GLAUCOMA SCALE

CRANIAL NAME TYPE ASSESSMENT METHOD

NERVE

I. OLFACTORY SENSORY  Ask the client to close eyes identify of

different mild commas such as coffee,
orange, Chocolate.

II. OPTIC SENSORY  Ask to read Snellen chart.

 Check Visual fields by confrontation
conduct an ophthalmoscopic.
 Conduct an ophthalmoscopic
examination
III. OCULOMOTOR MOTOR  Assess to ocular movements and pupil
reaction
IV. TROCHLEAR MOTOR  Assess to ocular movements

V. TRIGEMINAL SENSORY  Lightly touch sclera with sterile gauze

OPHTHALMIC while client looks up.
BRANCH  Have client close eyes and wipe a wisp
of cotton over forehead & paranasal
sinuses, to test for light sensation.
 Use alternating sharp and blunt ends of
a pen over some areas to test for deep
sensation.
MAXILLARY SENSORY  Assess skin sensation as for Ophthalmic
BRANCH branch above.

MANDIBULAR MOTOR &  Ask client to clench teeth.

BRANCH SENSORY

VI. ABDUCENS MOTOR  Assess the direction of gaze

VII. FACIAL MOTOR &  Ask the client to smile, raise eyebrows,
SENSORY frown, puff out cheeks, close eyes
tightly.
 Ask to identify various tastes placed on
the tip de sides of the tongue.
VIII. - Auditory SENSORY  Romberg Test
- Vestibular SENSORY  Assess ability to hear spoken word and
Branch vibrations of tuning fork
- Cochlear branch
IX. Glossopharyngea MOTOR & Apply tastes on posterior tongue for
l SENSORY identification. Ask to move tongue from side to
side and than up and down.

X. Vagus MOTOR & Assess for hoarseness of speech.

SENSORY

XI. Accessory MOTOR Ask to shrug Shoulders against resistance from

your hands. Ask to turn head from side to side
against resistance from your hand.

XII. Hypoglassal MOTORO Ask to protrude tongue at midline and move it

side to side

 Use a percussion hammer comparing one side of the body with the other to evaluate symmetry
of response:
0 - No reflex response.
+1 - minimal activity (hypoactive).
+2 - normal response.
+3 - more active than normal.
+4 - maximal activity (hyperactive).

 -Plantar / Babinski Reflex:

use a moderately sharp object and stroke the lateral of the sole of the client's foot starting at the
heel, continuing to the ball of the foot, then proceeding across the ball of the foot toward the big to
observe response.

 MOTOR FUNCTION
walking Gait : ask the client to walk across the room and back & assess the gait.
Romberg Tet : ask a client to stand with feet together and arms resting at the sides first with
eyes open and then closed
Standing on one foot with eyes closed: Ask the client to close the eyes and stand on one foot.
Repeat on the other foot.
Hear for Walking: ask to walk a straight line, placing the heel of one foot directing in front of the
toes of the other foot.
Toe or Heel walking: ask to walk several steps on the toes and then on the heels.
FINE MOTOR TESTS FOR UPPER EXTREMITES:

 FINGBR TO NOSE TEST - ask to abduct and extend arms at shoulder height and then rapidly
touch nose alternately with one index finger & then and another. - ask to repeat test with eyes
closed.
 ALTERNATING SUPINATION AND PRONATION OF HANDS ON KNEES - ask to pat both knees with
palms of both hands and then with the backs of the hands alternately at an ever- increasing
rete.
 FINGER TO NOSE AND TO THE NUPSE'S FINGER -ask to touch the nose and then your index
finger held at a distance 4cm at a rapid and increasing rate.
 FINGER TO FINGERS: ask to spread arms broadly at shoulder height and then finger together at
midline first with eyes open then closed, First slowly and then rapidly.
 FINGERS N THUMD (SAME HAND): ask to touch finger of one hand to the thumb of the Same
hand as rapidly as possible.
 FINGERS MOTOR TEST FOR THE LOWER EXTREMITES: ask to lie supine during the test.
 HEEL DOWN OPPOSHE SHIN: ask to place heel of one foot just below opposite knee and run heel
down the shin to the foot. Repeat with other foot.
 FOR OR BALL OF FOOT TO THE NURSES Finger: ask to touch your finger with the large toe of
each foot.

LIGHT TOUCH SENSATION :

- ask to close eyes and respond by saying "yes" / "No" whenever the client feels cotton
wisp touching the skin.
- with a wisp of written, lightly touch one specific spot and then the same Spot on the
other side of the body.
- test areas on forehead, cheek, hand, lower arm abdomen, foot, and lower leg. Check
the distal area of the Limb first.
- Pain Sensation: - ask the client to Close eyes and say "sharp" / "dull" I don't know when
the sharp or dull end of a pen is felt. Alternately use sharp or dull ends to lightly prick
designated anatomic areas at the random.
- Position / Kinesthetic Sensation : Support arm and hand with one hand. Place heels on
the examining table - ask to close eyes and grasp the middle finger or big toe firmly and
exert Some pressure on both sides of the finger or toe while moving it-move toe / finger
until it is up, doon, or straight out, and ask the client to identify position.
- DOCUMENT FINDINGS

AFTER:

 Observe patient every hour until GCS score is 15

 Once GCS score reaches 15 reassess using GCS every half h our for 2 consecutive hours
 If GCS Score remains at 15, Observe once every hour for 4 hours and then 2 hours after that.
 Document procedure / assessment done with attained GCS score
 Notify physician
 Formulate nursing care plan considering abnormal findings