Assessment
Subjective:
Objective:



Left Facial
Droop
Left Motor
Weakness:
Upper Limb
0/5, Lower
Limb 2/5
Slurred
Speech
Nursing Diagnosis
Impaired verbal
communication
related to brain
damage
Expected Outcome
Short Term Goal
After 4 hour of
nursing intervention
the patient will
relate findings of
decreased frustration
with communication
Long Term Goals
After 2 days of
nursing intervention,
the patient will be
able to:
o Use a form of
communication
to get needs met
and to relate
effectively with
persons on her
environment.
o Demonstrate
congruent verbal
and non-verbal
communication
o Use resources
effectively such
as *pictograph
Nursing Intervention
Establish rapport listening
carefully and attending to
client’s verbal and nonverbal expressions
Assess degree of
disorientation to time,
place, person, and situation
regularly and frequently.
Assess conditions or
situations that may hinder
the patient's ability to use
or understand language
(e.g., tracheostomy, oral or
nasal intubation).
Provide alternative
methods of
communication, like
pictures or visual cues,
gestures or demonstration
Rationale
Evaluation
Short Term
Friendly
Goal
relationship with
After 4 hour of
patient and to be
nursing
able to each other’s intervention the
concern
patient will relate
findings of
decreased
This will determine frustration with
the amount of
communication
reorientation and
intervention the
patient will need to
evaluate reality
Long Term
accurately
Goals
After 2 days of
nursing
When air does not
intervention, the
pass over vocal
patient will be
cords, sounds are
able to:
not produced.
o Use a form of
communicati
on to get
needs met
and to relate
effectively
Provide
with persons
communication
on her
needs or desires
environment.
based on individual
o
Demonstrate
situation or
congruent
underlying deficit
verbal and
Anticipate and provides
patient’s needs
Helpful in
decreasing
frustration when
dependent on
others and unable
to communicate
desires.
Taught techniques to
improve speech by initially
asking questions that client
can answer with a
“yes” or “no”
Reduces confusion
or anxiety and
having to process
and respond to
large amount of
question
Provide an atmosphere of
acceptance and privacy
through speaking slowly
and in a normal tone, not
forcing the client to
communicate.
Nursing actions
should focus on
decreasing the
tension and
conveying an
understanding of
how difficult the
situation must be
for the client
Place important objects
within reach
Maintain eye contact with
patient when speaking.
Stand close, within
To maximize
patient’s sense of
independence
Patients may have
defect in field of
non-verbal
communicati
on
o Use
resources
effectively
such as
*pictograph
patient’s line of vision
(generally midline).
Use and assist patient or
significant others to learn
therapeutic communication
skills of acknowledgment,
active-listening, and
messages.
Involve family and
significant others in plan of
care as much as possible.
Refer to appropriate
resources if needed (e.g.,
speech therapist, group
therapy, individual/family
and/or psychiatric
counseling).
vision or they may
need to see the
nurses’ face or lips
to enhance their
understanding of
what is being
communicated.
Improves general
communication
skills.
Enhances
participation and
commitment to
plan
Specialized
services may be
required to meet
needs.