Chapter 15 – Neurological system assessment
CN XII – Hypoglossal Nerves
- Ask the client to open their mouth and stick their tongue out as far as they can. Ask them to move it to one side and then the other side
- Normally, the tongue should be midline with no tremors and ease of movement.
- Abnormal findings would be a tongue that deviates to one side, with tremors and/or decreased or absent movement.
- Next, place your fingertips on one side of the client’s cheeks. Ask the client to move the tip of their tongue against the buccal mucosa inside their mouth so that they can feel your fingers. Tell them that you are going to apply pressure with your fingers and they should attempt to resist the pressure. Repeat on the other side.
- Normally, the client should be able to resist your pressure.
- Abnormal findings would be a client who is unable to resist your pressure.
See Video 14.
Video 14: Hypoglossal nerve testing (CN XII).
- Note the findings:
- Normal findings might be documented as: “Hypoglossal testing: Tongue midline, no deviation, able to move tongue from side to side and resist examiner’s pressure.”
- Abnormal findings might be documented as: “Hypoglossal testing: Tongue deviates to left side with tremors. Absent muscle resistance of tongue bilaterally.”
Contextualizing Inclusivity
- Your findings may be affected by the client’s age. As individuals age, they often experience a diminished ability to smell and taste bilaterally, as well as reduced peripheral vision.
- Some clients may feel vulnerable when a nurse is behind them; recall the steps of a trauma-informed approach.
