Communication in Special Situations

Box 4-6 Nursing Interventions for Patients With Impaired Verbal Communication

1.Determine language spoken; obtain language dictionary or interpreter if possible and accepted by the patient.
2.Listen carefully. Validate verbal and nonverbal expression, particularly when dealing with pain.
3.Anticipate patient’s needs until effective communication is possible.
4.Use simple communication; speak in a well-modulated voice, smile, and show concern for the patient.
5.Maintain eye contact at patient’s level and read patient’s eyes as able, if culturally appropriate.
6.Use touch as appropriate, if culturally appropriate. Holding a patient’s hand or stroking the arm is a simple, unobtrusive way of showing empathy and concern.
7.Spend time with the patient, allow time for responses, and make the call light readily available.
8.Explain all health care procedures.
9.Determine the patient’s literacy status.
10.Obtain communication equipment such as electronic devices, letter boards, picture boards, and magic slates as indicated.
11.With an individualized approach, establish an alternative method of communication such as writing or pointing to letters, words, phrases, picture cards, or simple drawings of basic needs.
12.If there is a comprehension deficit, keep environment quiet when communicating and get the patient’s attention before attempting to communicate (e.g., touch patient’s shoulder, call patient’s name).
13.Give praise for progress noted. Ignore mistakes and watch for frustration or fatigue.
14.Never raise your voice or shout at a patient.
15.Be persistent in deciphering what the patient is saying, and do not pretend to understand when the message is unclear.

Modified from Ackley BJ, Ladwig GB: Nursing diagnosis handbook: An evidence-based guide to planning care, ed. 9, St. Louis, 2011, Mosby.

communication. Does the patient appear to have received the message, and is the patient satisfied with it, or not? If the expected outcomes have been achieved but the impairment is ongoing, the nurse should continue with the current plan of care. If the impairment no longer exists, on the other hand, the nurse may consider the nursing diagnosis resolved. If the outcomes have not been met, the nurse must reexamine the phases of the nursing process to determine what revisions are necessary.

Communication in Special Situations

The communication techniques discussed thus far are generally applicable to any type of nurse-patient interaction. Some patients have unique communication needs. Three examples of such situations follow.

Patients with Ventilator Dependence

Patients who receive mechanical ventilation via endotracheal tube or tracheostomy experience an inability to speak because the trachea is obstructed by the tube. Patients often find this inability to speak devastating, and it often disrupts their sense of well being and control. When the patient is unable to produce sound, it is essential to identify and implement alternative methods of communication.

To determine which communication method is most appropriate, the nurse should carefully assess the patient’s ability (e.g., cognitive level, literacy, visual acuity, consciousness level, primary language, gross motor skills, and fine motor skills) to use a particular alternative. One valuable tool is a communication board. Depending on the patient’s literacy, a communication board includes the alphabet, commonly used phrases, pictures, or a combination of all three. If able to point, the patient points to pictures or phrases on the board to communicate a need or thought. If the desired picture or phrase is not on the board, the patient points to the letters that spell out the message. This method is not feasible for the patient who does not read or cannot see well enough to select from the board.

If the patient is unable to move well enough to point, alternative selection methods are necessary. Possibilities include setting up a “signal” system, such as one eye blink for “yes” and two blinks for “no.” The receiver (e.g., the nurse or a family member) systematically points to items or letters on the board, and the patient “signals” when the correct item is selected. This is a slow and rather cumbersome process for communicating and requires patience on the part of both the patient and the receiver of the message. In many cases, it is also very tiring for the patient. Nevertheless, it has the potential to be a helpful tool when no other means of communicating is available or feasible. Box 4-7 lists additional alternative methods of communication to use with the patient who is unable to speak.

Box 4-7 Alternative Methods of Communicating With Patients Who Are Unable to Speak

•Lip reading: Patient mouths words to be interpreted by the receiver.
•Sign language: Hand and finger signals used to indicate letters; used throughout the world for hearing-impaired patients.
•Paper and pencil or magic slate: Patient writes messages to communicate needs.
•Picture board: Patient points to pictures on a board or poster of typical patient needs.
•Word or picture cards: 3 × 5 cards with words or pictures on them; patient picks appropriate card or sorts cards into short phrases or sentences.
•Magnetic boards with plastic letters: Patient moves letters around on board to spell words or phrases.
•Eye blinks: Predetermined system in which the number of times a patient blinks in response to a question indicates yes or no answer.
•Computer-assisted communication: Patient uses keyboard to type messages.
•Clock face communicator: Messages placed at intervals around the clock face; clock hand scans the messages, and the patient presses a button to stop the hand on the desired message.

Patients with Aphasia

Aphasia is a deficient or absent language function that results from ischemic insult to the brain, such as stroke (cerebrovascular accident), brain trauma, or anoxia. Some patients experience expressive aphasia, in which they are unable to send the desired verbal message; and some suffer receptive aphasia, or an inability to recognize or interpret the verbal message being received. Communication methods recommended for the patient with aphasia are summarized in Box 4-8.

Unresponsive Patients

It is not certain whether, or how much, the unresponsive patient is able to hear or interpret verbal stimuli. Some patients, after regaining consciousness, have reported hearing actual statements that were made in the room while the patient was still in an unconscious state. Because of this, anyone interacting with the unresponsive patient must assume that all sound and verbal stimuli have the potential of being heard by the patient. Caution people nearby about making negative or anxiety-producing statements. Encourage health care providers, and family and friends, to speak to the

Box 4-8 Communicating With Patients With Aphasia

•Listen to the patient, and wait for the patient to communicate.
•Do not shout or speak loudly (hearing loss is not the problem).
•If the patient has problems with comprehension, use simple short questions and facial gestures to give additional clues.
•Speak of things familiar and of interest to the patient.
•If the patient has problems speaking, ask questions that require simple yes or no answers or blinking of the eyes. Offer pictures or a communication board the patient can point to.
•Give the patient time to understand; be calm and patient; do not pressure or tire the patient.
•Avoid patronizing and childish phrases.
•Collaborate with a speech pathologist.
•Encourage the patient to speak as much as possible, not to provide just yes or no answers.
•Use communication aids (see Box 4-7).

Modified from Potter PA, Perry AG: Fundamentals of nursing, ed. 8, St. Louis, 2013, Mosby.

unresponsive individual as if he or she were awake. This sometimes feels awkward, and family members and friends in particular often need support and encouragement to talk with the patient as they would have before the illness or accident. Talking about daily activities and reading books, cards, and newspapers is beneficial. Also, the LPN/LVN should always explain to the patient any procedure or activity that involves the patient. The nurse must remember not to have conversations with other health care providers about topics that do not place the patient at the center of the discussion or that might cause stress or anxiety if the patient were to hear it.