Nursing Dx

communication, and identifying specific needs/expectationshelps in developing realistic goals and determining likelihood of success.

• Evaluate mental status. Disorientation and psychotic conditionsmay be affecting speech and the communication ofthoughts, needs, and desires.

• Determine client’s developmental level of speech and language comprehension. Provides baseline information fordeveloping plan for improvement.

• Determine ability to read/write. Evaluating grasp of language as well as musculoskeletal states, including manual dexterity (e.g., ability to hold a pen and write), provides informationabout nature of client’s situation. Educational plan canaddress language skills. Neuromuscular deficits will requireindividual program to correct.

• Determine country of origin, dominant language, whetherclient is recent immigrant and what cultural, ethnic groupclient identifies as own. Recent immigrant may identify withhome country, and its people, language, beliefs, and healthcarepractices affecting desire to learn language and improveability to interact in new country.

• Ascertain if interpreter is needed/desired. Law mandates thatinterpretation services be made available. Trained, professionalinterpreter who translates precisely and possesses abasic understanding of medical terminology and healthcareethics is preferred to enhance client and provider satisfaction.

• Determine comfort level in expression of feelings andconcepts in nonproficient language. Anxiety about languagedifficulty can interfere with ability to communicate effectively.

• Note any physical barriers to effective communication (e.g.,talking tracheostomy, wired jaws) or physiological/neurologicalconditions (e.g., severe shortness of breath, neuromuscularweakness, stroke, brain trauma, hearing impairment, cleft palate, facial trauma). Client may be dealing withspeech/language comprehension or have voice productionproblems (pitch, loudness, or quality)that call attention tovoice rather than what speaker is saying. These barriers willneed to be addressed to enable client to improve communicationskills.

• Clarify meaning of words used by the client to describeimportant aspects of life and health/well-being (e.g., pain,sorrow, anxiety). Words can easily be misinterpreted whensender and receiver have different ideas about their meanings. This can affect the way both client and caregiver communicateimportant concepts. Restating what one has heardcan clarify whether an expressed statement has been understoodor misinterpreted.

• Evaluate level of anxiety, frustration, or fear; presence of angry,hostile behavior. Emotional/psychiatric issues can affect communicationand interfere with understanding.

• Evaluate congruency of verbal and nonverbal messages. It isestimated that 65% to 95% of communication is nonverbal,and communication is enhanced when verbal and nonverbalmessages are congruent.

• Determine lack of knowledge or misunderstanding of terms related to client’s specific situation. Indicators of need for additional information, clarification to help client improve ability to communicate.

• Evaluate need/desire for pictures or written communications and instructions as part of treatment plan. Alternative methods of communication can help client feel understood and promote feelings of satisfaction with interaction.

NURSING PRIORITY NO. 2. To improve client’s ability to communicate thoughts, needs, and ideas:
• Maintain a calm, unhurried manner. Provide sufficient time for client to respond. An atmosphere in which client is free to speak without fear of criticism provides the opportunity to explore all the issues involved in making decisions to improve communication skills.
• Pay attention to speaker. Be an active listener. The use of Active-listening communicates acceptance and respect for the client, establishing trust and promoting openness and honest expression. It communicates a belief that the client is a capable and competent person.
• Sit down, maintain eye contact, preferably at client’s level, and spend time with the client. Conveys message that the nurse has time and interest in communicating.
• Observe body language, eye movements, and behavioral clues. May reveal unspoken concerns, for example, when pain is present, client may react with tears, grimacing, stiff posture, turning away, and angry outbursts.
• Help client identify and learn to avoid use of nontherapeutic communication. These barriers are recognized as detriments  to open communication, and learning to avoid them maximizes the effectiveness of communication between client and others.
• Establish hand/eye signals if indicated. Neurological impairments may allow client to understand language but not be able to speak and/or may have a physical barrier to writing.

• Obtain interpreter with language or signing abilities as needed. May be needed to enhance understanding of words, language concepts, or needs to promote accurate interpretation of communication.
• Suggest use of pad and pencil, slate board, letter/picture board, if indicated.When client has physical impairments that interfere with spoken communication, alternate means can provide concepts that are understandable to both parties.
• Obtain/provide access to typewriter/computer. Use of these devices may be more helpful when impairment is longstanding or when client is used to using them.
• Respect client’s cultural communication needs. Different cultures can dictate beliefs of what is normal or abnormal (i.e., in some cultures, eye-to-eye contact is considered disrespectful, impolite, or an invasion of privacy; silence and tone of voice have various meanings, and slang words can cause confusion).
• Provide glasses, hearing aids, dentures, electronic speech devices as needed. These devices maximize sensory perception and can improve understanding and enhance speech patterns.
• Reduce distractions and background noises (e.g., close the door, turn down the radio/TV). A distracting environment can interfere with communication, limiting attention to tasks and making speech and communication more difficult. Reducing noise can help both parties hear clearly, improving understanding.
• Associate words with objects using repetition and redundancy, point to objects, or demonstrate desired actions. Speaker’s own body language can be used to enhance client’s understanding when neurological conditions result in difficulty understanding language.
• Use confrontation skills carefully when appropriate, within an established nurse-client relationship. Can be used to clarify discrepancies between verbal and nonverbal cues, enabling client to look at areas that may require change.

NURSING PRIORITY NO. 3. To promote optimum communication:
• Discuss with family/SO and other caregivers effective ways in which the client communicates. Identifying positive aspects of current communication skills enables family members to learn and move forward in desire to enhance ways of interacting.
• Encourage client and family use of successful techniques for communication, whether it is speech/language techniques or alternate modes of communicating. Enhances family relationships and promotes self-esteem for all members as they are able to communicate clearly regardless of the problems that have interfered with ability to interact.
• Reinforce client/SO(s) learning and use of therapeutic communication skills of acknowledgment, Active-listening, and I-messages. Improves general communication skills, emphasizes acceptance, and conveys respect, enabling family relationships to improve.
• Refer to appropriate resources (e.g., speech therapist, language classes, individual/family and/or psychiatric counseling). May need further assistance to overcome problems that are preventing family from reaching desired goal of enhanced communication.

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
• Progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge needs/referrals made, additional resources available.