Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient did not verbalize any needs to student nurse.

Objective

Pt could only respond to most questions with a nod or a shake of the head. 

No verbal communication that could be understood was used.

Difficultly communicating needs

Difficult to understand because cannot produce words easily.

Problem

Impaired verbal communication

Long Term:

Patient will use effective communication techniques by the time of discharge from the hospital.

Obtain communication equipment such as electronic devices, letter boards, or picture boards to help with communication because it enables humanness and can ease communication difficultly with family and staff (Ackley & Ladwig, 2008, p 217).

Use an individualized approach to communication such as pointing to letters, words phrases, or picture cards because these are easy ways to communicate with patient when they are unable to speak verbally (Ackley & Ladwig, 2008, p 217).

Goal still in progress.  Patient has demonstrated some effective communication techniques but more techniques need to be implemented to help with communication.  Continue to assess each shift the effectiveness of the communication and re-evaluate tomorrow at noon.

Continue to help patient with effective communication techniques.  Print out some hand outs and drawings and create picture cards that the patient can point to help with communication.  Re-evaluate communication tomorrow at noon.

R/T

pressure damage, decreased circulation to brain in speech center informational sources

Short Term:

1.       Patient will use alternative methods of communication effectively by the end of the shift

2.       Patient will demonstrate understanding even if not able to speak the end of the shift.

Involve a familiar person with patient when attempting to communicate with a client who has difficulty communicating because communication can be easier when someone that knows them is around to help ease communication barriers (Ackley & Ladwig, 2008, p 216).

Maintain eye contact at patient’s level  because good communication starts with good eye contact (Ackley & Ladwig, 2008, p 217).

Use appropriate touch to get patient attention because it conveys caring to the client (Ackley & Ladwig, 2008, p 217).

Spend time with the patient, allow for time for the patient to respond and make sure the call light is in reach so that the patient can be heard and knows that the nurse is willing to listen and take time with the patient.  It can help with overall health and quality of life (Ackley & Ladwig, 2008, p 217).

Goal met.  Patient was able to effectively nod or shake head to simple questions during lunch while student nurse was helping patient to eat lunch tray.

Goal still in progress.  Patient is able to understand some things and communicate accordingly but not all questions seemed to be understood by patient.  Will continue to evaluate and will reassess at the end of next shift.

Patient did not have family in room at the time of implementation.  Will continue to have family help with communication if family is present. Evaluation ongoing.

Continue to use eye contact with patient to help with communication. Evaluation ongoing.

Continue to use touch to gain patients attention and to help with caring for patient.  Evaluation ongoing.

Continue to spend time with client to create a bond with patient as well as to understand the patient’s needs and wants.  Evaluation ongoing.

AEB

difficult communicating needs to student nurse, cannot produce words easily, and difficultly comprehending usual communication patterns.