- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Brain injury that adversely affects the transmission, reception or interpretation of language or other forms of communication
- Structural problem such as cleft palate, laryngectomy, tracheostomy, intubation or wired jaws
- Cultural difference (e.g., speaks different language)
- Dyspnea
- Fatigue
- Patient has sensory challenge involving hearing or vision.
As evidenced by: [Check those that apply]
- IInability 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
Patient’s Diagnosis: –
Date:-
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- use a form of communication to get needs met and to relate effectively with persons and his or her environment.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess conditions or situations that may hinder the patient's ability to use or understand language (e.g., tracheostomy, oral or nasal intubation). | When air does not pass over vocal cords, sounds are not produced. |
| 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, family, or caregiver 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. |
| Assist the patient in seeking an evaluation of their home and work setting. | To evaluate the need for assistive devices, talking computers, telephone typing device, interpreters, and others. |
| 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. | To maximize patient's sense of independence. |
| Never talk in front of patient as though he or she comprehends nothing. | This increases the patient's sense of frustration and feelings of helplessness. |
| Keep distractions such as television and radio at a minimum when talking to patient. | To 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 they may need to see the nurses' face or lips to enhance their 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. |
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