Subjective
She appears frustrated
after questioning as evidenced by her facial expression and body language.
Patients daughter is staying with her, reports that her mother
doesn’t seem to be “herself” since the stroke, and that she sometimes had mood swings
and periods of confusion.
On the morning of her
admission, her daughter stated that she was cooking breakfast when she collapsed
onto the floor. She had complained for the past 2 days of a headache with visual
changes, difficulty speaking, and progressive right-sided weakness
Objective
Patient is alert and oriented
at present, but has a difficult time speaking, Patient has paralysis on her right
side with decreased grips and reflexes on the left side.
difficulties in expressing
her needs and thoughts, which caused her much frustration
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Problem
Impaired Verbal Communication
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Long Term:
Client will use effective
communication techniques by the time of discharge and continue using effective communication
techniques through rehab and speech therapy.
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Involve a familiar person
when attempting to communicate with a client who has difficulty with communication,
if accepted by the client. EB: Conversation
partners of individuals with aphasia, including healthcare professionals, families,
and others, play a role that is important for communication for individuals with
aphasia (Roth, 2004).
Listen carefully. Validate
verbal and nonverbal expressions particularly when dealing with pain.
EBN: Listening to a client was identified
as a caring behavior of nurses (Gregg, 2004). EBN:
Nonverbal indicators of pain observed by nurses of clients with intellectual disabilities:
moaning, crying, painful facial expression, swelling and screaming during manipulation,
not using (affected) body part, and moving the body in a specific way of behaving
(Zwakhalen et al, 2004).
Using an individualized
approach, establish an alternative method of communication such as writing or pointing
to letters, word phrases, picture cards, or simple drawings of basic needs.
EB: Alternative methods of communication
are necessary when the client is unable to speak verbally (Happ, Roesch & Kagan, 2005).
Teach the client and family
techniques to increase communication, including the use of communication devices.
Alternative methods of communication are necessary
when the client is unable to use verbal communication.
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R/T
Recent stroke,
alteration of central nervous and decrease in circulation
to brain
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Short Term:
Client will demonstrate
understanding of daily treatment even
if not able to speak by end of shift
on 1300 on [date]
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Use presence. Spend time
with the client, allow time for responses, and make the call light readily available.
EBN: Attentive presence makes explicit that
the other is cherished; it is a universal lived experience that is important to
health and quality of life (Carroll, 2002). EBN:
Time with the nurse had a positive effect on the healing process and recovery (Rudolfsson et al, 2003).
Explain all healthcare
procedures. EBN: Clients
who were nonvocal and ventilated were attuned to everything occurring around them,
and they appreciated explanations from the nurse (Carroll, 2004).
Teach the client and family
techniques to increase communication, including the use of communication devices.
Alternative methods of communication are necessary
when the client is unable to use verbal communication.
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