Chinese General Hospital Colleges

PARAS, SARAH JANE P.

IVB1


ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
Objective:
-Difficulty speaking
-Unable to speak
and open mouth
-Use of non-verbal
cues
-Difficulty to
express thoughts
verbally
-Difficulty in using
facial and body
expressions
-Difficulty in
maintaining usual
communication
pattern
Impaired verbal
communication
related to alteration
of central nervous
system
Injury


Entrance of
Clostridium tetani
inside the body


Central Nervous
System is affected


Muscle Spasms


Lockjaw


Impaired Verbal
Communication
Within 1 hour of
nursing
intervention, the
patient will
establish method of
communication in
which needs can be
expressed.
Independent:
-Anticipate patient needs and
pay attention to nonverbal
cues.







-Place important objects
within reach

-Never talk in front of patient
as though he or she
comprehends nothing.


-Do not speak loudly unless
patient is hearing-impaired.





- Maintain eye contact with
patient when speaking. Stand
close, within patient's line of
vision (generally midline).

-Nurse should set aside
enough time to attend to
all of the details of
patient care. Care
measures may take
longer to complete in the
presence of a
communication deficit


-To maximize patient's
sense of independence.

-This increases the
patient's sense of
frustration and feelings
of helplessness.

-Loud talking does not
improve the patient's
ability to understand if
the barriers are primary
language, aphasia, or a
sensory deficit.

-Patients may have
defect in field of vision
or they may need to see
the nurses' face or lips to
Goal met; After 1 hour of
nursing intervention, the
patient was able to
establish method of
communication in which
his needs can be
expressed.
Chinese General Hospital Colleges
PARAS, SARAH JANE P.
IVB1






- Give the patient ample time
to respond.





-Use short sentences and ask
only one question at a time.


-Speak slowly and distinctly,
repeating key words to
prevent confusion.
Supplement verbal
communication with
meaningful gestures.

Dependent:
-Attend to rehabilitation
sessions
enhance their
understanding of what is
being communicated.

-It may be difficult for
patients to respond
under pressure; they
may need extra time to
organize responses, find
the correct word

-This allows the patient
to stay focused on one
thought.

-This provides the
patient with more
channels through which
information can be
communicated.



-To improve muscle
movements