Impaired verbal communication.

CVA
Dementia
Said “what” after physical therapist continuously repeated her name
Primary nurse reported hearing her say “yes” and “no”
Moans when in pain
Closes her eyes when someone is looking at her.


Impaired communication r/t cognitive impairment

Cognitive impairment is any disorder that impairs cognitive functioning. It may affect the ability to use and understand language. The total loss of speech, impaired articulation, or the inability to find or name words may develop. It can also alter the ability to send, receive, or comprehend messages. When an individual experiences a decrease, delayed, or absent ability to receive process, transmit and use a system of symbols. Communication is impaired. According to Carpenito impaired communication is thestate in which an individual experiences or is at high risk to experience difficulty exchanging thoughts, ideas, desires, wants, or needs with others
Ms. CR had dementia and a history of CVA. Brain damage due to both of the diseases can impair communication. Pt. doesn’t verbalize her wishes and desires. She is able to articulate simple words, however really does so.
Pt. will use alternative method of communication WIMC.

1.Assess mental status
2. Assess developmental level.
3.. Assess pts. anxiety level
4.Establish Rapport
5.Maintain therapeutic
communication
5a. Using silence
5b. Using touch
5c. paraphrasing
5d. Offering self
5e. Listen attentively to pt.
5f. Offer support to pt. and caregiver
6. Identify alternative method of communication.
7. Refer pt. to speech therapy.

1. It reveals the clients general cerebral function. The functions it includes are intellectual and emotional.
(Kozier pg 642)
2. According to Erickson the developmental stage is adulthood and the task at this time is generativity VS stagnation. Those that achieve generativity are creative, productive, and concerned for others. Those that are in stagnation are self indulgence, self concern, with lack of interests and commitments.
(Kozier pg 353)
3. A person with mild anxiety can learn to alter lifestyle habits, more severe anxiety can be paralyzing. Pts. experiencing anxiety may be worried and therefore unable to focus on complete essential self care activities.
(Brunner pg 116)
4. It is an understanding between two people. It allows the client to have control over the communication, the purpose, subject matter, and pacing. It is an appropriate approach to gain information. It is a process of establishing good will and trust.
( Kozier pg 183 & 186)
5. It promotes understanding and can help establish a constructive relationship between the nurse and the client.
(Kozier pg 467)
5a.Allows the pt. to put thoughts together.
(Kozier pg 469)
5b. Providing appropriate touch reinforces caring feelings.
(Kozier pg 469)
5c.This conveys that the nurse has listened and understood the client’s basic message and also offers client’s a clearer idea what they have said.( Kozier pg 469)
5d. Suggesting your presence will allow you to understand the pt. without making any demands. (#6, 469)
5e. Allows you to pay attention to the total message, both verbal and nonverbal. It allows you to absorb both the content and the feelings the person is conveying. You listen to the pts. needs. It encourages pt. to communicate
(Kozier pg 468)
5f. It enhances exploration of feelings and let the clients and their caregivers know that the nurse acknowledge their feelings.
(Kozier pg 1089)
6. To determine how the pt. best receive messages i.e. by listening, looking, through touch, or an interpreter. It is often helpful to use alternative communication strategies such as word boards, pictures, or paper pencil.
(Kozier pg 479)
7. Speech therapy would be able to do their own assessment and establish a system of communication.
(Brunner pg 612)

1. Patient is alert and responds to her name. I was unable to establish orientation to time and place due to patient’s inability to communicate.
2. I assessed developmental to be older adult. Developmental task is integrity vs. despair. Pt. appears to be in despair. She understands simple statements and is able to articulate at least some words. (she said “what” after physical therapist continuously repeated her name) however, it appears she doesn’t want to communicate her wishes and doesn’t wish to respond to questions in other way.
3. Pt sees to be angry and wishes to be left alone. Was unable to assess emotional further due to lack of verbal communication.
4. I attempted to establish rapport by using therapeutic communication, however patient refused to communicate with me. It appears I was able to improve rapport on a second day. Patient closed her eyes as soon as she saw hospital stuff looking at her, however she kept her eyes opened when I was with her alone with curtain closed
5. I maintained therapeutic communication.
5a. I asked the pt how she is feeling and waited for response. She didn’t answer so I started asking more direct questions, such as “Does anything hurt you”
5b. I touched pt’s arm when talking to her. She didn’t pull her arm away when I touched her.
5c. Pt wasn’t talking to me, however I reacted to her actions by asking her questions about reason she does this. For example when she pulled her nasal cannula, I asked her if it feels uncomfortable and then expected nasal cannula and noticed it was too tight.
5d. I let her know that I am there for her in case she needs anything and every time I was leaving I reminded her that if she needs me, she can use a call bell.
5e. patient did not use verbal communication, however I paid close attention to nonverbal communication. I told the pt. I was going to feed her, she turned away and closed her eyes. This message showed me she doesn’t want to eat.
5f. I offered support and tried to explore feelings by asking about physical therapist, she seemed to be angry at him, I acknowledged her feelings and said that is must be hard to have people always telling you what to do and when.
6. I asked patient to squeeze my hand for “yes” and squeeze my hand twice for “no”.
7. I talked to the primary nurse about referral to speech therapy.
Goal not met. patient didn’t attempted to communicate with me, however the progress was present and if more time was given, I would be able to improve the communication further.

1. I was unable to determine orientation, however due to dementia; patient might not be oriented to time and place.
2. patient’s lack of desire to communicate is a barrier to communication.
3. anger is a barrier to communication and teaching. Anger has to be resolved prior to teaching alternative methods of communication.
4. rapport improved slightly, however it wasn’t improved enough for patient to open up enough to talk to me or even use alternative methods of communication in order to make her wishes known. If more time was given to establish rapport, I might’ve gotten her to respond to my questions.
5. Therapeutic communication techniques were not as successful as I hoped they would be, however they did help to establish rapport and improved communication.
5a. patient didn’t speak to me, however she became more relaxed, and did not get frustrated.
5. patient did not seem to react to touch. she did however resisted when people whom she never seen before would touch her.
5c. pt. became more calm and didn’t pretend to be sleeping as long as I was the only person in the room or the curtain was closed and she didn’t see anyone other then me.
5d. pt. did not ask me for help or used the call bell.
5e. I was able to understand when the pt. needs help and when she wants to be left alone by closely monitoring her nonverbal messages. This helped me to show the patient that I can help her whenever she needs it, yet I was not trying to invade her personal space.
Patient was more relaxed after she saw that I’m only there to help
5f. patient turned away from me and pretended to be asleep when I started acknowledging her feelings. She seemed to be upset. Although she got upset, I don’t think she was upset about me asking her about it but rather she was upset because she remembered about the way she was treated.
6. this intervention was not successful, how ever if I had more time to establish rapport, she would be more likely to communicate.
7. nursed stated that she will refer the patient to speech therapy. It is unclear how well the patient can articulate verbal message. However it could be the case since patient has a history of CVA.

This NPR is on risk for aspiration. I passed it and was told it's perfect, but i passed it with the easiest instuctor ever.

Dysphagia
CVA
Pure/ thickened fluid diet
Dementia
Unable to elevate upper body
Poor oral care
Depressed gag reflex

Risk for aspiration related to depressed laryngeal and glottic reflexes secondary to CVA

Cerebral vascular infarction results when an area of the brain loses blood supply because of vascular occlusion. One of the signs of CVA is inability to swallow due to depresses laryngeal and glottis reflexes. (#7, 530) Depressed laryngeal and glottic reflexes places person at risk for aspiration. Risk for aspiration in the sate in which a person is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages (#1, 247)
Ms. CR has a history of CVA and has dysphagia, this places her at risk for aspiration.
Patient will not aspirate while in my care as evidence by absent adventitious breath sounds.

1.assess level of consciousness.
2. Position patient in a high Fowler’s position (head of the bead elevated at least 45degrees)
3. Provide pureed and thick liquid diet
4. Provide oral care following each meal
5. Auscultate the lungs
6. place suctioning equipment at the bedside
7. Assess vital signs
7a. Assess blood pressure
7b. Assess respiration.
7c. Assess pulse
7d. Assess temperature.
8. Educate patient/ family about aspiration precautions.
9. Obtain WBC count
10. Assess oxygen saturation.
11. Assess mental status
12. Assess skin color

1.A decreased level of consciousness is a prime risk factor for aspiration
2. Patients with neuro-muscular dysfunction may not be able to change position most congruent to maintaining their airway.
3. Pureed and thick liquids are easy to swallow. This diet is often ordered for patients who have difficulty swallowing. Thick fluids have a slower transit time and allow more time to trigger the swallowing reflex(#6, 522)
4. it is important to remove residual from the mouth of the patient who is suffering from dysphasia as it can cause them to aspirate. Pocketed food can be easily aspirated at a later time (#9, 1298)
5. Stridor can be an indication of lower airway obstruction. (#3, 1298)
6. Suctioning may be necessary to clear the airway passage. (#3, 1318)
7a. Unusual increase in blood pressure may be a sign of hypoxia (#7, 724)
7b. tachypnea/dyspnea are signs of hypoxia.(#9, 724)
7c. Dysrhythmia is a sign of hypoxemia. Hypoxemia usually leads to hypoxia, which is life threatening. Tachycardia is a sign of hypoxia. (#9, 724)
7d. Patients with certain types of pneumonia (aspiration pneumonia) usually have a sudden onset of chills and rapidly rising fever (38.5 to 40.5 C or 101 to 105 F) (#7, 636)
8. Aspiration of gastric contents causes a chemical burn of the tracheobronchial tree and pulmonary parenchyma. An inflammatory response occurs. This results in the destruction of alveolar–capillary endothelial cells, with a consequent outpouring of protein-rich fluids into the interstitial and intra-alveolar spaces. As a result, surfactant is lost, which in turn causes the airways to close and the alveoli to collapse. Finally, the impaired exchange of oxygen and carbon dioxide causes respiratory failure. (#9, 681)
9. WBC's protect the body from invasion by foreign objects. WBC count is often elevated if infection is present. Pneumonia can be caused by aspirated food (#9, 872)
10. Pulse oximetry is performed to determine the need for oxygen and to evaluate the effectiveness of the therapy. Pulse oximetry can help to determine the need for oxygen therapy. Decreased oxygen saturation is a sign of hypoxia which could be caused by blockage of airway(#9, 638)
11. Changes in mental status, such as impaired judgment, agitation, disorientation, confusion, lethargy, and coma are signs of hypoxia. If hypoxia is not identified and treated early many complications and even death may occur. (#9, 724)
12. cyanotic nail beds are demonstrating central cyanosis (A late sign of hypoxia) (#7, 636)

1. I assessed patient to be alert. She responded to her name by opening her eyes.
2. I elevated the head of the bed 45 degrees when patient was at rest and 90 degrees during meals.
3. I attempted to feed patient on 4/23 with puree food and thickened liquids, however she pretended to sleep as soon as she hear me saying I was going to feed her. She ate breakfast on 4/24. Her meal was pureed and liquids thickened.
4. I provided oral are after breakfast. There was no residual left in the mouth
5. I auscultated lung sounds. Pt. had clear lung sounds
6. Suctioning equipment was kept at a bedside.
7a. I assessed blood pressure to be 132/72 on 4/23 and 128/65 on 4/24
7b. I assessed respirations to be 18 regular, non labored , deep on 4/23 and 20 on 4/24
7c. I assessed pulse to be 83 on 4/23 and 88 on 4/24
7d. I assessed temperature to be 98.9 on 4/23 and 99.2 on 4/24
8. I was unable to teach the patient about aspiration precaution due to dementia. I explained to pt’s daughter that she shouldn’t feed her mother by her self, since she cannot use suctioning equipment in case the pt. aspirates.
9. WBC count was 11.6H on 4/22, 12.3H on 4/23, 13.9H on 4/24
10. I assessed pulse oximetry to be 96% on
4/23 and 97% on 4/24
11. Patient is alert and responds to her name. I was unable to establish orientation to time and place due to patient’s inability to communicate.
12. I assessed patient’s skin to be pink

1. Pt. is alert and therefore this factor is not contributing to risk for aspiration.
2. Patient did not aspirate during meals and there was no stomach content in the lungs by the evidence of clear lung sounds.
3. Patient tolerated food well and didn’t aspirate.
4. patient did not aspirate residual left from the meal
5. Pt. doesn’t have airway obstruction caused by aspiration.
6. Patient did not aspirate while in my care, therefore suctioning equipment was not used. However if patient would’ve aspirated, suctioning would’ve cleared airway.
7a. patient’s blood pressure is slightly elevated; however it is not unusual for this patient since she has a history of HTN. Other assessments are needed to determine presence of hypoxia
7b. respirations are within a normal range which shows that pt. is not experiencing hypoxia.
7c. pulse is within a normal range, therefore pt. is not experiencing hypoxia and have not aspirated.
7d. temperature is slightly elevated, therefore an infections process is suspected. Thee is a possibility of aspiration pneumonia. To determine cause of temperature elevation more assessments are needed.
8. Daughter stated she will not feed her mother unless appropriate personnel is in the room.
9. elevated WBC count is an evidence of infection. This result is consistent with other findings (elevated temperature). Although there is a possibility of aspiration pneumonia, due to clear lung sounds, I believe this infection is of other origin
10. Patient is not experiencing hypoxia, therefore she did not aspirate
11. I was unable to determine orientation, however due to dementia; patient might not be oriented to time and place. Other assessments are needed to determine hypoxia
12. patient is not experiencing hypoxia