1. Chapter 4: Communication Challenges Roosevelt Health Science Clinical Rotations Successful Nursing Assistant Care, 2 nd Ed. (Ch. 3) Simmers DHO Health Science, 8 th ED. (Ch. 4) Medical Assisting: Administrative & Clinical Competencies, 7 th ED (Unit 4,5)

2. Chapter 4 Objectives Define important words Identify communication guidelines for visual impairment Identify communication guidelines for hearing impairment Explain defense mechanisms as methods of coping with stress List communication guidelines for anxiety or fear Discuss communication guidelines for depression Identify communication guidelines for anger Identify communication guidelines for combative behavior Identify communication guidelines for inappropriate sexual behavior Identify communication guidelines for disorientation and confusion Identify communication guidelines for comatose resident Identify communication guidelines for functional barriers

3. Visual Impairment Impairment- loss of function or ability; can be a partial or complete loss. Several diseases can cause visual impairment or blindness, including diabetes and glaucoma. A visual impairment is also something that can exist at birth. Visual impairments can effect people of all ages May occur in one or both eyes

4. Communication Guidelines for Visual Impairment Announce yourself and greet the patient when you first enter the room. Do not touch him/her before you have identified yourself. Tell him/her why you are there. Do not shout. Look at the patient the entire time you are speaking with him/her. Make sure there is proper lighting in the room. Tell him/her about the care you are going to perform. Keep talking to him/her during care. Use the face of an imaginary clock to explain the position of objects. When taking the resident to a new area, orient him/her to the room. Ex: “There is a table with 4 chairs around it at 3 o’clock. There is a sofa at 7 o’clock.”

5. Communication Guidelines for Visual Impairment Do not use words such as “see,” “look,” and “watch.” Make sure the patient has his/her glasses on if he/she wears them. Check to see that they are clean, fit properly, and are in good condition. If they are damaged or do not fit properly, report this to the nurse. Do not move personal items or furniture without the patient’s permission. If he/she agrees, tell him/her the new location of the items. Put everything back where you found it Read menus to the patient. Encourage the patient to use his/her other senses, such as smell, touch, and hearing. Announce when you are going to leave the patient’s area. Do not play with or distract guide dogs. There are many helpful items for people with visual impairments, like books on tape, large print books and newspapers, and large clocks. Offer them when available. Be empathetic. Try to imagine what it feels like to not be able to see or see well.

6. Hearing Impairments Can be in one or both ears or temporary due to noise level in the room. Most hearing loss occurs gradually. If you notice any of these, report them to the nurse: Trouble hearing high-pitched noises Trouble hearing soft consonants, such as “s” and “t.” Trouble hearing what is said in a setting that has background noise. Being unable to hear people when they are not in the same room. Not understanding the meaning of words. Favoring one ear over the other one. Avoiding movies or special events due to not being able understand the dialogue. Patient complains of ringing in the ears. Patient complains of pain in one or both ears.

7. Communication Guidelines for Hearing Impairment Get the patient’s attention before speaking. Do not approach him/her from behind. Walk in front of him/her if possible. Stand or sit so that the resident can see your face. Make sure there is proper lighting in the room. Look directly at the patient while speaking. A hearing- impaired patient may read lips. If the patient uses a hearing aid, make sure it is turned on. Be familiar with any hand gestures a hearing-impaired patient uses. Turn off TV or radios. Speak clearly in a low tone of voice. Do not shout. If the person favors one ear, speak to that side. Lower the pitch of your voice. Do not chew gum or cover your moth with your hand while speaking. Do not exaggerate pronunciation of words. Use simple words and short sentences. Use a pen and paper or picture cards when needed.

8. Defense Mechanisms Communicating with patients under stress requires empathy and sensitivity. Defense Mechanisms- unconscious behaviors used to release tension and/or help a person cope with stress. Help to block uncomfortable or unpleasant feelings which may cause anxiety. Prevent the person from facing the real reason a situation has occurred. Overuse of these mechanisms keeps a person from understanding his/her emotional problems and actions.

9. Defense Mechanisms Denial: Blocking reality; rejecting the thought or feeling—A patient refuses to believe his diagnosis of cancer. Displacement: Transferring a strong feeling to a less threatening object—A patient who is mad at her son yells at the nursing staff. Projection: Seeing feelings in others that are actually one’s own—A staff member says that a patient does not like her. Rationalization: Making excuses to justify something—An elderly man fails a driving test and say the test was “unfair.” Repression: Blocking painful events or feelings from the mind—A woman cannot recall abuse she suffered as a child. Regression: Going back to behavior from the past for comfort—A patient who is stressed starts to rock back and forth.

10. Anxiety Anxiety- is an uneasiness, often about a situation or condition. Feeling anxious is not the same as being afraid Anxiety occurs when unpleasant feelings develop as a result of anticipation that something bad could happen in the future. Anxiety can cause physical symptoms including nausea, shaking, sweating, chest pain, and chest palpations. The goal of communication with an anxious person is to reduce the anxiety and stress levels.

11. Communication Guidelines for Anxiety or Fear Greet the patients when you first enter the room. Do not touch him/her before you have identified yourself. Use touch only if it does not upset the patient. Speak softly. Reduce the noise level. Speak slowly and calmly. Listen to the patient. Be patient. Ask gentle questions to try to identify what is causing the anxiety or fear. Be empathetic. Be calm and reassuring. Avoid demanding behavior. Reassure the patient that he/she is safe.

12. Depression Mental illness that causes withdrawal, lack of energy, and loss of interest in activities, as well as other symptoms Patients may be depressed because of personal issues, losing a loved one, their own medical status, or chemical imbalances in the brain. Depression is not something people can overcome by choosing to be well.

13. Communication Guidelines for Depression Be pleasant, respectful, and supportive Use touch to help comfort the patient. Consider cultural differences before using touch. Sit down and listen carefully to the patient. Lean forward and keep good eye contact. This body language shows you are interested. Think before you speak. Try to empathize with the patient’s feelings and situation. Use normal tone of voice when speaking. Use simple, clear statements. Do not talk to adults as if they were children. Talk about feelings if they are the patient’s wishes Encourage social interaction

14. Anger Anger is natural emotion; it may be due to many reasons such as disease, fear, pain, grief, loneliness, and loss of independence. Anger may be expressed by yelling, throwing things, threatening, sarcasm, and pacing. Or anger can be expressed by withdrawing, being silent, or sulking. Narrowed eyes, clenched fists, and raised fists are signs of anger Always report angry behavior to the nurse at the first sign of it. If a resident’s anger requires more time from staff, a care conference may be scheduled. Assertive means being confident in dealing with other people, while aggressive means expressing oneself in a way that humiliates or overpowers another person.

15. Communication Guidelines for Angry Behavior Be pleasant and supportive. Let the patient know you are there for him/her and that you are available to help. Try to find out what caused the patient’s anger. Listen closely as he/she speaks. Note the exact words the patient uses. Being silent may help him/her explain. Watch patient’s body language Think before you speak. Empathize with the patient. Try to understand what he/she is feeling.

16. Communication Guidelines for Angry Behavior Do not argue with the patient. Stay calm. Speak in a normal tone. Consider your responses carefully. Treat the patient with dignity and respect. Answer call lights promptly. If the patient’s anger increases, get the nurse immediately. Stay at a safe distance if the patient becomes combative. Try to involve the patient in activities if he/she is willing. Ex: are taking a walk or listening to music.

17. Combative Behavior Combative- means violent or hostile; includes hitting, shoving, kicking, throwing things, and insulting others. Can occur because of increased anger, frustration, or due to a disease affecting the brain. In general, combative behavior is not a reaction to you. Try to not take it personally. If you see a patient becoming combative, call for the nurse right away. Make sure to keep everyone safe! Combative behavior require special techniques.

18. Communication Guidelines for Combative Behavior Call for the nurse immediately or get someone to call. Try not to leave the patient alone. Keep yourself and other people at a safe distance from the patient. If a patient tries to hit you, or does hit you, NEVER hit back. Stay calm. Do not appear threatening to the patient. Be reassuring, and try to find out what triggered the behavior Do not respond to insults. Follow the direction of the nurses. Report the facts you know. When anger passes, sit with the patient for a while to provide comfort if instructed to do so.

19. Inappropriate Sexual Behavior Sometimes patients will display inappropriate sexual behavior including acts like patients removing clothing in public places, making sexual advances or comments, and masturbation. This behavior can be due to illness, dementia, confusion, or medication. Changes in the brain may make a person unable to tell the difference between proper and improper behavior. Keep in mind that residents have the right to engage in mutually-agreed-upon sexual relationships. There is a variety of sexual behavior in all age groups, including the elderly.

20. Guidelines for Inappropriate Sexual Behavior Do not overreact to an embarrassing situation. Be matter-of-fact. Remain calm and try to distract the person. Tell the nurse. If a resident is engaging in a consensual sexual act, provide privacy for them. Listen to the resident if he or she wants to talk. Do not judge the behavior Sometimes a confused resident will show inappropriate behavior that is really due to having a rash, or clothes that are too tight, too hot, or too scratchy. Always report all inappropriate behavior to the nurse.

21. Disorientation and Confusion People who are oriented should be able to tell you who he/she is, who you are, the city, state, the name of facility, and the correct year. Disorientation- confusion about person, place, or time. May be permanent, due to an injury or disorder in the brain May be temporary, due to dehydration, constipation, hypoxia (lack of oxygen to the brain) or medication Confusion- the inability to think clearly and logically. A confused person has trouble focusing his/her attention and may feel disoriented. Confusion interferes with the ability to make decisions and may change a person’s personality.

22. Causes of Confusion Low Blood Sugar Head Trauma or Head Injury Dehydration Nutritional Problems Fever Sudden drop in body temperature Constipation Not using Hearing Aids Lack of oxygen Medications Infections Brain Tumor Illness Loss of Sleep Seizures

23. Communication Guidelines for Disorientation Do not leave a confused patient alone. Stay calm. Provide a quiet environment. Speak in a lower tone of voice. Speak clearly and slowly. Introduce yourself each time you see the patient. Remind the patient of his/her location, name, and the date. Repeat directions if needed. Use short, simple sentences. Break tasks into steps. Have patience. Do not rush him/her. Listen to the patient closely. Observe how the patient is communicating. Watch his/her body language. Do not focus on the words alone. Tell the patient about plans for the day. Keep a routine. Encourage the use of glasses and hearing aids. Make sure they are clean and are not damaged. Tell the patient when you are leaving the area. Repeat if needed. Report observations to the nurse.

24. Comatose Coma- state of unconsciousness; a patient cannot respond to any change in the environment, including pain. Can occur due to illness (like meningitis), a condition (like a drug overdose), or injury (such as a motor vehicle accident) A comatose patient deserves your respect in the same way that an alert patient does. Even when people are unconscious, they may still be able to hear what is going on around them. Unconscious people have been known to regain consciousness and relate many of the things they heard while they were unconscious.

25. Communication Guidelines for Comatose Patients Introduce yourself when entering the patient’s room Explain each procedure you will be performing. List the steps you will take. Do not hold personal discussions while caring for a comatose patient. Announce when you are going to leave the room Speak respectfully.

26. Functional Barriers Patients may have a functional problem that interferes with their ability to speak. Some causes of these problems are difficulty in breathing, physical problems with the mouth or lips, or an artificial airway. Physical problems can include mouth sores, dental problems, poorly fitting dentures, birth defects (cleft palate), and paralysis of one side of the mouth due to stroke. An artificial airway is any plastic, metal, or rubber device inserted into the respiratory tract for the purpose of maintaining ventilation. These are needed when the airway is obstructed from illness, injury, secretions, or inhaling fluid into the lungs. Some people who are unconscious will need an artificial airway. Tracheostomy- opening made surgically through the neck into the trachea for the air to reach the lungs

27. Communication Guidelines for Functional Barriers Give the resident plenty of time to speak. Be patient. If a person has difficulty breathing, never push him/her to speak. Ask the patient to write down anything you do not understand. Do not tire the patient. Use a communication board or picture cards if the patient becomes tired. Do not remove a patient’s oxygen for any reason. Only nurses do this.

28. Communication Guidelines for Functional Barriers Report mouth sores, poorly-fitting dentures, or complaints of mouth pain to the nurse. Use other methods of communication if the person cannot speak. Try writing notes, drawing pictures, and using communication boards. Watch for hand and eye signals. Ex: you can use one blink for “yes” and two blinks for “no.” Be reassuring and calm. Be empathetic to the patient’s situation. It can be frightening and uncomfortable to have an artificial airway. Some patients may choke or gag.