Lesson #5 Impairments of Communication Swallowing

1. Lesson #5Impairments of CommunicationSwallowing Rehabilitation Nursing

2. Impairment of Communication

3. 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

4. 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

6. 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

7. 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?

8. Normal Speech Requirements Basic Requirements Levels of Language Production

9. 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

10. 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

11. Brain Damage Areas Specific Language Patterns Communication Problems

12. Aphasia

13. Normal Brain • Normal Speech Center • Located in the dominate cerebral hemisphere • Left hemisphere for a right hand dominate • Right hemisphere for left hand dominate

14. 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

15. Types of Aphasia

16. #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

17. #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

18. #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

19. #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!!

20. #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

21. #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

22. #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

23. #2 Fluent Aphasia

24. #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

25. Wernicke’s Aphasia • Damaged area is left superior temporal area • Major problem is Semantics • Normal Left Temporalbrain responsibilities: • Analysis of sensory impulses • Understand detail • Recognizes and understands sounds • Understands language • Correctly interprets visual information

26. 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

27. 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

28. Nursing ProcessInterventions Communicating to patient with Aphasia

29. 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

30. Impaired CommunicationNursing Diagnosis or Priorities • Impaired Verbal Communication • Impaired Social Interaction • Social Isolation

31. 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

32. 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

33. 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)

35. 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

36. Impaired CommunicationAphasia Interventions • Patient’s without speech need to communicate: • Use picture boards • Facial expressions • Computers (Dynawrite) • I phone App (My voice)

37. Dysarthria Impaired Communication

38. Dysarthria • A problem in forming or articulating words of speech • RT nerve difficulty • CNS nerve damage • Peripheral Nerve damage

39. DysarthriaSigns and Symptoms • Drooling • Chewing motion • Swallowing problems • Important Note: • Can understand language/speech • Dysarthria seen in many neurological disorders

40. Types of Dysarthria • Flaccid • Spastic • Ataxic • Hypokinetic • Hyperkinetic • Mixed

41. 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

42. Impaired Swallowing Dysphagia

43. 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

44. 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

45. 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

46. Normal Swallowing ProcessStages Stage 1 Stage 2 Oral Preparatory Oral(lingual)

47. Normal Swallowing Stages Stage 3 Stage 4 Pharyngeal Stage Esophageal Stage

48. 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

49. 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

50. 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