Head-To-Toe Assessment K. Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or the six cardinal position of gaze.
Follow the given steps:
1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s eyes.
2. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is with out moving the neck.
3. The nurse moves the object in a clockwise direction hexagonally.
4. Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal gazes.
5. The examiner should watch for any jerky movements of the eye (nystagmus).
6. Normally the client can hold the position and there should be no nystagmus.