Communication, Impaired Verbal
Deidra Gradishar, RNC, BS
NANDA: The state in which an individual experiences a decreased
or absent ability to use or understand language in human interaction
Human communication takes many forms. Persons communicate
verbally through the vocalization of a system of sounds that has been
formalized into a language. They communicate using body movements to
supplement, emphasize or even alter what is being verbally communicated. In
some cases, such as American Sign Language (the formal language of the deaf
community) or Signed English, communication is conducted entirely through hand
gestures that may or may not be accompanied by body movements and pantomime.
Language can be read by watching an individual's lips to observe words as they
are shaped. Humans communicate through touch, intuition, written means, art and
sometimes a combination of all of the mechanisms listed above. Communication
implies the sending of information as well as the receiving of information.
When communication is received it ceases to be the sole product of the sender
as the entire experiential history of the receiver takes over and interprets
the information sent. At its best, effective communication involves a dialogue
that not only involves the transmission of information but also clarification
of points made, expansion of ideas and concepts and exploration of factors that
fall out of the original thoughts transmitted. Communication is a multifaceted
kinetic, reciprocal process. Communication may be impaired for any number of
reasons but rarely are all avenues for communication compromised at one time.
The task for the nurse, whether encountering the patient in the hospital or in
the community, becomes recognizing when communication has become ineffective
and then using strategies to improve transmission of information.
- 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)
- Patient has sensory challenge involving hearing or vision.
- Inability 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 is able to use a form of communication to get needs met
and to relate effectively with persons and his or her environment.
- (i) independent
- (i) Assess the following:
- The patient's primary and preferred means of communication
(i.e., verbal, written, gestures)
- Ability to understand spoken word
- It is important for health care workers to understand
that the construct of gestured language has an entirely different structure
from verbal and written English. Signed English is not the true language of the
deaf community but an instructional mechanism developed to teach it the
structure of English so that individuals with hearing impairments may read and
write it. Some members of the deaf community learn to do so effectively.
American Sign Language is the true language of the deaf community. U.S. Federal
law requires the use of an official interpreter to communicate with persons who
choose to receive informed consent and other important medical information in
their own language.
- The patient's preferred language for verbal and written
- Patients may speak a language quite well without being
able to read it effectively. Discharge self-care and follow-up information must
be communicated and reinforced with written information that the patient can
use. The nurse can no longer assume that it is the patient's responsibility to
grasp the information that is being provided. In recognition of the vast array
of cultures and physical challenges that patients face, it is the nurse's
responsibility to communicate effectively.
- Ability to understand written words, pictures, gestures
- In some cases the only way to be certain that
communication has been effective is to arrange for a certified interpreter to
validate information from both sides of the dialogue.
- (i) Assess conditions or situations that may
hinder the patient's ability to use or understand language, such as the
- Alternate airway (e.g., tracheostomy, oral or nasal
- When air does not pass over vocal cords, sounds are not
- Orofacial/maxillary problems (e.g., wired jaws).
- Words are articulated by coordinated movement of mouth
and tongue and when movement is impinged, communication may be
- (i) Assess for presence of expressive aphasia
(inability to convey information verbally) and receptive aphasia (i.e., word
meaning may be scrambled during the processing of information by the patient's
- (i) Assess for presence and history of
- Patients who are experiencing breathing problems may reduce
or cease verbal communication that may complicate their respiratory
- (i) Assess energy level.
- Fatigue and/or shortness of breath can make communication
difficult or impossible.
- (i) Assess knowledge of patient's,
family's, or caregiver's 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.
- (i) independent
- (i) 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.
- (i) 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.
- (i) Place important objects within
- To maximize patient's sense of independence.
- (i) Provide alternate means of communication
for times when interpreters are not available, for instance, a phone contact
who can interpret the patient's needs.
- (i) Encourage patient's attempts to
communicate; praise attempts and achievements.
- (i) Listen attentively when patient
attempts to communicate. Clarify your understanding of the patient's
communication with the patient or an interpreter.
- (i) 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.
- (i) 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.
- (i) Do not speak loudly unless patient is
- Loud talking does not improve the patient's ability to
understand if the barriers are primary language, aphasia, or a sensory
- (i) Maintain eye contact with patient when
speaking. Stand close, within patient's line of vision (generally
- 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
- (i) Give the patient ample time to
- 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.
- (i) 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.
- (i) If the patient's ability to speak is
limited to yes and no answers, try to phrase questions so that the patient can
use these responses.
- (i) Use short sentences and ask only one
question at a time.
- This allows the patient to stay focused on one
- (i) Speak slowly and distinctly, repeating
key words to prevent confusion. Supplement verbal communication with meaningful
- This provides the patient with more channels through which
information can be communicated.
- (i) Give concrete directions that the
patient is physically capable of doing (e.g., "Point to the pain," "open your
mouth," "turn your head," and others).
- (i) Avoid finishing sentences for the
patient. Allow the patient to complete his or her sentence and thought, but if
the patient appears to be having difficulty, ask the patient for permission to
help them. Say the word or phrase slowly and distinctly if help is requested.
Be calm and accepting during attempts; do not say you understand if you do
- For this may increase frustration and decrease the
patient's trust in you.
- (i) When patient has difficulty with
verbal expressions, support the work the patient is doing in speech therapy by
providing practice sessions often throughout the day. Begin with simple words,
then progress (e.g., "yes," "no," "this is a cup," and others).
- (i) When patient cannot identify objects
by name, give practice in receiving word images (e.g., point to an object and
clearly enunciate its name: "cup" or "pen").
- (i) Correct errors.
- Not correcting errors reinforces undesirable performance,
and will make correction more difficult later.
- (i) Provide a list of words patient can
say; add new words to it. Share this list with family, significant others, and
other care providers
- To broaden the group with whom the patient can
- (i) Provide patient with word-and-phrase
cards, writing pad and pencil, or picture board.
- This is especially helpful for intubated and tracheal
patients or those whose jaws are wired.
- (i) Carry on a one-way conversation with a
totally aphasic patient.
- It may not be possible to determine what information is
understood by the patient, but it should not be assumed that the patient
understands nothing about his or her environment.
- (c) Consult a speech therapist for
additional help. See that patient is well-rested before each session with
- Fatigue may have an adverse effect on learning
- (c) Consider use of electronic speech
generator in postlaryngectomy patients.
Education/Continuity of Care
- (i) independent
- (i) Inform patient, significant other, or
caregiver of the type of aphasia the patient has and how it affects speech,
language skills, and understanding.
- Many family members assume that a patient's mentation has
been affected by a brain injury; this may or may not be true, and if true, some
of the effects may be amenable to remediation.
- (i) Offer significant others the
opportunity to ask questions about patient's communication problem.
- Provide answers and helpful suggestions for what is known
while not providing false assurances. It is important for the family to know
that there are many ways to send information to someone and that time may be
needed to understand the special needs of the patient.
- (i) Encourage family member/caregiver to
talk to patient even though patient may not respond.
- Decreases patient's sense of isolation and may assist in
recovery from aphasia.
- (i) Encourage patient to socialize with
family and friends.
- Communication should be encouraged despite
- (i) Explain that brain injury decreases
- Suggest that the family engage the patient often throughout
the day for short periods. Encourage the family to look for cues that the
patient is overstimulated or fatigued.
- (c) Provide patient with an appointment
with a speech therapist, if not already done.
- (i) Inform patient and significant others
to seek information about aphasia from the American Speech-Language-Hearing
Association, 10810 Rockwell Pike, Rockville, MD 20852.
- (i) Deaf patients and their families
should be referred to their local hearing society for community support,
education, and sign language training.
Active Listening; Communication Enhancement: Hearing Deficit;
Communication Enhancement: Speech Deficit
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