Communication Disorders of Patient and Nursing Education
What are Communication Disorders
Communication disorders can affect an individual's ability to both send and receive messages. A cerebrovascular accident is the most common cause of impaired communication and is the leading cause of long-term disability in the United States. A stroke occurs about every 40 seconds and death from a stroke happens on average every 4 minutes.
Approximately 800,000 Americans have a stroke each year. African Americans and Native Americans are at greatest risk for stroke. More than 7 million Americans are living with its long-term effects, about one third have mild impairments, another third is moderately impaired, and the remainder are severely impaired (American Heart Association & American Stroke Association, 2017; Mozaffarian et al . , 2016).
Aphasia as Communication Hurdle
One of the most common residual deficits of a stroke is aphasia, which “is an impairment of language, affecting the production or comprehension of speech and the ability to read or write” (National Aphasia Association, 2017, p. 1). Aphasia results from damage to the language center of the brain and is not the result or cause of an impairment in intelligence.
Although commonly seen in adults who have suffered a stroke, aphasia can also result from a brain tumor, infection, head injury, or dementia.An estimated 1 million people in the United States today suffer from aphasia. The type and severity of the language dysfunction depends on the precise location and the extent of the damaged brain tissue (National Aphasia Association, 2017).
Many forms of aphasia are possible, and newly diagnosed patients usually work with a speech therapist. Some of the more common types of aphasia include global aphasia, expressive aphasia, receptive aphasia, and anomic aphasia (National Aphasia Association). Determining the type of aphasia involved will assist the nurse in developing an appropriate teaching plan for the patient.
Global aphasia is the most severe form of aphasia and produces deficits in both the ability to speak and understand language as well as to read and write. Global aphasia is typically the result of extensive damage to the left side of the brain, which is where the primary function of language resides in most people.
Expressive aphasia affects the dominant cerebral hemisphere and results in patients having difficulty conveying their thoughts, speaking haltingly, and using sentences consisting of a few disjointed words, but they understand what is being said to them.
Specifically, expressive aphasia occurs when an injury damages the inferior frontal gyrus, just anterior to the facial and lingual areas of the motor cortex, known as Broca's area. Because Broca's area is so close to the left motor area, the stroke often leaves a person with right-sided paralysis as well.
Receptive aphasia is a result of damage to Wernicke's area of the temporal lobe and affects auditory and reading comprehension. Although the hearing in patients is not impaired, they are nevertheless unable to understand the significance of the spoken or written word.
Individuals with anomic aphasia understand what is being said to them and can speak in full sentences, but they have difficulty finding the right noun or verb to convey their thoughts. Circumlocution, or speaking around an issue, switching thoughts when they can't remember a word, or taking new pathways to describe the word they can't remember is common. The specific anatomical abnormality that results in anomic aphasia, however, is unclear.
The inability to communicate normally is a devastating consequence of a brain injury and requires the full support of the healthcare team. Aphasia has the potential to be a highly frustrating experience for both the patient and his or her caregivers. Speech therapy should be one of the earliest interventions, and the nurse will need to incorporate those strategies identified as effective by the speech therapist into the teaching-learning plan.
Every effort must be made to establish communication at some level. Without communication, nurses are ha mpered in their ability to conduct an assessment, establish a relationship with the patient, and engage in meaningful interaction (Thompson & McKeever, 2014). Regardless of how severe the communication deficit is, with effort, it is almost always possible to assist patients who have had a stroke to communicate in some manner and to some extent.
Family plays a key role in working with patients who have aphasia. Knowledge of the person is key to establishing a therapeutic relationship between the patient and the nurse. Family can help to fill in the gap and assist the nurse in understanding who the patient is, where they have been, and where they had hoped to go in their lives. Also, family can provide insight into the patient's likes and dislikes, habits, and ways of being (Thompson & McKeever, 2014).
First and foremost, when working with a patient who has expressive aphasia, it is important to remember that communication will take time. Patients who struggle to find the right word may need extra minutes to express themselves, so communication cannot be hurried. As these patients struggle to speak, nurses must resist the temptation to finish sentences or fill in the gaps for them without asking permission to do so.
Patients with receptive aphasia may suddenly find that their native language sounds foreign. These individuals may need extra time to process and understand what is being said. They may find it especially difficult to follow very fast speech, like that heard on the radio or television news, and can easily misinterpret the subtleties of language (eg, taking the literal meaning of sarcasm or a figure of speech such as “He kicked the bucket”).
With any type of aphasia, the nurse should focus on what the patient can do rather than on the speech deficits (National Aphasia Association, 2017; Sander, 2014).Environmental control is critical for all teaching sessions with patients who have aphasia. The nurse must make sure that he or she has the individual's full attention before attempting to communicate and that a quiet, disruption free area is created.
Because patients are often frustrated or embarrassed by their disability, a private area is also preferred. Furthermore, the nurse must always remember that the patient's difficulty with communication is not reflective of an inability to think or understand. Therefore, neither the nurse nor members of the family should talk down to the patient.
Ample praise and positive reinforcement for attempts to speak or efforts to understand are also important. It is unnecessary and demoralizing to correct every misunderstanding or error in word selection and pronunciation the goal is communication rather than perfection.
Finally, it is important that the nurse, as well as the family, avoid the tendency to protect the patient by shielding him or her from group conversations, especially those conversations that are important to the patient (National Aphasia Association, 2017).
Nursing Educator Strategies for Aphasia Disorders
The augmentative and alternative communication (AAC) describes the strategies and technologies that can be used to aid communication with a patient who has aphasia following a brain injury, such as a stroke (Wallace & Bradshaw, 2011). Additional strategies and technologies that can be used by the nurse include the following (Jensen et al., 2015; McKelvey, Hux, Dietz, & Beukelman, 2010; Wallace & Bradshaw, 2011):
Be sure you have the patient's attention, and that he or she is comfortable and is ready to attempt to engage in interaction before you begin communication.
Establish a consistent system for everyone to use that allows patients to respond to yes/no questions. It is critical that all staff use the same system. If one person asks the patient to shake his or her head up and down for “yes” and side to side for “no” and yet another suggests squeezing the nurse's hand for “yes, ” the patient will become frustrated and confused.
During teaching sessions, the nurse should use this system not only to get information from the person but also to verify that he or she is grasping the material being presented in a teaching session.
Teach the patient to point to certain objects to quickly express common needs. For example, the nurse might explain that “when you point to your water pitcher, I will know that you want a drink of water.”” Use simple sentence structure, speak slowly, and emphasize important words. Repeat significant points using different words or phrases. Ask only one question at a time. Break questions down into parts so that simple answers are acceptable.
Avoid jumping from topic to topic. Keep like topics together, and announce when you are changing topics-for example, “We just finished talking about when to take your medicine; Now I want to talk about how to take your pills.”
Teach the patient to use exaggerated facial expressions, hand movements, or tone of voice to improve speech comprehension. For example, a patient who grimaces when attempting to ask for pain medication is more easily understood. It is important that the patient, the family, and the nurse be open to using different ways to enhance communication.
The nurse also can model messages using exaggerated facial expressions to assist the patient who has difficulty with comprehension.Make use of available communication boards that provide a platform for pictures, letters, or other symbols to be displayed so a patient can point or gesture to convey a message. Communication boards range in style and level of technological enhancement, but all provide a simplified way of assisting patients to communicate.
Some are digitized so that, for example, a question mark on the board might be programmed to elicit a voice that says, “I don't understand; please repeat.” If a communication board with pictures or letters is not available, the nurse can create one with personally relevant, context-related photographs specific to the learning that needs to take place.
For example, when teaching the patient about medications, the nurse might illustrate the medicines ordered, the purpose of each agent, and how it should be taken. When assessing the patients understanding of the information, the nurse could then say, “Point to the pill you will take for pain” or “Show me whether you are supposed to take this medicine with food or with water.”
Support patients' speech therapy programs by having them recall word images and by first naming commonly used objects ( eg spoons, knives, forks) followed by those objects in the immediate environment (eg, bed, table). Another strategy is to have the person repeat the words spoken by the nurse. It is wise to begin with simple terms and work progressively towards more complex phrases.
The act of communicating may be exhausting for the patient with expressive aphasia, so it is important to keep teaching sessions short and focused. Most people become tired when sessions are longer than 20 minutes. Often their speech will become slurred at this point, and they will experience mental fatigue.
Whenever possible and if the patient agrees, it may be helpful to have a family member or significant other present during teaching sessions so that they can reinforce learning as needed.
As nurses attempt to work with and engage patients with aphasia in a teaching-learning intervention, they must be aware of their own attitudes. The effort to communicate with someone without using their usual speech and language can be a frustrating experience. Nurses should be sure to take time out and reflect on the rewards of assisting the patient and family in overcoming this barrier.
Dysarthria as Communication Hurdle
Many people with degenerative disorders, such as Parkinson's disease, multiple sclerosis, and myasthenia gravis, also have dysarthria. Dysarthria is a neuro-motor disorder that is caused by damage to the nerves or muscles associated with eating and speaking, including the mouth, tongue, larynx, or vocal cords.
Individuals with dysarthria have problems that range from mild to severe with their speech being unintelligible, audible, natural, and efficient (Mackenzie, 2011; Sander, 2014). The type (flaccid, spastic, ataxic, hypo-kinetic, and mixed) and severity of dysarthria depend on which area of the nervous system is affected (ASHA, 2017a).
The intervention of a speech-language pathologist may help improve the function of various muscles used for speech in patients with dysarthria. In some cases, for example, Parkinson's disease medication may help to improve speech. Some mechanical devices have been developed as well, such as a prosthetic palate, which is used to control hypernasality.
Sign language may be used if the person's arm and hand muscles are not significantly affected. The nurse should work with the speech-language pathologist to determine whether any of the other nonverbal aids would be appropriate, such as communication boards or a portable electronic voice synthesizer. With the advent of adaptive technologies, the possibilities are almost limitless.
Nursing Education Regarding Dysarthria Disorders
To improve communication with people with dysarthria, the nurse should implement the following strategies (ASHA, 2017a; Yorkston et al., 2001):
- Control the communication environment by reducing distractions.
- Pay attention to the patient and watch him or her while speaking.
- Be honest and let the patient know when understanding him or her is difficult.
- Encourage the patient to speak more slowly if he or she is hard to understand.
- Convey the part of the message that is not understandable so that the patient does not have to repeat the entire message.
- Ask questions that require a “yes” or “no” answer or have the patient write out his or her message when the patient cannot be understood.
- Conduct teaching sessions when the patient is rested because fatigue causes speech to become more difficult to understand.
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