Nursing Dx

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize or indicate an understanding of the communication difficulty and plans for ways of handling.
• Establish method of communication in which needs can be expressed.
• Participate in therapeutic communication (e.g., using silence, acceptance, restating reflecting, Active-listening, and Imessages).
• Demonstrate congruent verbal and nonverbal communication.
• Use resources appropriately.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Review history for neurological conditions that could affect speech, such as CVA, tumor, multiple sclerosis, hearing loss, and so forth.
• Note results of neurological testing such as electroencephalogram (EEG), computed tomography (CT) scan.
• Note whether aphasia is motor (expressive: loss of images for articulated speech), sensory (receptive: unable to understand words and does not recognize the defect), conduction (slow comprehension, uses words inappropriately but knows the error), and/or global (total loss of ability to comprehend and speak). Evaluate the degree of impairment.
• Evaluate mental status, note presence of psychotic conditions (e.g., manic-depressive, schizoid/affective behavior). Assess psychological response to communication impairment, willingness to find alternate means of communication.
• Note presence of ET tube/tracheostomy or other physical blocks to speech (e.g., cleft palate, jaws wired).

• Assess environmental factors that may affect ability to communicate (e.g., room noise level).
• Determine primary language spoken and cultural factors.
• Assess style of speech (as outlined in Defining Characteristics).
• Note level of anxiety present; presence of angry, hostile behavior; frustration.
• Interview parent to determine child’s developmental level of speech and language comprehension.
• Note parent’s speech patterns and manner of communicating with child, including gestures.

NURSING PRIORITY NO. 2. To assist client to establish a means of communication to express needs, wants, ideas, and questions:
• Determine ability to read/write. Evaluate musculoskeletal states, including manual dexterity (e.g., ability to hold a pen and write).
• Obtain a translator/written translation or picture chart when writing is not possible.
• Facilitate hearing and vision examinations/obtaining necessary aids when needed/desired for improving communication. Assist client to learn to use and adjust to aids.
• Establish relationship with the client, listening carefully and attending to client’s verbal/nonverbal expressions.
• Maintain eye contact, preferably at client’s level. Be aware of cultural factors that may preclude eye contact (e.g., some American Indians).
• Keep communication simple, using all modes for accessing information: visual, auditory, and kinesthetic.
• Maintain a calm, unhurried manner. Provide sufficient time for client to respond. Individuals with expressive aphasia may talk more easily when they are rested and relaxed and when they are talking to one person at a time.
• Determine meaning of words used by the client and congruency of communication and nonverbal messages.
• Validate meaning of nonverbal communication; do not make assumptions, because they may be wrong. Be honest; if you do not understand, seek assistance from others.
• Individualize techniques using breathing for relaxation of the vocal cords, rote tasks (such as counting), and singing or melodic intonation to assist aphasic clients in relearning speech.
• Anticipate needs until effective communication is reestablished.
• Plan for alternative methods of communication (e.g., slate board, letter/picture board, hand/eye signals, typewriter/ computer) incorporating information about type of disability present.

• Identify previous solutions tried/used if situation is chronic or recurrent.
• Provide reality orientation by responding with simple, straightforward, honest statements.
• Provide environmental stimuli as needed to maintain contact with reality; or reduce stimuli to lessen anxiety that may worsen problem.
• Use confrontation skills, when appropriate, within an established nurse-client relationship to clarify discrepancies between verbal and nonverbal cues.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review information about condition, prognosis, and treatment with client/SO(s). Reinforce that loss of speech does not imply loss of intelligence.
• Discuss individual methods of dealing with impairment.
• Recommend placing a tape recorder with a prerecorded emergency message near the telephone. Information to include: client’s name, address, telephone number, type of airway, and a request for immediate emergency assistance.
• Use and assist client/SO(s) to learn therapeutic communication skills of acknowledgment, Active-listening, and Imessages. Improves general communication skills.
• Involve family/SO(s) in plan of care as much as possible. Enhances participation and commitment to plan.
• Refer to appropriate resources (e.g., speech therapist, group therapy, individual/family and/or psychiatric counseling).
• Refer to NDs ineffective Coping; disabled family Coping (as indicated); Anxiety; Fear.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/pertinent history information (i.e., physical/ psychological/cultural concerns).
• Meaning of nonverbal cues, level of anxiety client exhibits.
PLANNING
• Plan of care and interventions (e.g., type of alternative communication/translator).
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care

DISCHARGE PLANNING
• Discharge needs/referrals made, additional resources available.