Nursing Diagnosis: Application to Clinical Practice
11th Edition

Impaired Communication*
DEFINITION
Impaired Communication: The state in which a person experiences, or is at risk to experience, difficulty exchanging thoughts, ideas, wants, or needs with others
DEFINING CHARACTERISTICS
Major (Must Be Present)
Inappropriate or absent speech or response
Impaired ability to speak or hear
Minor (May Be Present)
Incongruence between verbal and nonverbal messages
Stuttering
Slurring
Word-finding problems
Weak or absent voice
Statements of being misunderstood or not understanding
Dysarthria
Aphasia
Language barrier
RELATED FACTORS
Pathophysiologic
Related to disordered, unrealistic thinking secondary to:
  • Schizophrenic disorder
  • Delusional disorder
  • Psychotic disorder
  • Paranoid disorder
Related to impaired motor function of muscles of speech:
or
to ischemia of temporal frontal lobe secondary to:
Cerebrovascular accident
Oral or facial trauma
Brain damage (eg, birth/head trauma)
Central nervous system (CNS) depression/increased intracranial pressure
Tumor (of the head, neck, or spinal cord)
Chronic hypoxia/decreased cerebral blood flow
Nervous system diseases (eg, myasthenia gravis, multiple sclerosis, muscular dystrophy, Alzheimer’s disease)
Vocal cord paralysis/quadriplegia
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Related to impaired ability to produce speech secondary to:
Respiratory impairment (eg, shortness of breath)
Laryngeal edema/infection
Oral deformities
  • Cleft lip or palate
  • Malocclusion or fractured jaw
  • Missing teeth
  • Dysarthria
Related to auditory impairment
Treatment-Related
Related to impaired ability to produce speech secondary to:
  • Endotracheal intubation
  • Surgery of the head, face, neck, or mouth
  • CNS depressants, anesthesia
  • Tracheostomy/tracheotomy/laryngectomy
  • Pain (especially of the mouth or throat)
Situational (Personal, Environmental)
Related to decreased attention secondary to fatigue, anger, anxiety, or pain
Related to no access to or malfunction of hearing aid
Related to psychological barrier (eg, fear, shyness)
Related to lack of privacy
Related to unavailable interpreter
Maturational
Infant/Child
Related to inadequate sensory stimulation
Older Adult (Auditory Losses)
Related to hearing impairment
Related to cognitive impairments secondary to (specify):
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Focus Assessment Criteria
Subjective Data
Assess for Defining Characteristics.
Note the usual pattern of communication as described by the person or family.
  • Very verbal
  • Sometimes verbal
  • Uses sign language
  • Writes only
  • Responds inappropriately
  • Does not speak/respond
  • Speaks only when spoken to
  • Gestures only
Does the person feel he or she is communicating normally today?
If not, what does the client feel may help him or her to communicate better?
Would the client like to talk with or have present a specific person to help express ideas?
Does the client have trouble hearing?
  • Hearing problem
  • Both ears or one
  • How long? gradual? sudden?
  • Use of a hearing aid
  • Family history of hearing loss
  • History of exposure to loud noises
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Ask person/caregiver to:
  • Rate ability to communicate on a scale of 0 to 10, with 0 signifying “completely unable to communicate” and 10 signifying “communicates well.”
Describe factors that aid communication.
Assess for Related Factors.
Does the person feel that barriers hinder his or her ability to communicate?
  • Lack of privacy
  • Fear of uncertain origin
  • Fear of being inappropriate or “stupid”
  • Not enough time to gather thoughts and ask questions
  • Need for significant other or familiar face
  • Language, dialect, or cultural barrier (specify)
  • Lack of knowledge of subject being discussed
  • Pain, stress, or fatigue
Objective Data
Assess for Defining Characteristics.
Describe Ability to Form Words.
  • Not able
  • Fair
  • Good
Speech Pattern
  • Slurred speech
  • Lisping
  • Stuttering
  • Voice weakness (whisper)
  • Language barrier
Ability to Comprehend
Follows simple commands or ideas
Can follow complex instructions or ideas
Sometimes can follow instructions or ideas
Can follow simple instructions or ideas
Follows commands and ideas only if hearing aid is working
Follows commands and ideas only if he or she can see speaker’s mouth (lip-reads)
What is the Developmental Age?
Describe Ability to Form Sentences.
  • Good
  • Slow
  • Not able
  • Unclear ideas
  • Nonsensical or confused
  • Can make short, simple sentences
  • Language barrier
Is Eye Contact Maintained?
  • Yes
  • No
  • Occasionally
  • Rarely
  • Blind/impaired vision
Hearing Loss (Check Each Ear Separately)
External ear
  • Deformities
  • Lumps or tenderness
  • Lesions
Middle and inner ear
  • Cerumen
  • Redness
  • Discharge
  • Swelling
Auditory acuity
Can hear ticking watch or whispered words
With decreased hearing
Weber and Rinne test results
Hearing aid?
  • Left ear
  • Right ear
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Assess for Related Factors.
Barriers
Tracheostomy
Endotracheal tube
Affect or Manner
  • Nervous
  • Angry
  • Fearful
  • Flat
  • Attentive
  • Comfortable
  • Anxious
  • Uncomfortable
  • Withdrawn
Contributing Factors
Do contributing factors inhibit ability to communicate (see Related Factors)?
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The person will report improved satisfaction with ability to communicate.
Indicators
  • Demonstrate increased ability to understand.
  • Demonstrate improved ability to express self.
  • Use alternative methods of communication, as indicated.
General Interventions
Identify a Method to Communicate Basic Needs.
Assess Ability to Comprehend, Speak, Read, and Write.
Provide Alternative Methods of Communication.
Use computer, pad and pencil, hand signals, eye blinks, head nods, and bell signals.
Make flash cards with pictures or words depicting frequently used phrases (eg, “Wet my lips,” “Move my foot,” “I need a glass of water” or “I need a bedpan”).
Encourage person to point, use gestures, and pantomime.
Identify Factors that Promote Communication.
Create Atmosphere of Acceptance and Privacy.
Provide a Nonrushed Environment.
Use normal loudness level and speak slowly in short phrases.
Encourage client to take time talking and to enunciate words carefully with good lip movement.
Decrease external distractions.
Delay conversation when the person is tired.
Assess Client’s Frustration Level; Do not Push Beyond It.
Estimate 30 s of passed time before providing client with the word he or she may be trying to find (except when person is frustrated or needs the request immediately [eg, bedpan]).
Provide cues through pictures or gestures.
Use Techniques to Increase Understanding.
Face client and establish eye contact if possible.
Use uncomplicated one-step commands and directives.
Have only one person talk (following a conversation with multiple parties can be difficult).
Encourage the use of gestures and pantomime.
Match words with actions; use pictures.
Terminate conversation on a note of success (eg, move back to an easier item).
Validate that client understands message.
Give information in writing to reinforce.
Initiate Health Teaching and Referrals, if Needed.
Seek consultation with a speech or audiology specialist.
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Rationales
  • Using alternative forms of communication can help decrease anxiety, isolation, and alienation; promote a sense of control; and enhance safety (Iezzoni et al., 2004).
  • Communication is the core of all human relations. Impaired ability to communicate spontaneously is frustrating and embarrassing. Nursing actions should focus on decreasing tension and conveying understanding of how difficult the situation must be for the client (Underwood, 2004).
  • The nurse should make every attempt to understand the client. Each success, regardless of how minor, decreases frustration and increases motivation.
Rationales
  • Listening carefully will allow you to pick up cues about issues for the child or adolescent.
  • The initial interaction sets the tone for future interactions with the child and family.
  • Use of open-ended, nonjudgmental style can reduce suspicions.
  • Criticizing or lecturing does not promote an understanding of risk behaviors.
  • Successful communication depends on the nurse’s ability to involve the adolescent in discussions.
  • Adolescents need opportunities to demonstrate their independence and to appraise options accurately (Wong, 2003).
  • For deaf infants, visual and tactile modalities are particularly important for communicating, interacting, and gaining information about their environment (Koester, Karkowski & Traci, 1998).
Footnote
*Note: This diagnosis was developed by Rosalinda Alfaro-LeFevre and is not currently on the NANDA list, but is included here for clarity and usefulness.
RELATED TO EFFECTS OF HEARING LOSS
Goal
The person will relate/demonstrate an improved ability to communicate.
Indicators
  • Wear functioning hearing aid if appropriate.
  • Communicate through alternative methods.
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Interventions
Ask the Person What Mode of Communication He or She Desires.
Record on Care Plan the Method to Use (May be Combination of the Following):
  • Writing
  • Speaking
  • Gesturing
  • Speech-reading (or lip-reading)
  • Sign language
Assess Ability to Receive Verbal Messages.
If Client Can Hear With a Hearing Aid, Make Sure that it is on and Functioning.
Check batteries by turning volume all the way up until it whistles. (If it does not whistle, insert new batteries.)
Make sure volume is at a level that enhances hearing. (Many people with hearing aids turn the volume down occasionally for peace and quiet.)
Make a special effort to ensure client wears the hearing aid during off-the-unit visits (eg, special studies, the operating room [OR]).
If Client Can Hear With Only One Ear, Speak Slowly and Clearly Directly into the Good Ear. It is More Important to Speak Distinctly than Loudly.
Place bed in a position so the person’s good ear faces the door.
Stand or sit on the side on which client hears best (eg, if left ear is better, sit on the left).
If the Person Can Speech-Read:
Look directly at the person and talk slowly and clearly.
Avoid standing in front of light—have the light on your face so the person can see your lips.
Minimize distractions that may inhibit the person’s concentration.
Minimize conversations if the person is fatigued or use written communication.
Reinforce important communications by writing them down.
If Client Can Read and Write, Provide Pad and Pencil at All Times.
If Client Can Understand Only Sign Language, Have an Interpreter With Him or Her as Much as Possible.
Address all communication to the person, not to the interpreter (eg, do not say, “ask Mrs. Jones…”).
Record name and phone number of interpreter(s) on the care plan.
If in a group setting (eg, diabetes class), place client at front of the room near the instructor or send interpreter with him or her.
Carefully evaluate the person’s understanding of required knowledge.
Give information in writing.
Use Factors that Promote Hearing and Understanding.
Talk distinctly and clearly, facing the person.
Minimize unnecessary sounds in the room:
  • Have only one person talk.
  • Be aware of background noises (eg, close the door, turn off the television or radio).
Repeat, then rephrase a thought, if the person does not seem to understand the whole meaning.
Use gestures to enhance communication.
Encourage the person to maintain contact with other deaf people to minimize feelings of social isolation.
Write as well as speak all important messages.
Validate the person’s understanding by asking questions that require more than “yes” or “no” answers. Avoid asking, “Do you understand?”
Initiate Referrals as Needed.
Seek consultation with a speech or audiology specialist.
Rationales
  • Under the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990, hospitals must offer reasonable accommodations for hearing-impaired clients. For example, they must provide qualified interpreters and auxiliary tools such as teletype machines, unless doing so imposes an undue financial or other burden.*
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  • When using an interpreter, some things may be omitted or misunderstood. Whenever possible, give information in writing as well as through the interpreter.
  • Hearing aids magnify all sounds. Therefore, extraneous sounds (eg, rustling of papers, minor squeaks) can inhibit understanding of voiced messages.
  • Deafness can disrupt the reciprocal relationship necessary in the health care process.
  • Speech-reading is difficult and fatiguing in the hospital. Unfamiliar terminology, anxiety, and poor lighting all can contribute to errors.
  • Writing messages is slow, causing a tendency to abbreviate content. Moreover, expressing emotions in writing is difficult.
  • The following are available to assist clients with hearing impairment:
    • DEAFNET, a computer system that allows clients to type messages to a computer at the phone company, which a voice synthesizer translates verbally
    • Telecommunication devices for the deaf (know as TDD) that operate by communicating electronically messages that are typed, infrared systems, computers, voice amplifiers, amplified telephones, low-frequency doorbells and telephone ringers, closed-caption TV decoders, flashing alarm clocks, flashing smoke detectors, hearing aids, and lip reading and signing instruction
    • Deaf service centers available in most communities to help with housing, job seeking, travel arrangements, recreation, and adult education opportunities
  • Many older adults with hearing impairments don’t wear hearing aids. Those who wear them must be encouraged to use them consistently, clean and maintain them, and replace batteries. They should be assertive in letting significant others know about situations and environmental areas in which they experience difficulty because of background noise.
Footnote
RELATED TO EFFECTS OF APHASIA ON EXPRESSION OR INTERPRETATION
Aphasia is a communication impairment—a difficulty in expressing, a difficulty in understanding, or a combination of both—resulting from cerebral impairments.
Goal
The person will report decreased frustration with communication.
Indicators
  • Demonstrate increased ability to understand.
  • Demonstrate improved ability to express ideas, thoughts, needs.
Interventions
Use Techniques that Enhance Verbal Expression.
Make a Concerted Effort to Understand the Person.
Allow enough time to listen.
Rephrase messages aloud to validate what was said.
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Acknowledge when you understand, and do not be concerned with imperfect pronunciation at first.
Ignore mistakes and profanity.
Do not pretend you understand if you do not.
Observe nonverbal cues for validation (eg, answers yes and shakes head no).
Allow person time to respond; do not interrupt; supply words only occasionally.
Teach Techniques to Improve Speech.
Ask to slow speech down and say each word clearly, while providing the example.
Encourage client to speak in short phrases.
Explain that client’s words are not clearly understood (eg, “I can’t understand what you’re saying.”).
Suggest a slower rate of talking, or taking a breath before beginning to speak.
Ask client to write down message, or to draw a picture, if verbal communication is difficult.
Focus on the present; avoid controversial, emotional, abstract, or lengthy topics.
Explain the Benefits of Daily Speech Practice. Consult with Speech Therapist for Specific Exercises.
Acknowledge Client’s Frustration and Improvements.
Verbally address frustration over inability to communicate, and explain that both nurse and client need to use patience.
Maintain a calm, positive attitude (eg, “I can understand you if we work at it.”).
Use reassurance (eg, “I know it’s difficult, but you’ll get it.”); use touch if acceptable.
Maintain a sense of humor.
Allow tears (eg, “It’s OK. I know it’s frustrating. Crying can let it all out.”).
Give the person opportunities to make care-related decisions (eg, “Would you rather have orange juice or prune juice?”).
Provide alternative methods of self-expression
  • Humming/singing
  • Dancing/exercising/walking
  • Writing/drawing/painting/coloring
  • Helping (tasks such as opening mail, choosing meals)
Identify Factors that Promote Comprehension.
Assess Hearing Ability and Use of Functioning Hearing Aids.
Assess Ability to See, and Encourage the Person to Wear Glasses if Indicated.
Explain that seeing better will increase understanding of what is happening in the environment.
Even if the person is blind, look at him or her when talking to “throw” voice in that direction.
Provide Sufficient Light and Remove Distractions (see Disturbed Sensory Perception).
Speak When the Person is Ready to Listen.
Achieve eye contact, if possible.
Gain the person’s attention by a gentle touch on the arm and a verbal message of “Listen to me” or “I want to talk to you.”
Modify your Speech.
Speak slowly; enunciate distinctly.
Use common adult words.
Do not change subjects or ask multiple questions in succession.
Repeat or rephrase requests.
Do not increase volume of voice unless person has a hearing deficit.
Match your nonverbal behavior with your verbal actions to avoid misinterpretation (eg, do not laugh with a coworker while performing a task).
Try to use the same words with the same task (eg, bathroom vs toilet, pill vs medication).
Keep a record at bedside of the words to maintain continuity.
As the person improves, allow him or her to complete your sentences (eg, “This is a…[pill]”).
Use Multiple Methods of Communication.
Use pantomime.
Point.
Use flash cards.
Show what you mean (eg, pick up a glass).
Write key words on a card, so client can practice them while you show the object (eg, paper).
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Show Respect when Providing Care.
Avoid discussing the person’s condition in his or her presence; assume client can understand despite deficits.
Monitor other health care providers for adherence to plan of care.
Talk to the person whenever you are with him or her.
Initiate Health Teaching and Referrals, if Indicated.
Teach communication techniques and repetitive approaches to significant others.
Encourage family to share feelings concerning communication problems.
Explain the reasons for labile emotions and profanity.
Explain the need to include the person in family decision making.
Seek consultation with a speech pathologist early in treatment regimen.
Rationales
  • See Rationales for Impaired Communication.
  • Deliberate actions can improve speech. As speech improves, confidence increases and the client will make more attempts at speaking.
  • Improving the client’s comprehension can help decrease frustration and increase trust. Clients with aphasia can correctly interpret tone of voice.
  • Daily exercises help improve the efficiency of speech musculature and increase rate, volume, and articulation.
RELATED TO FOREIGN LANGUAGE BARRIER
Goal
The person will communicate needs and concerns (through interpreter if needed).
Indicators
  • Demonstrate ability to understand information.
  • Relate feelings of reduced frustration and isolation.
Interventions
Assess Ability to Communicate in English.*
Assess language the client speaks best.
Assess client’s ability to read, write, speak, and comprehend English.
Do not evaluate understanding based on “yes” or “no” responses.
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Identify Factors that Promote Communication Without a Translator.
Face the person and give a pleasant greeting, in a normal tone of voice.
Talk clearly and somewhat slower than normal (do not overdo it).
If the person does not understand or speak (respond), use an alternative communication method.
  • Write message.
  • Use gestures or actions.
  • Use pictures or drawings.
  • Make flash cards that translate words or phrases.
Encourage client to teach others some words or greetings of his or her own language (helps to promote acceptance and willingness to learn).
Do not correct a client’s or family’s pronunciation.
Clarify the exact meaning of an unclear word.
Use medical terms and the slang word when indicated (eg, vomiting/throwing up).
Be Cognizant of Possible Cultural Barriers.
Be careful when touching the person; some cultures may consider touch inappropriate.
Be aware of different ways the culture expects men and women to be treated (cultural attitudes may influence whether a man speaks to a woman about certain matters, or vice versa).
Make a conscious effort to be nonjudgmental about cultural differences.
Make note of what seems to be a comfortable distance from which to speak.
Initiate Referrals, When Needed.
Use a fluent translator when discussing important matters (eg, taking a health history, signing an operation permit). Reinforce communications through the translator with written information.
If possible, allow the translator to spend as much time as the person wishes (be flexible with visitors’ rules and regulations).
If a translator is unavailable, plan a daily visit from someone who has some knowledge of the person’s language (many hospitals and social welfare offices keep a “language” bank with names and phone numbers of people who are willing to translate).
Use AT&T telephone translating system when necessary.
Rationales
  • An answer of “yes” may be an effort to please, rather than a sign of understanding.
  • Although the nurse cannot speak another’s language, he or she can convey acceptance by talking in a pleasant tone of voice and using actions to demonstrate meaning (eg, smiling and motioning to sit down, while saying, “Sit down, please.”).
  • Usually language comprehension is far greater than the ability to speak or write language.
  • An attempt on the nurse’s part to communicate over a language barrier encourages the client to do the same.
  • People should overcome the human tendency either to ignore or to shout at people who do not speak the dominant language.
  • Be aware that, when one learns a language, one usually learns only one meaning for a word. Some words have more than one meaning, such as “discharge” and “pupil.”
  • During the initial assessment, start with general questions. Allow time for the person to talk even if it is not related. Use nondirect, open-ended questions when possible. Delay asking very personal questions, if possible.
  • Nurses must have transcultural sensitivity, understand how to impart knowledge, and know how to advocate to represent the client’s needs. Interpreting with cultural sensitivity is much more complex than simply putting words in another language (Giger & Davidhizar, 2003).
  • Appropriate distance between communicators varies across cultures. Some normally stand face to face, whereas others stand several feet apart to be comfortable.
  • Communicating through touch or holding varies among cultures. Some cultures view touch as an extremely familiar gesture, some shy away from touching a given part of the body (a pat on the head may be offensive), and some consider it appropriate for men to kiss one another and for women to hold hands.
Footnote
*English is used as an example of the dominant language.