NCP Nursing Diagnosis: Impaired Verbal Communication

Nursing Diagnosis: Impaired Verbal Communication
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Communication: Expressive Ability
* Communication: Receptive Ability
* Information Processing

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Active Listening
* Communication Enhancement: Hearing Deficit
* Communication Enhancement: Speech Deficit

NANDA Definition: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols

Human communication takes many forms. Persons communicate verbally through the vocalization of a system of sounds that has been formalized into a language. They communicate using body movements to supplement, emphasize, or even alter what is being verbally communicated. In some cases, such as American Sign Language (the formal language of the deaf community) or Signed English, communication is conducted entirely through hand gestures that may or may not be accompanied by body movements and pantomime. Language can be read by watching an individual’s lips to observe words as they are shaped. Humans communicate through touch, intuition, written means, art, and sometimes a combination of all of the mechanisms listed above. Communication implies the sending of information as well as the receiving of information. When communication is received it ceases to be the sole product of the sender as the entire experiential history of the receiver takes over and interprets the information sent. At its best, effective communication involves a dialogue that not only involves the transmission of information but also clarification of points made, expansion of ideas and concepts, and exploration of factors that fall out of the original thoughts transmitted. Communication is a multifaceted, kinetic, reciprocal process. Communication may be impaired for any number of reasons, but rarely are all avenues for communication compromised at one time. The task for the nurse, whether encountering the patient in the hospital or in the community, becomes recognizing when communication has become ineffective and then using strategies to improve transmission of information.

* Defining Characteristics: Inability to find, recognize, or understand words
* Difficulty vocalizing words
* Inability to recall familiar words, phrases, or names of known persons, objects, and places
* Unable to speak dominant language
* Problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding

* Related Factors: Brain injury that adversely affects the transmission, reception or interpretation of language or other forms of communication
* Structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws)
* Cultural difference (e.g., speaks different language)
* Dyspnea
* Fatigue
* Sensory challenge involving hearing or vision

* Expected Outcomes Patient is able to use a form of communication to get needs met and to relate effectively with persons and his or her environment.

Ongoing Assessment

* Assess the following:
o The patient’s primary and preferred means of communication (e.g., verbal, written, gestures).
o Ability to understand spoken word. It is important for health care workers to understand that the construct of gestured language has an entirely different structure from verbal and written English. Signed English is not the true language of the deaf community but an instructional mechanism developed to teach it the structure of English so that individuals with hearing impairments may read and write it. Some members of the deaf community learn to do so effectively. American Sign Language is the true language of the deaf community. U.S. federal law requires the use of an official interpreter to communicate with persons who choose to receive informed consent and other important medical information in their own language.
o The patient’s preferred language for verbal and written communication. Patients may speak a language quite well without being able to read it effectively. Discharge self-care and follow-up information must be communicated and reinforced with written information that the patient can use. The nurse can no longer assume that it is the patient’s responsibility to grasp the information that is being provided. In recognition of the vast array of cultures and physical challenges that patients face, it is the nurse’s responsibility to communicate effectively.
o Ability to understand written words, pictures, gestures. In some cases the only way to be certain that communication has been effective is to arrange for a certified interpreter to validate information from both sides of the dialogue.
* Assess conditions or situations that may hinder the patient’s ability to use or understand language, such as the following:
o Alternate airway (e.g., tracheostomy, oral or nasal intubation). When air does not pass over vocal cords, sounds are not produced.
o Orofacial/maxillary problems (e.g., wired jaws). Words are articulated by coordinated movement of mouth and tongue; when movement is impinged, communication may be ineffective.
* Assess for presence of expressive aphasia (inability to convey information verbally) and receptive aphasia (i.e., word meaning may be scrambled during the processing of information by the patient’s brain).
* Assess for presence and history of dyspnea. Patients who are experiencing breathing problems may reduce or cease verbal communication that may complicate their respiratory efforts.
* Assess energy level. Fatigue and/or shortness of breath can make communication difficult or impossible.
* Assess knowledge of patient’s, family’s, or caregiver’s understanding of sign language, as appropriate. Individuals who have no formal training in sign language usually develop mechanisms for communication; but since communication is such a critical aspect of everyone’s life, consider formal training for patient and caregivers to enhance communication.

Therapeutic Interventions

* Assist the patient in seeking an evaluation of his or her home and work settings. This will evaluate the need for things such as assistive devices, talking computers, telephone typing device, and interpreters.
* Anticipate patient needs and pay attention to nonverbal cues. The nurse should set aside enough time to attend to all of the details of patient care. Care measures may take longer to complete in the presence of a communication deficit.
* Place important objects within reach. This maximizes patient’s sense of independence.
* Provide alternate means of communication for times when interpreters are not available (e.g., a phone contact who can interpret the patient’s needs).
* Encourage patient’s attempts to communicate; praise attempts and achievements.
* Listen attentively when patient attempts to communicate. Clarify your understanding of the patient’s communication with the patient or an interpreter.
* Never talk in front of patient as though he or she comprehends nothing. This will prevent increasing the patient’s sense of frustration and feelings of helplessness.
* Keep distractions such as television and radio at a minimum when talking to patient. This will keep patient focused, decrease stimuli going to the brain for interpretation, and enhance the nurse’s ability to listen.
* Do not speak loudly unless patient is hearing-impaired. Loud talking does not improve the patient’s ability to understand if the barriers are primary language, aphasia, or a sensory deficit.
* Maintain eye contact with patient when speaking. Stand close, within patient’s line of vision (generally midline). Patients may have defect in field of vision or may need to see the nurse’s face or lips to enhance understanding of what is being communicated.
* Give the patient ample time to respond. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations.
* Praise patient’s accomplishments. Acknowledge his or her frustrations. The inability to communicate enhances a patient’s sense of isolation and may promote a sense of helplessness.
* If the patient’s ability to speak is limited to yes and no answers, try to phrase questions so that the patient can use these responses.
* Use short sentences and ask only one question at a time. This allows the patient to stay focused on one thought.
* Speak slowly and distinctly, repeating key words to prevent confusion. Supplement verbal communication with meaningful gestures. This provides the patient with more channels through which information can be communicated.
* Give concrete directions that the patient is physically capable of doing (e.g., "point to the pain," "open your mouth," and "turn your head").
* Avoid finishing sentences for the patient. Allow the patient to complete his or her sentence and thought; but if the patient appears to be having difficulty, ask the patient for permission to help them. Say the word or phrase slowly and distinctly if help is requested. Be calm and accepting during attempts; do not say you understand if you do not. This may increase frustration and decrease the patient’s trust in you.
* When patient has difficulty with verbal expressions, support the work the patient is doing in speech therapy by providing practice sessions often throughout the day. Begin with simple words (e.g., "yes," "no," "this is a cup"), then progress.
* When patient cannot identify objects by name, give practice in receiving word images (e.g., point to an object and clearly enunciate its name: "cup" or "pen").
* Correct errors. Not correcting errors reinforces undesirable performance, and will make correction more difficult later.
* Provide a list of words patient can say; add new words to it. Share this list with family, significant others, and other care providers. This broadens the group of people with whom the patient can communicate.
* Provide patient with word-and-phrase cards, writing pad and pencil, or picture board. This is especially helpful for intubated and tracheal patients or those whose jaws are wired.
* Carry on a one-way conversation with a totally aphasic patient. It may not be possible to determine what information is understood by the patient, but it should not be assumed that the patient understands nothing about his or her environment.
* Consult a speech therapist for additional help. See that patient is well-rested before each session with the speech therapist. Fatigue may have an adverse effect on learning ability.
* Consider use of electronic speech generator in postlaryngectomy patients.

Education/Continuity of Care

* Inform patient, significant other, or caregiver of the type of aphasia the patient has and how it affects speech, language skills, and understanding. Many family members assume that a patient’s mentation has been affected by a brain injury; this may or may not be true, and if true, some of the effects may be amenable to remediation.
* Offer significant others the opportunity to ask questions about patient’s communication problem. It is important for the family to know that there are many ways to send information to someone and that time may be needed to understand the special needs of the patient.
* Provide answers and helpful suggestions for what is known while not providing false assurances.
* Encourage family member/caregiver to talk to patient even though patient may not respond. This decreases patient’s sense of isolation and may assist in recovery from aphasia.
* Encourage patient to socialize with family and friends. Communication should be encouraged despite impairment.
* Explain that brain injury decreases attention span.
* Suggest that the family engage the patient often throughout the day for short periods. Encourage the family to look for cues that the patient is overstimulated or fatigued.
* Provide patient with an appointment with a speech therapist, if not already done.
* Inform patient and significant others to seek information about aphasia from the American Speech-Language-Hearing Association, 10810 Rockwell Pike, Rockville, MD 20852.
* Deaf patients and their families should be referred to their local hearing society for community support, education, and sign language training.