added into
flowsheets in EMR for documentation
● Alterations in neurovascular status should be documented in flowsheets and
the leading medical team should be notified immediately
● Photographs can be taken with permission/consent from the parents/guardian
and saved in the media file in EMR, to document any changes in neurovascular
status and allows the medical team to view progress.
 II. PUPILLARY
ASSESSMENT
A. Parameters and method of exam and interpretation of results

Pupillary assessment is an important part of neurological assessment because

changes in the size, equality and reactivity of the pupils can provide vital diagnostic
information in the critically ill patient (Smith, 2003).

1. Pupil size and shape

➔ Pupil size should be measured, ideally with reference to a neurological
observation chart or similar. The average size is 2-5 mm (Bersten et al, 2003).
The pupils should be equal in size.
➔ Pupil shape should be ascertained. It should be round; abnormal shapes may
indicate cerebral damage; oval shape could indicate intracranial hypertension
(Fairley, 2005). The pupils should be identical in shape.
2. Reaction to a bright light

➔ Pupil reaction to light should be brisk and after removal of the light source, the
pupil should return to its original size. There should also be a consensual
reaction to the light source, that is the opposite pupil also constricts when the
light source is applied to one eye (Jevon, 2007).
➔ Pupil reaction should be documented as per local policy, for example B (brisk),
S (sluggish) or N (no reaction). Both pupils should react equally to light.
➔ Unreactive pupils can be caused by an expanding mass, for example a blood
clot exerting pressure on the third cranial nerve; a fixed and dilated pupil may
be due to herniation of the medial temporal lobe.
3. Pupillary assessment

Prior to undertaking pupillary assessment:

➔ Note if the patient has any pre-existing irregularity with the pupils, for example
cataracts, false eye or previous eye injury;
➔ Check if there are any pre-existing factors that can cause pupillary dilation, for
example medications including tricyclics, atropine and sympathomimetics and
traumatic mydriasis (Bersten et al, 2003).
➔ Check if there are any pre-existing factors that can cause pupillary constriction, for
example medications including narcotics and topical beta-blockers.

PROCEDURE:

1. Explain the procedure to the patient, even if she or he is unconscious.

2. Undertake pre-procedure checks (see above) to ascertain if there are any pre-
existing irregularities with the patient’s eyes or factors that can influence pupillary
assessment findings.
3. Assemble equipment: a pen torch and the patient’s observation chart (in some
situations a neurological assessment chart).
4. If possible, dim the overhead light source (a darkened room is ideal but practically this
will rarely be possible); dim light will facilitate a better view of the pupils and their
reaction to light.
5. Wash and dry hands.
6. Adopt a position in front of the patient.
7. Look into each of the patient’s eyes, examining the size of the pupils.
8. Note the size (mm) of each pupil; if available use the scale printed on the neurological
assessment chart as a comparison.
9. Compare the sizes of the pupils.
10. Note the shape of each pupil.
11. Compare the shapes of the pupils.
12. After providing prior warning to the patient, move the torchlight from the side of the
head towards the pupil and note any change in pupil size and the speed of the
reaction (brisk or sluggish).
13. Taking care to avoid shining the light in the other eye, observe whether the opposite
pupil also reacts (consensual reflex).
 14. Repeat the above procedure in the opposite eye.
15. Document the findings of the pupillary assessment as per local policy and
guidelines.
16. If necessary, inform the nurse in charge of any changes or abnormalities.

Professional responsibilities

➔ This procedure should be undertaken only after approved training, supervised

practice and competency assessment, and carried out in accordance with
local policies and protocols.
 III. GLASGOW COMA SCALE
A. Parameters and method of exam and interpretation of results
➔ The Glasgow Coma Scale (GCS) is the standard measure used to quantify
level of consciousness in head injured patients.
➔ Widely used in scoring systems and treatment protocols.
➔ Used as a initial assessment tool and for continual re-evaluation of head
injured patients
➔ Low score in Glasgow coma scale indicates deteriorating brain function
➔ The GCS is scored between 3 and 15, 3 being the worst(dead), and 15
( conscious person)the best.
 METH
1. Best Eye Response (4) A. Spontaneous eye opening (4) is
OD: recorded when a patient is observed to
be awake with her or his eyes open. This
observation is made without any speech
or touch. Spontaneous eye opening is
allocated a score of four.
B. Eye opening to speech(3). If there is
no spontaneous eye opening, eye
opening to speech is recorded when a
patient opens her or his eyes to loud,
clear commands. Eye opening to speech
is allocated a score of three.
C. Eye opening to pain(2).This can be
recorded if a patient opens her or his
eyes to a painful stimulus - fingertip
pressure and supraorbital ridge pressure
are the two most commonly used
methods.Eye opening to pain is
allocated a score of two.
C. None(1). A recording of ‘none’
should be made when no response
to a painful stimulus is observed. A
complete lack of eye opening is
given a score of one.
2. Best Verbal Response (6) A. Oriented(5). To be classified as
orientated, patients must be able to
identify - Who they are; - Where they
are; - The month or year. All three
components must be identified correctly
for a patient to be classified as
orientated. Such a patient is allocated a
score of five.
B. Confused(4).A patient is classified as
confused when one or more of the
above questions are answered
incorrectly. A patient who is confused is
allocated a score of four.
C. Inappropriate words(3). A patient is
classified as using inappropriate words
when conversational exchange is
absent, that is, she or he tends to use
single words more than sentences.
Swearing is also common. A patient who
is using inappropriate words is allocated
a score of three.
D. Incomprehensible sounds(2). A
patient is classified as using
incomprehensible sounds when her or
his words and speech cannot be
identified.

E. None(1). A recording of ‘none’ should

be made when the patient does not
respond verbally to verbal or physical
stimuli. A lack of verbal response is
allocated a score of one.
3. Best Motor Response (5) A. Obeying commands(6).A patient’s
ability to obey commands is assessed
by asking her or him to grip and let go
of the assessor’s fingers (both sides
should be assessed). The patient must
grip and ungrip to discount a reflex
action. If there is any doubt, the patient
should be asked to raise her or his
eyebrows. A patient who obeys the
commands achieves a score of six.
B. Localizing to pain(5).If the patient is
unresponsive to verbal commands she
or he should be assessed for response
to a painful stimulus. It is important to
differentiate between localizing to pain
and flexion to pain: localizing is a
purposeful response and an indication of
better brain function. A patient who is
localizing to pain is allocated a score of
five.
C. Normal flexion response(4). No
localisation to pain is seen. This is
recorded when, in response to a painful
stimulus, a patient bends her or his
arms at the elbow. It is a rapid response
(likened to withdrawing from touching
something hot) and is associated with
abduction of the shoulder. A patient who
has a flexion response to pain is
allocated a score of four.
D. Abnormal flexion(3), is recorded
when, in response to a painful stimulus,
the patient’s elbow flexes. It is
characterized by internal rotation and
adduction of the shoulder and flexion of
the elbow. It is a much slower response
than normal flexion and may be
accompanied by spastic wrist flexion. A
patient who exhibits abnormal flexion to
pain is allocated a score of three.
E. Extension to pain(2) is recorded when
there is no abnormal flexion to painful
stimulus. A patient presents with
straightening of the elbow joint,
adduction and internal rotation of the
shoulder and inward rotation and
spastic flexion of the wrist. A patient
who has extension to pain is allocated a
score of two.

F. None(1). No motor response is

recorded when there is no response to a
painful stimulus. No motor response is
allocated a score of one.
 IV. Cranial Nerve
I. OLFAC
Assessment
Cranial Nerve
Assessment TORY
Normal Response Documentation

Ask the client to smell Clients are able to Client was able to
and identify the smell of identify different smells describe the odour of
cologne with each with each nostril the materials used.
nostril separately and separately and with
with the eyes closed. eyes closed unless such
conditions like colds are
present.
 II.
Cranial Nerve
Assessment
OPTI
Normal Response Documentation

Provide adequate
lighting and ask the
C
The client should be
able to read with each
Client was able to read
with each eye and both
client to read from a eye and both eyes. eyes.
reading material held at
a distance of 36 cm. (14
in.).
 III.
Cranial Nerve
Assessment
OCULOM
Normal Response Documentation

Reaction to light:
Using a penlight and
OTOR
Illuminated and non-
illuminated pupils
PERRLA (pupils equally
round and reactive to
approaching from the should constrict. light and
side, shine a light on the accommodation)
pupil. Observe the
response of the
illuminated pupil. Shine
the light on the pupil
again, and observe the
response of the other
pupil.
 Cranial Nerve Normal Response Documentation
Assessment
Reaction to Pupils constrict when PERRLA (pupils equally
accommodation: looking at a near object, round and reactive to
Ask the client to look at dilate when looking at a light and
a near object and then distant object, converge accommodation)
at a distant object. when the near object is
Alternate the gaze from moved towards the
the near to the far nose.
object. Next, move an
object towards the
client’s nose.
 IV.
Cranial Nerve
Assessment
TROCHL
Normal Response Documentation

Hold a penlight 1 ft. in

front of the client’s eyes.
EAR
Client’s eyes should be
able to follow the
Both eyes are able to
move as necessary.
Ask the client to follow penlight as it moves.
the movements of the
penlight with the eyes
only. Move the penlight
upward, downward,
sideward and diagonally.
 V.
Cranial Nerve
Assessment
TRIGEMI
Normal Response Documentation

While the client looks

upward, lightly touch
NAL
Client should have a (+)
corneal reflex, able to
Client was able to elicit
corneal reflex, sensitive
the lateral sclera of the respond to light and to pain stimuli and
eye to elicit a blink deep sensation and able distinguish hot from
reflex. to differentiate hot from cold.
cold.
 Cranial Nerve Normal Response Documentation
Assessment
To test light sensation, (same as above) (same as above)
have the client close
eyes, wipe a wisp of
cotton over the client's
forehead.

To test deep sensation, (same as above) (same as above)

use alternating blunt
and sharp ends of an
object. Determine
sensation to warm and
cold object by asking
client to identify warmth
and coldness.
 VI.
Cranial Nerve
Assessment
ABDUCE
Normal Response Documentation

Hold a penlight 1 ft. in

front of the client’s eyes.
NS
Both eyes coordinate,
move in unison with
Both eyes move in
coordination.
Ask the client to follow parallel alignment.
the movements of the
penlight with the eyes
only. Move the penlight
through the six cardinal
fields of gaze.
 VII.
Cranial Nerve
Assessment
FACIA
Normal Response Documentation

Ask the client to smile,

raise the eyebrows,
L
Clients should be able to
smile, raise eyebrows,
Clients performed
various facial
frown, and puff out and puff out cheeks and expressions without any
cheeks, close eyes close eyes without any difficulty and were able
tightly. Ask the client to difficulty. The client to distinguish varied
identify various tastes should also be able to tastes.
placed on the tip and distinguish different
sides of the tongue. tastes.
 VIII.
Assessment
Vestibulococ
Cranial Nerve Normal Response Documentation

hlear
Have the client occlude
one ear. Out of the
Clients should be able to
hear the tickling of the
Client was able to hear
tickling in both ears.
client’s sight, place a watch in both ears.
tickling watch 2 to 3 cm.
Ask what the client can
hear and repeat with the
other ear.

Ask the client to walk The client should have The client was able to
across the room and upright posture and stand and walk in an
back and assess the steady gait and be able upright position and was
client’s gait. to maintain balance. able to maintain
balance.
 IX.
Assessment
Glossophary
Cranial Nerve Normal Response Documentation

ngeal
Ask the client to say Clients should be able to Client was able to elicit
“ah” and have the elicit gag reflex and gag reflex and was able
patient yawn to observe swallow without any to swallow without
upward movement of difficulty. difficulty.
the soft palate.

Elicit gag response. (same as above) (same as above)

Note ability to swallow. (same as above) (same as above)

 X:
Cranial Nerve Vag
Normal Response Documentation
Assessment
Ask the patient to
us
The client should be Client was able to
swallow and speak (note able to swallow without swallow without
hoarseness) difficulty and speak difficulty and speak
audibly. audibly.
 XI:
Cranial Nerve
Assessment
Accesso
Normal Response Documentation

Ask the client to shrug

shoulders against
ry
Clients should be able to
shrug shoulders and
Client was able to shrug
his shoulders and turn
resistance from your turn their head from his head from one side
hands and turn head to side to side. to the other.
side against resistance
from your hand (repeat
for the other side).
 XII:
Cranial Nerve Hypoglos
Normal Response Documentation
Assessment
Ask the client to
sal
The client should be The client was able to
protrude tongue at able to move their move tongue in different
midline and then move tongue without any directions.
it side to side. difficulty.
 4
GUIDELINES IN THE TOOLS FOR
NEUROVASCULAR ASSESSMENT,
PAPILLARY ASSESSMENT, GLASGOW
COMA SCALE AND CRANIAL NERVE
ASSESSMENT
REPORTER: DANAQUE, CHRISANNE JOY S.
 NEUROVASCULAR
ASSESSMENT
Pulses
● Assess upper extremity peripheral pulses (brachial, radial, and ulnar) and lower
extremity peripheral pulses (femoral, popliteal, posterior tibialis, and dorsalis
pedis) bilaterally. Be sure to assess for the presence of pulses distal to any injury.
● Use a 0-4 point scale (0=absent and 4=strong/bounding), noting also if the pulse
is weak, diminished or absent.
● Use a marker to indicate a pulse palpation site that is difficult to locate; this can
help others with their assessment and provide consistency.
● A manual Doppler scan should be utilized if a pulse palpation site is challenging
to find or if the pulse is weak.
● If possible, pulses should be assessed as soon as the patient is admitted so that
a baseline can be established.
 NEUROVASCULAR
ASSESSMENT
Pulses
● If palpable pulses are not accessible due to casting, assess all other parameters.
● Document if a change in the pulse is detected and notify the appropriate health
care provider. Capillary refill.
● Assess capillary refill by pressing on the nail beds to evaluate the peripheral
vascular perfusion.
● Pressure is applied to the nail bed until it turns white. Once the tissue has
blanched, pressure is removed. After the pressure is removed, measure the time
it takes for blood to return to the tissue.
● Note how long it takes for the distal capillary bed to regain its color after
pressure has been applied to cause blanching (Pickard, Karlen, & Ansermino,
2011).
● Capillary refill time can be affected by age, temperature, ambient light, and
pressure application (Pickard, Karlen, & Ansermino, 2011). Skin color
 NEUROVASCULAR
ASSESSMENT
Pulses
● Compare the color of the skin bilaterally.
● Consider the patient’s usual skin tone and any skin conditions when performing
this assessment; cyanosis can present differently in different skin tones.
Temperature
● Use the back of your hands to assess skin temperature bilaterally.
● Skin should be warm to touch. Cool skin may indicate inadequate arterial supply;
warmth may indicate inadequate venous return (Schreiber, 2016).
 NEUROVASCULAR
ASSESSMENT
Sensation
● Ask the patient about changes in sensation, such as tingling, numbness
(paresthesia), pressure, or burning.
● A pressure sensory exam often consists of assessing light touch with a
cotton swab and assessing temperature discrimination with warm and cold
stimuli; pinprick sensation can be tested using the sharp end of a disposable
safety pin.
● Test on the area which has higher sensitivity (e.g. middle part of foot sole),
avoid thickened skin area (less sensitivity toward stimulation).
● If indicated, consider using the 2-point discrimination test.
● Complaints of numbness or tingling in an extremity should be investigated
immediately, with the assessment proximal and distal to the site of injury or
surgery (if not precluded by a cast or splint).
 NEUROVASCULAR
ASSESSMENT
Sensation
● Nerve involvement, compromised blood flow, or the use of ice can alter a
patient's sensory function. Motor function
● Assess range of motion and strength. The patient's ability to perform specific
movements is a key indicator of motor function of specific nerves.
● Loss of motor function is often a late sign of neurovascular compromise;
thus, frequent assessment and careful attention is required to detect these
subtle changes in the patient.
 NEUROVASCULAR
ASSESSMENT
Pain
● Complications can be prevented when pain is identified and treated early.
● Pain can be caused by sensory nerve damage and/or diminished blood flow.

● Use a pain assessment tool to assess severity of pain.

● Note the location, severity, and areas of radiating pain.
● In sedated patients or those who can’t verbalize information, be aware of
non-verbal pain cues including grimacing, guarding, tachycardia, and
hypotension.
 NEUROVASCULAR
ASSESSMENT
Edema
● Edema can result from musculoskeletal injury, can contribute to vascular
compromise, and can cause damage to muscle and nerve tissue.
● Pre-existing disease processes (i.e. heart failure, cirrhosis, or kidney disease) can
place a patient at increased risk for edema-related complications.
● Elevating the limb, no higher than heart level, can help decrease edema.
Frequency of observations
● 1 hourly for the first 24 hours post injury, surgery or application of cast.
● Then 4 hourly for a further 48 hours or as specified by the treating medical team.
 NEUROVASCULAR
ASSESSMENT
Edema
● More frequently if any deviations from baseline observations. For cardiac
catheter patients:
● Neurovascular observations should be conducted on the affected limb/s with
routine post anaesthetic observations and then with every set of observations.
● Sensation and motor function should be assessed appropriately according to the
affected limb.
● With each set of neurovascular observations, the puncture site should be
assessed for bleeding or ooze, colour, warmth and signs of infection.
 PAPILLARY ASSESSMENT

● Obtain an informed consent before proceeding with the assessment of the eyes.
● Both eyes should be checked and compared against each other.
● Use a pupillometer, if available. It is a hand-held instrument which provides
quantitative pupillary measurements by taking 30 pictures per second of the
pupil's response to light stimulus.
● Pupil evaluation includes assessment of pupil size, shape, and equality before
and after exposure to light.
● Report any significant change in pupil size/reactivity, decrease pupil size, and
falling constriction velocities to the ophthalmologist.
● Document the response from the different tests and immediately report any
changes from baseline data.
 PAPILLARY ASSESSMENT

● Note that fixed and dilated pupils are an ominous sign that warrant immediate
physician notification (unless the patient’s pupils have just been dilated
chemically)
● Be aware that the patient may have a false or glass eye, mark on the
neurological observation chart accordingly
● Assist the physician who views through the various lenses of an ophthalmoscope
to view and assess the internal structures of the eye of the client.
 GLASGOW COMA SCALE
GCS Assessment Method:
● Assess: To assess the client for factors that may interfere with the scoring (e.g.
sedation, intoxication, edema, hearing or speech impediment, eye damage, and
presence of other injuries).
● Observe: To observe the expected spontaneous response of the client per
parameter measured.
● Stimulate: If spontaneous response is not present, it is the medical professional’s
initiative to proceed to stimulation and observe the will now be added, and the
final score will now indicate the client’s current health status responses per
parameter stimulated.
● Rate: After the various parameters are measured, the scores will now be added,
and the final score will now indicate the client’s current health status
 CRANIAL NERVE
ASSESSMENT
● To test cranial nerve I which is the olfactory nerve: Have the client close their
eyes and place a familiar and nonirritating odor, such as coffee under the nose
and have them identify it.
● To test cranial nerve II which is the optic nerve: Perform the confrontation visual
field test and visual acuity test with a Snellen chart.
● To test Cranial Nerve V which is the trigeminal nerve: This nerve is responsible
for many functions and mastication is one of them. Have the patient bite down
and feel the masseter muscle and temporal muscle. Then have the patient try to
open the mouth against resistance
 CRANIAL NERVE
ASSESSMENT
● The cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are assessed
together.
○ Have the patient follow your pen light by moving it 12-14 inches from the
patient’s face in the six cardinal fields of gaze (start in the midline) and
watch for any nystagmus (involuntary movements of the eye)
○ Check if reactive to light by dimming the lights and have the patient look at
a distant object (this dilates the pupils) c.
○ Check the accommodation by making the lights normal and have the patient
look at a distant object to dilate pupils, and then have the patient stare at
pen light and slowly move it closer to the patient’s nose. d.
○ If all these findings are normal , document PERRLA (Pupils are Equal and
Round and are Reactive to Light and Accommodation)
 CRANIAL NERVE
ASSESSMENT
● To test cranial nerve VII which is the facial nerve: have the patient close their
eyes tightly, smile, frown, puff out cheek. Monitor if they can do this with ease.
● To test cranial nerve VIII which is the vestibulocochlear nerve, Test the hearing
by occluding one ear and whispering two words and have the patient repeat
them back. Repeat this for the other ear.
● To test cranial nerve IX (glossopharyngeal) and X (vagus) have patient say “ah”…
the uvula will move up (cranial nerve IX intact) and if the patient can swallow
with ease and has no hoarseness when talking, cranial nerve X is intact.
● Test cranial nerve XI which is the accessory nerve: Have the patient move head
from side to side and up and down and shrug shoulders against resistance.
● To test cranial nerve XII which is the hypoglossal: have patient stick tongue out
and move it side to side
 5
NORMAL AND ABNORMAL
FINDINGS
REPORTER: CORTES, MARIA YSABEL C.
 NEUROVASCULAR
PARAMETER
ASSESSMENT
NORMAL FINDINGS
ABNORMAL
FINDINGS
Cyanotic, dusky, mottled
Pallor / Color Pink or purple black coloration;
pale and shiny skin

Cool skin
Temperature Skin is warm to touch

Capillary refill 2 seconds or less Longer than 2 seconds

Weak, diminished, or
Pulses Strong/bounding absent

Swelling No swelling Significantly swollen

 NEUROVASCULAR
PARAMETER
ASSESSMENT
NORMAL FINDINGS
ABNORMAL
FINDINGS
Able to flex, extend and
Decreased or loss of
Paralysis (movement) abduct their foot, hand,
motor function
fingers and toes

Constant, burning pain;

Pain Absent may be present even in
passive motion

Decreased sensation,
hypersensation, tingling,
Paraesthesia (sensation) Normal sensation “pins and needles”,
numbness or loss of
sensation
 PUPILLARY
PARAMETER
ASSESSMENT
NORMAL FINDINGS
ABNORMAL
FINDINGS
If the difference in pupil size
changes throughout the
Pupil Size Equal in size (3-5mm) pupillary response tests, the
inequality of size is
abnormal.

Round with a regular Irregular/misshapen

Pupil Shape
border pupils; uneven borders

Pupils quickly and

symmetrically constrict to a Sluggish response to light;
bright light directed into pupils do not react to direct
Reaction to light either of the eyes and when and consensual pupil testing
the bright light swings at all.
between the two eyes.
 PUPILLARY
PARAMETER
ASSESSMENT
NORMAL FINDINGS
ABNORMAL
FINDINGS
Pupils constrict and eyes
Pupils do not constrict; eyes
Accommodation converge when focusing on
do not converge
a near object
GLASGOW COMA
SCALE
 GLASGOW COMA
SCALE
NORMAL FINDINGS ABNORMAL FINDINGS

● GCS score of <15 indicates

some impairment in the level
of consciousness
○ GCS score of <8
GCS score of 15 indicates a fully indicates an unconscious
alert and oriented patient. patient.
○ GCS score of 3 indicates
severe impairment of
neurologic function,
coma, or brain death.
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
Inability to smell (neurogenic
Correctly identifies scent
CN I (olfactory) presented to each nostril
anosmia) or identify the
correct scent

● 20/20 visual acuity ● Difficulty reading Snellen

bilaterally chart, missing letters and
● Able to read print at 14 in. squinting
without difficulty ● Reads print by holding
● Full visual fields closer than 14 in. or
● Round reflex is present farther as in presbyopia
CN II (optic) ● Optic disc is 1.5mm, ● Loss of visual fields
round or slightly oval, ● Blurred optic disc margins
well-defined margins, and dilated pulsating
creamy pink with paler veins may lead to
physiologic cup papilledema (swelling of
● Retina is pink the optic nerve)
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
● Eyelid covers about 2 mm ● Ptosis (drooping of the
of the iris eyelid) due to weak eye
● Eye moves in a smooth, muscles
coordinated motion in all ● Abnormal eye movements
six directions (cardinal ● Other abnormalities:
fields) ○ Dilated pupil (6-7mm)
CN III (oculomotor), ● Bilateral illuminated pupils ○ Argyll Robertson
constrict simultaneously pupils
IV (trochlear), and VI ○ Constricted, fixed
(abducens) pupils
○ Unilaterally dilated
pupil unresponsive to
light/accommodation
○ Constricted pupil
unresponsive to
light/accommodation
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
● Temporal and masseter ● Decreased contraction in
muscles contract one of both sides
bilaterally ○ Asymmetric
● Able to correctly identify strength in moving
sharp and dull stimuli the jaw may be
and light touch to the seen with
CN V (trigeminal) forehead, cheeks and lesion/injury
chin ● Pain occurs with
● Eyelids blink bilaterally clenching of the teeth
● Inability to feel and
correctly identify facial
stimuli
● Absent corneal reflex
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
● Client has responsive ● Inability to perform motor
motor functions (smile, functions; facial paralysis
frown, raise eyebrows, may also be seen in
CN VII (facial) etc.) with symmetric certain conditions
movements ● Inability to identify correct
● Able to identify correct flavor on anterior two
flavor thirds of the tongue

● Able to hear whispered ● Vibratory sounds lateralize

words from 1-2 ft. to good ear in
● Weber’s Test: vibration sensorineural loss
CN VIII (acoustic/ heard equally well in both ● Air conduction is longer
vestibulocochlear) ears. than bone conduction, but
● Rinne Test: not twice as long in a
● AC > BC (air conduction is sensorineural loss
twice as long as bone
conduction)
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
● Gag reflex intact ● Absent gag reflex
● Swallows without ● Dysphagia or hoarseness
CN IX difficulty; no hoarseness ● Soft palate does not rise
● Uvula and soft palate with bilateral lesions
(glossopharyngeal) ● Unilateral rising of the soft
rise bilaterally and
and CN X (vagus) palate and deviation of the
symmetrically on
uvula with a unilateral
phonation lesion

● Symmetric, strong ● Asymmetric muscle

contraction of the contraction or drooping
CN XI (spinal trapezius muscles of the shoulder
accessory) ● Strong contraction of ● Atrophy with
sternocleidomastoid
fasciculations
muscle on the side
opposite the turned face
 CRANIAL NERVE
CRANIAL NERVES ASSESSMENT
NORMAL FINDINGS
ABNORMAL
(CN) FINDINGS
● Tongue movement is ● Fasciculations and
symmetric and atrophy of the tongue
CN XII (hypoglossal) smooth, and bilateral ● Tongue will deviate
strength is apparent toward the side with a
CN XII lesion
 6
PHYSIOLOGY OF
PUPILLARY
REACTIONS
 Behind a "normal" pupillary constriction is a balance between the
sympathetic and parasympathetic nervous systems.

Parasympathetic innervation leads to pupillary constriction. A

circular muscle called the sphincter pupillae accomplishes this task. The
fibers of the sphincter pupillae encompass the pupil. The pathway of
pupillary constriction begins at the Edinger-Westphal nucleus near the
oculomotor nerve nucleus. The fibers enter the orbit with CN III nerve
fibers and ultimately synapse at the ciliary ganglion.
Optic Nerve Fibers → Pretectal nuclei → Edinger-Westphal
Nucleus → Oculomotor Nerves
↓

Ciliary Ganglia → Iris Sphincter Muscle

 Sympathetic innervation leads to pupillary dilation. Dilation is
controlled by the dilator pupillae, a group of muscles in the peripheral
2/3 of the iris. Sympathetic innervation begins at the cortex with the first
synapse at the ciliospinal center. Post synaptic neurons travel down all
the way through the brainstem and finally exit through the cervical
sympathetic chain and the superior cervical ganglion. They
synapse at the superior cervical ganglion where third-order neurons travel
through the carotid plexus and enter into the orbit through the first
division of the trigeminal nerve.

Ciliospinal Center → Superior cervical Ganglion →

Hypothalamus → Iris Dilator Muscle
 6
LEVELS OF
CONSCIOUSNESS
 TYPE DEFINITION SCORE
Awake and alert, oriented to 15
Full Consciousness time, and place, ; behavior
appropriate for age

Confused Inability to think rapidly and 14

clearly. There is impaired
judgments and decision
making

Disorientation This is the beginning of the 13

loss of consciousness.

There is disorientation in
place, impaired memory and
confusion regarding time and
place

Lethargy Drowsy, sleeps a lot, but is 12

easily aroused with minimal
stimuli,(i.e voice), and then
responds

May not be oriented in time,

place or person
 TYPE DEFINITION SCORE
Obtundation Difficult to arouse but 10-11
aroused by repeated stimuli
(not pain), i.e. shaking and
will then respond to
questions or commands

Cannot make complete

sentences

Stupor No verbal response 8-9

A condition of deep sleep or

unresponsiveness

Patients can only be aroused

or caused to make a motor or
verbal response by vigorous
and repeated external
stimulation (painful
stimulation)

The patient may moan and

respond to pain by moving
extremities
 TYPE DEFINITION SCORE
Coma There is no motor and verbal Mild Coma (7)
response to the external Moderate Coma (5-6) Severe
environment or to any Coma (4)
stimuli, even deep pain or Deep Coma (3)
suctioning, no evidence of
awareness

TYPES:
● Mild Coma: brief LOC and
normal imaging
● Moderate Coma: brief
LOC and abnormal
imaging
● Severe Coma: longer
than 24 hours with
abnormal imaging
● Deep Coma: comatose
for very long periods of
time (can be for months,
years

Persistent Vegetative Permanently lost function of 3

State (PVS) the cerebral cortex
DEFINITIONS OF LEVELS OF AROUSAL
(CONSCIOUSNESS)
TYPE FINDINGS
Lethargy Client opens eyes, answers questions, and
falls back to sleep

Obtunded Client open eyes to loud voice, responds

slowly with confusion, and seems unaware of
environment

Stupor Client awakens to vigorous shake or painful

stimuli but returns to unresponsive sleep

Coma Client remains unresponsive to all stimuli;

eyes stay closed.
 7
ADULT & PEDIATRIC
GLASGOW COMA SCALE
REPORTER: DACLAN, JUBILEEN ANNE B.
Compare and contrast the Adult and Pediatric Glasgow Coma
Scales.

Adult Glasgow Coma Scale Pediatric Glasgow Coma Scale

- Used to assess the level of consciousness - used to assess the consciousness of

for adults and children older than 2 infants and children < 2 years old
years old
- The main difference from adult Glasgow
- Used to objectively describe the extent of coma scale comes in the verbal
impaired consciousness in all types of response.
acute medical and trauma patients (e.g. - (PGCS)—was created for children too
head injury, after traumatic brain injury, young to talk.
victims of trauma like subarachnoid
hemorrhage or presence of any critical - Without the verbal responses, the scale
illness) won’t be helpful to assess a child’s
orientation or obey the commands to
- a tool for assessing a patient’s response to evaluate their motor responses.
stimuli. Scores range from 3 (deep coma)
to 15 (normal).
Compare and contrast the Adult and Pediatric Glasgow Coma
Scales.

Adults, children SCORE Under 2 years

over 2 years
EYE OPENING RESPONSE
Spontaneous — opens 4 Eye opening
with blinking at baseline spontaneously

Opens to verbal common, 3 Eye opening to speech

speech or shout

Opens to pain 2 Eye opening to pain

None 1 No Eye opening

Compare and contrast the Adult and Pediatric Glasgow Coma
Scales.
Adults, children over 2 SCORE Under 2 years
years
VERBAL RESPONSE
Oriented and converses 5 Infant coos or babbles
(normal activity)

Confused, but able to answer 4 Infant is irritable and

questions continually cries

Inappropriate responses, words 3 Infant cries to pain

are discernible

Incomprehensible speech or 2 Infant moans to pain

sounds

None 1 No verbal response

Compare and contrast the Adult and Pediatric Glasgow Coma
Scales.
Adults, children over SCORE Under 2 years
2 years
MOTOR RESPONSE
Obeys commands for 6 Infant moves spontaneously or
movement purposefully

Purposeful movement to 5 Infant withdraws from touch

painful stimulus

Withdraws from pain 4 Infant withdraws from pain

Abnormal (spastic) flexion, 3 Abnormal flexion to pain for an

decorticate posture infant (decorticate response)

Abnormal Extension to pain, 2 Abnormal Extension to pain

decebrate posture (decerebrate response)
 8
nursing responsibilities before,
during and after using the different
assessment tools.
REPORTER: DACLAN, JUBILEEN ANNE B.
I. Neurovascular
Assessment
Before
1. Read the patient’s chart.
2. Explain the procedure and obtain consent.
3. Do medical handwashing and don gloves.

During
1. Assess the level of pain by asking the client
to rain their pain on a scale from 0 to 10. Note
the pain’s COLDSPA. Character, Onset, Location,
Duration, Severity, Pattern and Associated
Factors.
2. Ask the patient to flex and extend each
finger, wrist, ankle and toe. If a patient’s active
movement is impaired or absent, passive
movement must be tested.
3. Record whether there is any pain at rest
and on passive movement of the
extremity (passive stretch), particularly for
the affected muscle group. Pain may indicate
I. Neurovascular
Assessment
During

4. Compare the skin color of the unaffected

limb to the affected limb.
● Record the color of the affected limb.
A red extremity may indicate
hyperaemia or inflammation while a
pale skin tone indicates inadequate
arterial supply.

5. Place the back of your hand on the

extremity being examined.
● If it is hot to touch, it indicates venous
congestion. If it is cold to touch, there
is diminished arterial flow.
I. Neurovascular
Assessment
During

6. To measure the capillary refill time

● compress the tip of the patient’s finger/toe
between your thumb and index finger until
blanching occurs and release. The normal
capillary refill time is <
7. To assess the pulse
● apply gentle pressure on any palpable pulse
points. Then grade the pulse if it's strong, weak
8. To assess sensation,
● instruct the
or client
absent.to close her eyes first. Then, Test
each nerve-related area using the tip of your index
finger. When testing sensation, the location of
numbness, tingling or prickling must be determined
to indicate distribution of vascular compromise or
nerve damage. Assess and record the nerve
sensation as normal, pins and needles or absent.
I. Neurovascular
Assessment
During
9. Assess and record swelling as nil, small,
moderate or large. Limb circumference
measurement can assist in monitoring swelling.
● When measuring, mark the level(s) on the limb to
ensure accurate serial recording.
10. Assess blood loss on dressings, plasters and any
surgical drains to the affected limb.Mark the
dressing/plaster and outline the area of blood/ooze
and time (if appropriate).
● Record blood loss/ooze as ‘nil’, ‘small’, ‘moderate’ or
‘large’.
After
1. Assist the client in a comfortable position.
2. Do after care.
3. Document the responses of the client, the
actions being taken. Report to the physician
any abnormalities to be alert of.
I. Pupillary
Assessment
Before
1. Read the patient's chart.
a. To check the presence of pre-existing irregularity with the
pupils, for example cataracts, false eye or previous eye
injury
b. To check if there are any pre-existing factors that can
cause pupillary dilation
c. To check for medications that cause pupillary constriction
2. Do medical handwashing, dry thoroughly and don clean
gloves.
3. Establish rapport with the client to ensure client cooperation
and trust throughout the procedure.Ensure the client is
comfortable with sitting position.
4. Close the curtains, windows and doors to provide privacy.
5. Prepare the materials needed such as a pen torch and the
patient’s observation chart (in some situations a
neurological assessment chart).
I. Pupillary
Assessment
During
1. Explain the procedure to the patient, even if
she or he is unconscious.

2. Dim the overhead light source. A darkened

room is ideal but practically this will rarely be
possible); dim light will facilitate a better view
of the pupils and their reaction to light.
3. Look into each of the patient’s eyes, examining
the size of the pupils.
4. Note the size (mm) of each pupil; if available
use the scale printed on the neurological
assessment chart as a comparison
5. Compare the sizes of the pupils.
I. Pupillary
Assessment
During
6. Note the shape of each pupil.

7. Compare the shapes of the pupils.

8. Move the torchlight from the side of the head

towards the pupil and note any change in pupil
size and the speed of the reaction (brisk or
sluggish).

9. Taking care to avoid shining the light in the

other eye, observe whether the opposite pupil also
reacts (consensual reflex).

10. Repeat the above procedure in the opposite

I. Glasgow Coma Scale
Before
1. Explain the procedure to the client. If the patient is unconscious,
inform the significant other instead.
2. Do handwashing and don gloves.
3. Prepare the necessary personal protective equipment.
4. Conduct a primary survey, a rapid assessment of the client’s ABCs
which are airway, breathing, circulation. In addition, make sure to
consider the client’s D disability and E exposure.
5. Conduct a secondary survey, a complete head to toe assessment to
determine other serious injuries
6. Assess the client’s neurovascular status.
7. Monitor vital signs frequently.
8. Assess the client’s medication history.
I. Glasgow Coma Scale
Before
1. Explain the procedure to the client. If the patient is unconscious, inform the
significant other instead.
2. Do handwashing and don gloves.
3. Prepare the necessary personal protective equipment.
4. Conduct a primary survey, a rapid assessment of the client’s ABCs which are
airway, breathing, circulation. In addition, make sure to consider the client’s D
disability and E exposure.
5. Conduct a secondary survey, a complete head to toe assessment to determine
other serious injuries
6. Assess the client’s neurovascular status.
7. Monitor vital signs frequently.
8. Assess the client’s medication history.
I. Glasgow Coma EYE OPENING

Scale
During
Eyes
opening
initially observe if the patient is opening
their eyes spontaneously
spontaneous
1. Check the patient’s chart If however, the patient is not opening
ly their eyes spontaneously, perform the
to note any medical (4 points) following steps until a response is
condition that may affect obtained
the accuracy of the GCS.
(e.g. previous stroke that Eyes opening If the patient doesn’t open their eyes
affects the movement of to sound spontaneously, speak to the patient,
the client’s arms) (3 points) “Hey, are you ok?”

2. Check the neurological

Eyes opening If the patient does not open their eyes to
observation chart for the a painful stimulus
to pain (2
GCS scale.
points)
3. Eye opening Not testable If the patient cannot open their eyes for
some reason (e.g. edema, trauma,
dressings), you should document that
eye response could not be assessed (NT).
 VERBAL RESPONSE
III. Glasgow
Orientated initially observe if the patient is opening their eyes
Coma Scaleresponse
(5 points)
spontaneously

During
Confused If the patient doesn’t open their eyes spontaneously, speak
4. Verbal response
conversation to the patient, “Hey, are you ok?”
(4 points)
Inappropriate If the patient does not open their eyes to a painful stimulus
words
(3 points)
Incomprehensibl If the patient cannot open their eyes for some reason (e.g.
e sounds edema, trauma, dressings), you should document that eye
response could not be assessed (NT).
(2 points)
No response (1 If the patient has no response
point)
Not testable (NT) If the patient is intubated or has other factors interfering
with their ability to communicate verbally, their response
cannot be tested.
 MOTOR RESPONSE
III. Glasgow
Orientated initially observe if the patient is opening their eyes
Coma Scaleresponse
(5 points)
spontaneously

During
Confused If the patient doesn’t open their eyes spontaneously, speak
5. Motor response
conversation to the patient, “Hey, are you ok?”
(4 points)
Inappropriate If the patient does not open their eyes to a painful stimulus
words
(3 points)
Incomprehensibl If the patient cannot open their eyes for some reason (e.g.
e sounds edema, trauma, dressings), you should document that eye
response could not be assessed (NT).
(2 points)
No response (1 If the patient has no response
point)
Not testable (NT) If the patient is intubated or has other factors interfering
with their ability to communicate verbally, their response
cannot be tested.
III. Glasgow Coma
Scale
During
5. MOTOR RESPONSE
Obeys Instruct the client to do a two-part request by lifting his right arm off the bed
commands and then making a fist. They are given 6 points if they can follow this
command properly.
(6 points)
Localises to This involves applying a painful stimulus and observing the client for a
pain response.
(5 points) ● Do a trapezius squeeze by Squeezing one of the patient’s trapezius
muscles.
● Apply pressure to the patient’s supraorbital notch.
III. Glasgow Coma
Scale
During
Withdraws to pain If the patient does not open their eyes to a painful stimulus
(4 points)
Abnormal flexion response If the patient cannot open their eyes for some reason (e.g.
to pain edema, trauma, dressings), you should document that eye
response could not be assessed (NT).
(3 points)
Abnormal extension If the patient has no response
response to pain
(2 points)

No response (1 point) If the patient is intubated or has other factors interfering with
their ability to communicate verbally, their response cannot be
tested.

Not testable (NT) If the patient has paralysis

III. Glasgow Coma
Scale
After

1. Do aftercare.

2. Document client’s reaction.

3. Interpret the GCS score and explain

it to the client along with the
significant other.
IV.Cranial Nerve
Assessment
Before

1. Explain the procedure to the client.

2. Do handwashing and Don gloves.
3. Provide a comfortable environment by closing the doors and windows to
provide privacy.
4. Instruct the client to relax throughout the procedure to prevent any restraints
that may affect the outcomes of the tests.
5. Consider the client’s literacy level, medications and other factors that can
affect their ability to perform certain tests.
6. Prepare the necessary materials to minimize trips to the nursing station.
IV.Cranial Nerve
Assessment
During

1. To test cranial nerve I which is

the olfactory nerve:
a. Instruct the client to close
their eyes and place a
common odor, like coffee
under the nose and have them
identify it.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved
February 16, 2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

2. To test cranial nerve II which is the optic nerve: Perform the confrontation visual field
test and visual acuity test with a Snellen chart.
a. A confrontation visual chart is done to assess peripheral vision. Face the client and
stand an arm's length from the patient. Cover your left eye while the client covers their
right eye. Instruct the client to look at your nose and not at your fingers. In top and
bottom visual fields, hold up random numbers to your side and let the client recite them
back to you.
b. To do the Snellen chart, the client should stand 20 feet from the chart. Instruct them to
IV.Cranial Nerve
Assessment
During
3.To test cranial nerve III (oculomotor
nerve), IV (trochlear), VI (abducens):
a. Instruct the client to follow the pen
light and move it 12-14 inches from
the client’s face in six cardinal fields
of gaze starting from the midline.
b. Watch for any nystagmus
(involuntary movements of the eye)

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16,
2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During
3.To test cranial nerve III (oculomotor
nerve), IV (trochlear), VI (abducens):
a. Check if eyes are reactive to light by
i. dimming the lights and having the
patient look at a distant object (this
dilates the pupils).
ii. Then, shine light in from the side of
each eye.
iii. Note the pupil response: The eye
with the light shining in it should
constrict (note the dilatation size
and response size (ex: pupil size
goes from 3 to 1 mm) and the other
side should constrict as well.
Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16,
2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During
3.To test cranial nerve III (oculomotor
nerve), IV (trochlear), VI (abducens):
a. Check the accommodation by making the
lights normal and have the patient look at a
distant object to dilate pupils, and then have
the patient stare at pen light and slowly move
it closer to the patient’s nose.
i. Watch the pupil response: The pupils
should constrict and equally move to
cross.
ii. If all these findings are normal ,
document PERRLA (Pupils are Equal and
Round and are Reactive to Light and
Accommodation)

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16, 2022,
from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve V which is

the trigeminal nerve:
● Have the client bite down and feel
the masseter muscle and the
temporal muscle.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16, 2022, from
https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve V which is

the trigeminal nerve:
● Have the client bite down and feel
the masseter muscle and the
temporal muscle.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16, 2022, from
https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve VII which is the facial nerve:

● Have the client bite down and feel the masseter muscle and the temporal
muscle.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16, 2022, from
https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve VIII which is the

vestibulocochlear nerve:
1. test the hearing by occluding one ear
and whispering two words and have
the patient repeat them back. Repeat
this for the other ear.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February
16, 2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During
To test cranial nerve IX
(glossopharyngeal) and X
(vagus)
● have patient say “ah”…the uvula
will move up (cranial nerve IX
intact) and if the patient can
swallow with ease and has no
hoarseness when talking,
cranial nerve X is intact.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February
16, 2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve

XI which is the
accessory nerve:
● Instruct the patient to
move head from side
to side and up and
down and shrug
shoulders against
resistance.

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16,
2022, from https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
During

To test cranial nerve XI which is the

hypoglossal nerve:
● have patient stick tongue out and move
it side to side

Reference: Cranial nerve examination nursing. Registered Nurse RN. (2018, April 16). Retrieved February 16, 2022, from
https://www.registerednursern.com/cranial-nerve-examination-nursing/
IV.Cranial Nerve
Assessment
After
1. Remove gloves and dispose properly.

2. Perform medical hand washing then dry hands.

3. Document assessment findings, any abnormalities noted, and actions

taken.

4. Report any significant findings to the physician.

5. Ensure that the patient is left in a comfortable position

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https://www.nursingtimes.net/clinical-archive/neurology/neurological-assessment-part-2-pupillary-assessment-15-07-2008/

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Jevon, P. (2008, July 15). Neurological assessment Part 2 - Pupillary assessment. Nursing Times.
https://www.nursingtimes.net/clinical-archive/neurology/neurological-assessment-part-2-pupillary-assessment-15-07-2008/
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Maurya, N. (2018, June 16). Neet PG High Yeild &amp; Latest Trending Topic. www.medicoapps.org. Retrieved February 4, 2022, from
https://medicoapps.org/m-glasgow-coma-scalegcs/

Neurovascular Assessment. (2021). Lippincott Nursing Center.

https://www.nursingcenter.com/getattachment/Clinical-Resources/nursing-pocket-cards/Neurovascular-Assessment/Pocket-C
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0sensation%2C%20and%20motor%20function
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Neurovascular assessment guide - emergency department nursing. (n.d.). Retrieved February 4, 2022, from https://ed-
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RCH. (2012). Clinical Guidelines (Nursing) : Neurovascular observations. Rch.org.au.

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neurovascular_observations/

RXez, Rodriguez, A., Vera, M., Jordyn, Larose, J., Sharma, A., &amp; Jp. (2021, July 20). Cranial nerves assessment cheat sheet (free
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Weber, J. R., & Kelley, J. H. (2017). Health assessment in nursing (6th ed.). Lippincott Williams and Wilkins.