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Nursing Diagnosis: Impaired verbal [and/or written] Communication May be related to: Impaired cerebral circulation; neuromuscular impairment,

loss of facial or oral muscle tone and control; generalized weakness and fatigue Cause Analysis: The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Brocas area. It is located in a convolution adjoining the middle cerebral artery. This area is responsible for control of the combinations of muscular movements needed to speak each word. Brocas area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients who are paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1908) Cues Objective Cues Impaired articulation; soft speech or does not or cannot speak Inability to modulate speech, find and name words, identify objects; inability to comprehend written or spoken language, global Aphasia Inability to produce written communication, expressive aphasia Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Be able Indicate understanding of the communication problems. Long-term Objective Within 3 days of providing nursing interventions, the client will: Establish method of communication in which needs can be expressed. Use resources appropriately. Differentiate aphasia from dysarthria. Independent Assess type and degree of dysfunction, such as receptive aphasiaclient does not seem to understand words, or expressive aphasiaclient has trouble speaking or making self understood: Helps determine area and degree of brain involvement and difficulty client has with any or all steps of the communication process. Client may have trouble understanding spoken words (damage to Wernickes speech area), speaking words correctly (damage to Brocas speech areas), or may experience damage to both areas. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components, such as inability to comprehend written or spoken words or to write, make signs, and speak. A dysarthric person can understand, read, and write language, but has difficulty forming or pronouncing words because of weakness and paralysis of oral musculature, resulting in softly spoken speech. Client may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps client realize why caregivers are not understanding and responding appropriately and provides opportunity to clarify content and meaning. Tests for receptive aphasia. Nursing Interventions Rationale

Listen for errors in conversation and provide feedback.

Ask client to follow simple commands, such as Shut your eyes, Point to the door; repeat simple words or sentences. Point to objects and ask client to name them. Have client produce simple sounds, such as sh, cat.

Tests for expressive aphasiaclient may recognize item but not be able to name it. Identifies dysarthria because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia. Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when client is unable to use regular call system. Provides for communication of needs or desires based on individual situation or underlying deficit.

Ask client to write name and/or a short sentence. If unable to write, have client read a short sentence. Post notice at nurses station and clients room about speech impairment. Provide special call bell if necessary.

Provide alternative methods of communication, such as writing or felt board and pictures. Provide visual cluesgestures, pictures, needs list, and demonstration. Anticipate and provide for clients needs.

Helpful in decreasing frustration when dependent on others and unable to communicate desires. Reduces confusion and anxiety at having to process and respond to large amount

Talk directly to client, speaking slowly and distinctly. Use yes/no questions to start, progressing in complexity as client responds.

of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word and idea association. Client is not necessarily hearing impaired and raising voice may irritate or anger client. Forcing responses can result in frustration and may cause client to resort to automatic speech, such as garbled speech and obscenities. It is important for family members to continue talking to client to reduce clients isolation, promote establishment of effective communication, and maintain sense of connectedness with family. Promotes meaningful conversation and provides opportunity to practice skills.

Speak with normal volume and avoid talking too fast. Give client ample time to respond. Talk without pressing for a response.

Encourage SO and visitors to persist in efforts to communicate with client, such as reading mail and discussing family happenings even if client is unable to respond appropriately.

Discuss familiar topicsjob, family, hobbies, and current events. Respect clients preinjury capabilities; avoid speaking down to client or making patronizing remarks.

Enables client to feel esteemed because intellectual abilities often remain intact.

Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits and therapy needs. Collaborative Consult with or refer to speech therapist.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p246-247