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LESSON #5IMPAIRMENTS OF COMMUNICATION

SWALLOWINGRehabilitation Nursing

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Impairment of Communication

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Impaired Communication Terms

Aphasia Neurological condition Normal language function absent or disordered Inability to, in any combination:

Form/speak words Read written words Listen to words read or spoken Understand words read or spoken

Dysphasia Indicates the degree of language difficulty Does not indicate total inability to communicate

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Impaired Communication Terms Agnosia

Total or partial loss of ability to recognize something or someone familiar

Perceptual difficulties Every sense may be working But fails to accurately interpret or recognize what

they are sensing Agraphia

Inability to write Writing is usually unintelligible words May be able to form the letters/words but they

mean nothing

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Impaired Communication Terms

Alexia Inability to understand written words AKA “word blindness”

Anomia Form of aphasia Inability to name objects Ability to recognize and describe object

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Impaired Communication Terms

Dysarthria Difficult, poorly spoken speech Inability to use and control muscles for speech Usually disorder of CNS or peripheral nerve

damage Important Note!!!!

How does nurse tell difference?

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NORMAL SPEECH REQUIREMENTS

Basic RequirementsLevels of Language Production

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CommunicationBasic Requirements for any language

#1 Linguistic Competence Appropriate order of sounds(syllables)

#2 Cognitive Competence Appropriate application of word meaning

#3 Practical or Pragmatic Competence Appropriate use or application of words

during speech in plurality and tense In all situations and social settings

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CommunicationLevel of Language Production

#1 Autonomic Speech Habitual response

#2 Imitation Speech Copycat speech Must have ability to:

Hear /Understand the message Answer appropriately Reminder at this level!!!!

#3 Symbolic Speech Most advanced Speaks voluntarily Follows all language rules

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BRAIN DAMAGE AREASSpecific Language PatternsCommunication Problems

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Aphasia

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Normal Brain Normal Speech Center

Located in the dominate cerebral hemisphere Left hemisphere for a right hand dominate Right hemisphere for left hand dominate

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Speech Aphasia Defect in use of language Any combination of difficulty possible:

Speech Reading, Writing Understanding

Can be receptive, expressive or both AKA Fluent or Non-fluent aphasia

RT ease or lack of ease in speaking the words

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Types of Aphasia

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#1 Non-Fluent Aphasia Knows what to say Inability to get the words out Patient will:

Work hard at trying to talk Get frustrated while getting words out May say something they did not mean to say May have impaired writing or not make sense

Two types of non-fluent Aphasia: #1 Broca’s Aphasia #2 Global Aphasia

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#1 Broca’s Aphasia Discovered 1861 French Dr. Pierre Broca Through autopsies on several patients who could not talk Discovered damage to their brains in

same consistent area which is named after him

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#1 Broca’s Aphasia Usually from stroke Occurs in left frontal hemisphere Reminder of Normal Left frontal

hemisphere responsibilities: Imitation of autonomic gestures Elaboration of thought(development or

working out details) Ability to produce automatic and willed speech Syntax

Appropriate use of words in a sentence or phrase

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#1 Broca’s Aphasia Characteristics

Auditory Understanding Good Understands what is said If stroke extends…..

Speech Deficits show up Difficulty starting a conversation (willed speech) Difficulty in using names Difficulty with repletion (fluency) Recognizes when making verbal mistakes Speech telegraphic and inconsistent Reminder!!

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#1 Broca’s AphasiaCharacteristics

Writing Writing reflects how they talk

Related impairments: Apraxia

Inability to easily move tongue, mouth or throat used in speech

Note: Same muscles used in eating Can eat, just difficulty with speech

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#2 Global Aphasia Damage occurs in frontal area Great extension of damage leaves little

perception response RT little sensory perception is getting to brain

and able to be interpreted

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#2 Global AphasiaCharacteristics

Auditory understanding None

Speech Inappropriate word use May use automatic speech May appear fluent(repletion), but words

meaningless Use of perseveration or echolalia If dysarthria, then speechless

Writing Impaired and unintelligible

Reading Same as writing

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#2 Fluent Aphasia

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#2 Fluent Aphasia Ability to easily talk Problem is spoken words make no sense Client does not understand:

Spoken words Written words

One type of Fluent Aphasia: Wernicke’s Aphasia

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Wernicke’s Aphasia Damaged area is left superior temporal

area Major problem is Semantics Normal Left Temporal brain

responsibilities: Analysis of sensory impulses Understand detail Recognizes and understands sounds Understands language Correctly interprets visual information

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Wernicke’s AphasiaCharacteristics

Auditory Impaired Does not understand what is heard May hear talk, but lost on meaning of words

Speech Speaks fluently Gives impression they understand what is going on Most cases, they haven’t got a clue Speech smooth with normal rhythm, tone, phrase

length, grammar Abnormal semantics- meaning of words May use word substitutions

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Wernicke’s AphasiaCharacteristics

Writing characteristics Impaired writing

Reading Impaired

May be impaired understanding of visual perception

Important note when working with Wernicke’s Aphasia clients: Key is use whole body commands

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NURSING PROCESSINTERVENTIONSCommunicating to patient with

Aphasia

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Major Assessments for AphasiaImpaired Communication

Education level Developmental level Native spoken language Previous speech problems Any previous sensory perception

issues/corrections PT assesses physical strength to carry out

commands Auditory comprehension

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Impaired CommunicationNursing Diagnosis or Priorities

Impaired Verbal Communication Impaired Social Interaction Social Isolation

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Impaired Communication-AphasiaGoals and Expected Outcomes

#1 Find some way to communicate with patient

#2 Protect/maintain patient’s self-esteem #3 Listen to them/observe body

language/gestures for clues #4 Assess for changes #5 Encourage/Monitor for at least ONE

positive social interaction per day

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Impaired CommunicationAphasia Interventions

Encourage techniques of communication that should: Limit frustrations Reduce distractions Help correct misunderstandings

Some helpful techniques: Treat patient as an adult Encourage independence in their communication Build self-esteem by encouraging decision making Use appropriate eye contact Keep distractions to a minimum Consider their level of fatigue

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Impaired communicationAphasia Interventions

To help patient understand or comprehend: Speak normal tone Keep communication clear/ brief Support words with gestures/motions to

describe actions Use commercial aids(picture boards)

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Impaired CommunicationAphasia interventions

To help patient to express self and build self confidence: Maintain open body language Respond to all communication efforts by

patient Do not finish the patient’s statement for them

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Impaired CommunicationAphasia Interventions

Patient’s without speech need to communicate: Use picture boards Facial expressions Computers (Dynawrite) I phone App (My voice)

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DYSARTHRIAImpaired Communication

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Dysarthria A problem in forming or articulating

words of speech RT nerve difficulty

CNS nerve damage Peripheral Nerve damage

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DysarthriaSigns and Symptoms

Drooling Chewing motion Swallowing problems Important Note:

Can understand language/speech Dysarthria seen in many neurological

disorders

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Types of Dysarthria Flaccid Spastic Ataxic Hypokinetic Hyperkinetic Mixed

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DysarthriaAssessment of Cranial Nerves

CN 5= Trigeminal Nerve Ability to chew/move jaw

CN 7= Facial Nerve Assess symmetry and fatigue!!!

CN 9= Glossopharyngeal Nerve Assess gag reflex Assess ability to speak/cough

CN 12= Hypoglossal Nerve Assess tongue for symmetry, size, shape Paresis causes tongue to protrude toward weak side

Speech/nurses: Assess ability of tongue to be coordinated and rhythmic in

movement

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IMPAIRED SWALLOWING

Dysphagia

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Impaired Swallowing Terms

Dysphagia Difficulty with oral prep for swallowing Difficulty in moving the material from mouth

to stomach Difficulty with pain or discomfort with

swallowing

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Impaired swallowingMore Terms

Bolus Soft mass of chewed food Collection of saliva

Deglutition Swallowing process by which anything passes from

mouth through pharynx, esophagus to stomach Ataxic

Lack of coordination of muscle action of swallowing Aspiration

Inhalation of foreign substance into the lungs

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Normal Swallow Process Required to normally function and work

together: Swallow muscles Swallow nerves

Food must be placed in mouth for process to begin

There are four stages in the normal process of swallowing

Note: Difficulty can happen at any of these stages or a combination of these stages

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Normal Swallowing ProcessStages

Stage 1 Stage 2

Oral Preparatory Oral(lingual)

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Normal Swallowing Stages

Stage 3 Stage 4

Pharyngeal Stage Esophageal Stage

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Normal swallowing Very fast process Mouth to top of esophagus:

Takes less than 2 seconds Esophagus to stomach:

Takes 8-20 seconds Depends on length of esophagus

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Normal Swallowing Very safe process Larynx closes as food passes by Food is moved efficiently from mouth and

pharynx: Works in sequence No food left behind

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Swallow Problem If too big a bite at one time

Swallow takes longer Mouth and pharynx

Muscles fail to work in sequence which is normal Muscles must work at same time Often causes patient to hold breath to

swallow

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Normal Swallowing Swallowing changes based on type of

food Some things do not change:

Safety Efficiency of swallow

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Risk factorsindicating possible Impaired

Swallowing Any change in LOC Poor head/neck control Impaired cough/gag reflex Using therapeutic devices to eat

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Immediate Dysphagia intervention- Assess!!!

Place patient on Special Feeding Precautions

Customized instructions come from speech therapy after: Assessment of swallow

Bedside Swallow Evaluation on admission Gives safety guidelines immediately until further

testing done Barium Swallow Evaluation ASAP

Assists in detailed discovery of degree of difficulty with swallowing process and all involved stages

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More Speech Therapy Assessments!

Assess foods causing symptoms: Thin liquids Milk/nectar Certain foods(rice)

Assess patient’s eating habits(3 day history) Speech may come and sit alone with client observing:

Length of time to eat Speed of eating Fatigue level Cough/gag reflex triggered anytime during meal

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Nurses/Speech TherapistEven more assessments!!

Voice changes(nerve Innervation) Sleep problems (pharynx) Any esophageal problems Cardiac symptoms(chest pain) Respiratory Symptoms Current medications General medical history Neurological history Typical family diet Work history

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Speech Therapy Dysphagiagram or Barium Swallow

Defines specific areas of weakness Bedside Swallow Evaluation

Done within 4 hours of admission NPO until done Makes recommendation to physiatrist who then gives

diet order Uses various forms of water/ other food May attempt use of straw Observes patient’s response to different consistencies Notifies OT for necessary adaptive tools Notifies nursing of safety precautions for eating

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Silent Aspiration VS. Aspiration

Silent Aspiration S&S

Tachycardia Dyspnea Cyanosis HTN Delayed cough Possible elevated temperature 101° F with 30 minutes of aspiration Gurgled voice

Aspiration Shows all the above Except has immediate cough

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Choking Considered a protective mechanism of

airway Interventions:

Have client flex at waist or neck May help clear airway If food lodged, then Heimlich Maneuver

appropriate Prudent to have portable suction available

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NURSING DIAGNOSISINTERVENTIONS

Dysphagia

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DysphagiaNursing Diagnosis/Priorities

Impaired Swallowing Risk for Aspiration Nutrition: Less than Body Requirements,

Imbalanced Deficient Fluid Volume

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DysphagiaGoals/ Interventions

#1 Prevent Aspiration Staging diet helps improved control and safety

over food bolus Often these patients are also supplemented

through PEG tube Food likes/dislikes do not change with

dysphagia Caution: Normal Healthy food intake

should take minimum of 20 minutes, so do not hurry these individuals with Dysphagia

Change and monitor liquid consistencies

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Diet Stage 1 Pureed

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Diet Stage 2 pureed More texture found in food

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Diet Stage 3 Ground Mechanical Soft

Mashed food with small pieces

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Diet Stage 4Chopped or Cut Mechanical Soft

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Diet Stage 5Regular Texture

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Prevent AspirationLiquid Classifications

Thin liquids cause most aspiration problems

Liquid consistencies can be changed by adding thickeners to change consistency

Thickened liquids take a longer time to swallow. This increases patient’s ability to control bolus

Warning: Do not mix consistencies! Can cause patient to choke!

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Liquid Classifications

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Thickeners Added to obtain a safe swallowing

consistency Used until throat muscles are stronger

and able to react faster Products can be pre-thickened or may

need to add thickener Thick-it product

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Thin Liquid Consistencies

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Medium Thick or Nectar Consistencies

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Medium Thick Plus or HoneyConsistency

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Spoon Thick Consistencies

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Goal #2 Assess/Maintain Nutrition

Level Ensure enough calories intake:

Repair Coping with stress of injury Coping with exercise activity in PT Maintain body weight

Report any weight changes!

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Feeding Program Interventions

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Feeding InterventionsCorrect Position

Ordered by ST Upright Head midline Arms supported on table Chin tuck with neck flex Food placed on unaffected side Lip of cup on client’s lower lip for sipping Client remains upright for 30-40 minutes after

meal If in bed, HOB to at least semi-Fowlers position

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Feeding InterventionsEnvironment

Well lighted Minimal distractions TV off Quiet environment

No talk with mouth full Mouth care prior to meal May require one-on-one during meals Mandatory check tray for diet accuracy Ensure all required adaptive equipment is used and

protected Sit down with client Encourage client to see and smell food Identify the food placed in patient’s mouth

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Feeding InterventionsRate of eating

Encourage rest prescription prior to mealtime

Coordinate medications to ensure comfort and safety during mealtime

Check swallowing before giving next bite ensuring mouth has completely emptied

If changed the diet which requires more chewing watch closely for fatigue!!!!!!

Allow 30-40 minutes to assist these patient’s with their meal. DO NOT RUSH!!!

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Feeding InterventionsAmounts of Eating

Patients initially are fed small amounts to ensure ability to control

Alternate liquid and solid to help empty mouth

Avoid Straws!!!

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Feeding InterventionsTexture

May not be able to safely swallow more than one texture Avoid mixing foods Use pulp free drink

Avoid bland food! Use thickeners as needed

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Feeding InterventionsAdaptive Devices/techniques

Suction machine should be available in dining room

Client chokes: Lower chin Flex forward at waist Heimlich maneuver

Use lightweight utensils: Modified built-up handles Velcro straps

Drinking cups Plate guards

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Feeding InterventionsExtra Techniques

Promote independence Cue and coach to swallow before next bite or

swallow Stroke digastric muscles to encourage swallow Encourage ST exercises to strengthen involved

muscles Points to Remember about Medications:

Medications may be given in custard, jelly or blended fruit gelatin

Avoid applesauce RT it falls apart during swallow process Reminder to thicken all liquid medications to appropriate

consistency

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Review What did you learn? How will you put this into your practice as

a nurse?

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