CHAPTER 19. The Mentally and Physically Challenged Patient
Theresa Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List special considerations in interviewing the mentally challenged patient.
2. List different stages of Alzheimer’s disease and manifestation of limitations in each stage.
3. State effective communication techniques to use with the hearing impaired.
4. Identify techniques to facilitate learning and reduce apprehension for visually impaired patients.
5. Identify manifestations of select physical disabilities and incorporate management of these symptoms and risks in the nursing plan of care.
6. Identify effective techniques related to caring for the pediatric patient with intellectual and/or physical challenges.
I. OVERVIEW
A. According to the Americans with Disabilities Act (ADA) of 1990, a person is considered to have a “disability” if that individual has:
1. A physical and/or mental impairment that substantially limits one or more major life activities
2. A recorded history of such impairments
3. Perceived by others as having such impairments
B. Health care providers and institutions are required to offer the disabled patient full and equal access to the facility’s:
1. Goods
2. ervices
3. rograms
4. Activities
C. Patients with disabilities present significant challenges in providing quality nursing care.
D. Perianesthesia standards for ethical practice require that quality care be given to all patients regardless of their disabilities.
II. THE MENTALLY CHALLENGED PATIENT
A. Communication considerations
1. Communication: an act by means of which one person conveys to another his or her ideas, thoughts, needs, or feelings
2. A person must have some communication channel open to convey information to those around him or her.
3. Communication involves:
a. Getting information to the brain
b. Processing the information
c. Transmitting the brain’s response
4. Normal channels of communication may not be available.
5. Mental ability may be impaired from birth or acquired as a result of disease or injury.
a. Congenital defect
b. Infectious process
c. Trauma
d. Manifestation of a medical problem
e. Psychiatric disorder
6. Level of impairment of developmentally disabled
a. Mild—85%
(1) Slow learner
(2) Rarely asks questions
(3) Answers questions with a minimum of words
(4) Usually functions at a 10-year-old level
(5) Minimal impairment in sensorimotor areas
(6) Usually achieves academic skills necessary for minimum self-support
b. Moderate—10%
(1) Has little or no speech
(2) Understands and can follow simple commands
(3) Can learn simple tasks; may need supervision to perform
(4) May be able to function at a 2- to 6-year-old level
(5) May perform unskilled or semiskilled work under supervision
c. Severe and profound—5%
(1) May learn to perform simple self-care tasks with supervision
(2) Shows basic emotional response
(3) May cause self harm
(4) May function at a 2-year-old level or less
7. Cognitive considerations of the mentally challenged patient
a. Degree of impairment will determine method of instruction.
b. Simple words and phrases are more likely to be understood than complex words and ideas.
c. Common traits
(1) Short attention span
(2) Decreased retention capability
(3) Decreased sensory capability
d. Instructions may be taken very literally.
(1) May need to have basic concepts deconstructed to the essence
(2) Instructions should build on this basic essence.
e. Becomes confused and distracted easily
f. Fearful of changes in environment, loss of familiar routine
g. May have a history of previous bad experiences with health care
8. Mental status—patient may:
a. Be agitated
b. Show aggression
c. Not exhibit any response
d. Have delusions, hallucinations, and/or paranoia
9. Sensory function—patient may have:
a. Visual deficits
b. Auditory deficits
c. Asthenia
10. Communication problems
a. Poor articulation, especially consonants
b. More inarticulate when upset, frustrated, or discussing emotionally charged information
c. Use words that he or she does not really understand.
d. Be eager to please and say what thinks interviewer wants to hear.
e. Need extra time to formulate answers
f. Use sign language, read lips.
g. Use nonverbal forms of communication.
B. Improving communication successes
1. Determine the patient’s strengths and weaknesses.
2. Show respect to the patient.
a. Do not talk down to the patient.
b. Determine the “age appropriateness” of words, remembering not only the “calendar age” of a person but the “mental age” as well.
c. Maintain good eye contact.
3. Be sensitive to nonverbal communication.
a. Do not cover or hide your mouth.
b. Do not mimic how the patient pronounces words.
4. Allow adequate time.
a. Remain calm, relaxed, and unhurried.
b. Maintain a low volume.
c. May need to repeat information
d. May need to reformulate the question
5. Use the name to which the patient is accustomed.
6. Be aware that some patients may have delusions, hallucinations, and/or paranoia.
a. Approach in a calm, nonthreatening, reassuring manner.
b. Avoid activities that may feed into abnormal thinking.
(1) No sudden movement
(2) Avoid standing too close.
(3) Do not whisper or joke in patient’s presence.
(4) Do not show signs of impatience.
(5) Do not touch the patient.
(6) Challenge or agree with patient’s delusions, hallucinations, or paranoia.
7. Communicate slowly and clearly.
a. Use open-ended questions.
b. Be prepared to reword questions if the patient does not grasp the meaning of what is being asked.
c. Avoid running words together.
d. Provide a small pause between words if the patient seems to be struggling.
e. Opt for simple words instead of ones that are complex. The more basic a word is, the better the chance is that it will be understood.
f. Maintain eye contact when possible.
8. Encourage and allow patient independence according to abilities.
9. Include family and caregiver in planning care and instructions as appropriate.
10. Demonstration may be more effective than verbal explanations.
11. Provide frequent reinforcement.
C. Preadmission, preoperative interview and management
1. An in-person interview is preferable to a telephone interview.
a. Nonverbal communication may be as important as verbal communication.
b. Face to face may be a good way to communicate with the person.
c. Allow adequate time for the interview and assessment.
(1) Engage patient to increase desensitization to setting.
2. Determine the patient’s functional ability and needs.
a. Conduct developmental assessment if appropriate.
b. Include the family’s and caregiver’s perceptions about the patient’s abilities.
c. Assess family’s and caregiver’s successful management techniques.
d. Assess use of assistive devices (i.e., glasses, braces, hearing aid).
e. Identify most effective means of communication for the patient.
f. Determine willingness and capability of family and caregiver to participate in preoperative preparation and postoperative care.
3. Determine the patient’s, the family’s, and the caregiver’s knowledge and expectations of the proposed procedure.
4. Complete health history per protocol.
a. Cause of disability
(1) At birth or acquired
(2) Degree of disability
(a) Retains self-determination capabilities
(b) Caregiver shares decision-making.
(c) Durable power of attorney for health care
(d) Appointed legal guardian
b. Consider common health conditions associated with multiple disabilities.
(1) Alimentary—dental caries, high arched palate, gum disease, facial asymmetry, mandible subluxation, jaw and tongue asymmetry, oral sensitivity, inadequate nutrition
(2) Sensory—limited communication abilities, visual and hearing impairment
(3) Cardiovascular—reduced cardiac and lung functions linked to spinal curvature, conduction defects, cardiac anomalies
(4) Respiratory—possible history of aspiration, chronic pneumonitis, and chronic respiratory infections
(5) Musculoskeletal—spinal curvatures such as scoliosis; hyperlordosis; hyperkyphosis; deformities of shoulders, elbows, wrists and hands, knees and feet; hypertonia; hypotonia; fluctuating muscular tone; athetosis
(6) Skin—damage to skin integrity from pressure and incontinence
(7) Elimination—urinary and fecal incontinence, urinary tract infection (UTI), constipation, urinary retention, bowel impaction
(8) Central nervous system—epilepsy, seizures
c. Past illnesses—especially those for which the patient was hospitalized
(1) Coping mechanisms to handle illness-related stress
(2) Length of recuperative period
(3) Frequency of respiratory infections
(4) Normal response to pain
(5) Bladder function difficulties
(6) Bowel function difficulties
d. Other health problems
(1) Congenital heart defect and other cardiovascular disorders
(2) Diabetes—mellitus, insipidus
(3) Seizures
(a) Time of last seizure
(b) Frequency of seizures
(c) Description of seizures
(4) Elicit if any other problems.
e. Medications
(1) Current medication use
(a) Prescription
(b) Over-the-counter
(c) Herbal preparations
(d) Dietary supplements
(2) Behavior changes caused by medications
(3) Previous response to medications
f. Allergies
(1) Medications
(2) Environmental
(3) Food
(4) Latex
(5) Tape
(6) Type of reactions to allergies
g. Nutritional requirements and modifications
(1) Special dietary restrictions
(2) Food consistency
(3) Preferences
(4) Ability to swallow
(5) Ability to eat independently or amount of assistance needed
h. Usual behavior
(1) Patient’s interaction with people and environment
(2) Orientation to time and place
(3) Emotional stability
(a) Mood swings
(b) Potential for violence
(c) Panic attacks
(d) Hallucinations, delusions, paranoia
(4) State of consciousness
(5) Language ability
5. Physical assessment per protocol
a. Vital signs and oxygen saturation (vital signs usually within expected range for size and age)
(1) Past tendency for pronounced temperature deviations
b. Body size
(1) Obese
(2) Emaciated
c. Skin color and blemishes may provide clues to other illnesses.
(1) Pallor may indicate anemia.
(2) Uneven coloring and/or mottling may indicate poor neural functioning of the autonomic system.
(3) Excessive pigmentation (freckles) could indicate pathology.
(4) Multiple café au lait spots indicate neurofibromatosis (von Recklinghausen’s disease).
(5) Port wine stain on the face along the trigeminal nerve may indicate Sturge-Weber syndrome.
d. Differences in skin temperature, skin turgor
e. Defects of the craniofacial area
(1) Anatomical deformities that interfere with intubation
(2) Weakness of pharyngeal muscles
(3) Large tongue
f. Joint deformities
(1) Pain on movement
(2) Muscle strength
(3) Involuntary movements or spasms
(4) Altered stance, gait, or posture
(5) Contractures
g. Deficits in hearing or vision
6. Psychosocial assessment per protocol
a. Anxiety
(1) Fear of strange environment
(2) Loss of independence
(3) Change in daily routine
b. Support system
(1) Ensure competent and willing adult to assist with preoperative care and after discharge.
(2) May need early social service referral for discharge care
7. Develop a plan of care based on the assessment of the patient’s and caregiver’s knowledge and needs.
8. Preoperative teaching per protocol and using techniques listed in prior sections
a. Explain what will happen in simple terms.
b. Explain what to expect preoperatively and immediate postoperatively.
c. Determine the patient’s regular schedule and incorporate that schedule into the hospital routine whenever possible.
d. Include family and caregiver in the preoperative and postoperative preparations.
e. Encourage the patient to bring some familiar comfort item from home.
f. Demonstrate preoperative preparation or postoperative exercises and/or treatments and have the patient or caregiver do a return demonstration.
g. Nothing by mouth (NPO) requirements—consider harm of extensive NPO time element to patient’s emotional well-being.
h. Medications to take or hold
(1) Maintain regular dose schedule as much as possible.
(2) Keep in mind the interactions with anesthesia of tricyclic antidepressants and monoamine oxidase inhibitors when giving instructions—seek clarification from the anesthesia provider if necessary.
i. Pain scale (modify to suit patient’s learning ability)
(1) Demonstrate use of pain scale to patient.
(2) Have patient return demonstration.
j. Ensure that appropriate person will be available to sign necessary consents.
k. Ensure arrangements for safe transport to and from the hospital.
l. Ensure that there will be a responsible adult to assist with care after discharge.
9. Complete preparation for admission per protocol.
a. Make referrals as necessary.
b. Preoperative testing as ordered
c. Document and communicate special needs to the perianesthesia staff.
D. Day of admission (Box 19-1)
BOX 19-1
ADMISSION PROCEDURE
▪ Review data collected during preadmission interview.
▪ Verify compliance to preoperative instructions with patient, family, and caregiver.
▪ Verify safe transportation home and competent adult help at home.
▪ Verify consents are appropriately signed.
▪ Perform physical assessment (history and physical per policy).
▪ Provide emotional support to patient and family and caregiver.
▪ Institute appropriate nursing measures to decrease anxiety.
▪ Decrease stimulation in the waiting area.
▪ Limit number of personnel who interact with the patient while providing continuity.
▪ Allow family and caregiver to remain with the patient as long as possible.
▪ Allow patient to use assistive devices as long as possible.
▪ Consider preoperative medications to decrease anxiety.
▪ Consider applying topical anesthetics at least 1 hour before IV insertion.
▪ Maintain a calm, unhurried, and accepting attitude.
▪ Call patient by name he or she is most familiar with.
▪ Allow patient to take comfort item to surgery if permissible.
▪ Prepare patient for procedure per protocol.
▪ Communicate patient’s special needs to all members of the health care team (surgical, anesthesia, and perianesthesia team members).
IV, Intravenous line.
E. Preoperative holding and intraoperative (Box 19-2)
BOX 19-2
PREOPERATIVE HOLDING AND INTRAOPERATIVE
▪ Whenever possible, have the PACU nurse meet the patient beforehand so that the patient will recognize and be comforted by a familiar face in an unfamiliar and frightening environment.
▪ Review collected data.
▪ Provide routine care per protocol.
▪ Provide emotional support.
▪ Use the name with which the patient is familiar.
▪ Reassure the patient you are with him or her; touch patient if it will provide comfort.
▪ Allow patient to keep comfort item.
▪ Whenever possible, allow patient to keep hearing aid, glasses, etc.
▪ Maintain normothermia, taking care not to overheat.
▪ When moving patient, lift rather than pull, especially if joint deformities are present.
▪ Communicate the patient’s special needs to the PACU staff.
PACU, Post anesthesia care unit.
F. Phase I (Box 19-3)
BOX 19-3
PHASE I
▪ Review collected data.
▪ Provide routine care per PACU protocol and ASPAN Standards.
▪ Be alert for agitation, disorientation, or combative behavior.
▪ Minimize risk of aspiration.
▪ Observe for return of gag and swallowing reflexes.
▪ Elevate head of bed if not contraindicated.
▪ Suction as necessary.
▪ Position on side if not contraindicated.
▪ Provide for safety—use restraints for protection only as a last resort to prevent injury (refer to facility policy on restraint use).
▪ Assess frequently for pain, administer medication, and monitor response as indicated.
▪ Recognize patient may not be able to tell you pain is present.
▪ Be attuned to nonverbal communication.
▪ Provide emotional support.
▪ Use the name with which the patient is familiar.
▪ Provide reassurance to the patient that you are present.
▪ Allow use of comfort item if sent with a patient.
▪ Reorient patient to surroundings.
▪ Allow use of assistive devices as soon as possible.
▪ Have a family member and caregiver with the patient if possible.
▪ Communicate patient’s special needs to phase II team.
ASPAN, American Society of PeriAnesthesia Nurses; PACU, post anesthesia care unit.
G. Phase II (Box 19-4)
BOX 19-4
PHASE II
▪ The patient may return to phase II directly from the operating room (fast-tracking).
▪ Patient may be disoriented, combative, or agitated.
▪ Review collected data.
▪ Provide routine care per protocol and ASPAN Standards.
▪ Minimize risk of aspiration.
▪ Observe for return of gag and swallowing reflexes.
▪ Elevate the head of bed if not contraindicated.
▪ Suction as necessary.
▪ Position on side if not contraindicated.
▪ Use caution when giving liquids or solids.
▪ Assess for pain level per protocol.
▪ Use a pain scale that is appropriate for the patient.
▪ Medicate as needed and observe for response.
▪ Use relaxation methods as appropriate.
▪ Document reactions to interventions.
▪ Provide emotional support.
▪ Allow family and caregiver to be with patient as soon as possible.
▪ Allow use of assistive devices as soon as possible.
▪ Reorient to surroundings.
▪ Prepare for discharge.
▪ Verify safe transportation home and competent adult to care for patient at home.
▪ Include family and caregiver when reviewing instructions; if a procedure is to be done at home, have patient or caregiver perform a return demonstration.
▪ Recognize the possible need to give instructions to protect operative site based on patient’s psychological needs.
▪ Provide written as well as verbal home care instructions.
▪ Use large type if necessary for written instructions.
▪ It may be necessary to use a tape recorder if reading skills are inadequate.
▪ Obtain a phone number to reach the patient and caregiver for postoperative follow-up phone call.
▪ Give appropriate phone numbers so the patient and caregiver can obtain assistance if questions or problems arise at home.
ASPAN, American Society of PeriAnesthesia Nurses.
H. Postdischarge (Box 19-5)
BOX 19-5
POSTDISCHARGE
▪ Contact patient and caregiver within 24 hours of discharge.
▪ Identify yourself and state purpose of the call.
▪ Identify compliance with postoperative instructions.
▪ Identify potential complications:
▪ Unrelieved pain and nausea
▪ Unexpected or excessive bleeding or swelling
▪ Elevated temperature
▪ Redness or drainage from operative site
▪ Other adverse occurrences
▪ Refer to appropriate physician or agency as necessary.
▪ Complete postdischarge assessment per facility protocol.
III. ALZHEIMER’S DISEASE
A. Background information
1. Alzheimer’s disease (AD): a complex progressive, ultimately fatal, neurodegenerative disorder.
a. Certain types of nerve cells in particular areas of the brain degenerate and die.
b. Affected cells include cortical pathways involved in:
(1) Catecholaminergic
(2) Serotonergic
(3) Cholinergic transmission
c. Advancing pathology leads to the classic clinical symptoms.
(1) Memory loss
(2) Changes in personality
(3) Noticeable decline in cognitive abilities (including speech and understanding)
(4) Loss of executive function (decision-making)
(5) Losses impairing activities of daily living (ADLs; dressing, eating, toileting, etc.)
d. Most common cause of dementia in people 65 years or older
2. Stages of progression
a. Forgetful stage—changes in:
(1) Short-term memory
(2) Depression
(3) Conflict with others
(4) Expressive aphasia
(5) Frustration
b. Confused stage:
(1) Agnosia (inability to recognize common objects)
(2) Decreased time sense
(3) Withdrawn
(4) Impaired reading abilities
(5) Difficulty managing daily activities (money, driving, cooking, cleaning)
(6) Wandering, night walking, walking without lifting feet
(7) Belligerence
(8) Confusion
(9) Paranoia
(10) Agitation
(11) Delusions
(12) Aggression
c. Demented stage:
(1) Loss of ability to perform ADLs
(2) Decreased awareness
(3) Repetitive behaviors
(4) Decline in language ability
d. End-stage dementia—loss of purposeful mobility, loss of communication, dependence in ADLs. Patient is at risk for:
(1) Contractures
(2) Weight loss
(3) Skin breakdown
(4) Repeated infections
(5) Aspiration
3. Treatment—stabilize symptoms and minimize or prevent behavioral problems.
a. Acetylcholinesterase inhibitor drugs temporarily delay worsening cognitive symptoms.
(1) Donepezil hydrochloride (Aricept)
(2) Rivastigmine (Exelon)
(3) Galantamine (Reminyl)
b. Vitamin E—may delay the progression from one stage to the next
(1) Antioxidant properties
(2) Doses prescribed range from 400 to 1200 IU twice per day.
c. Behavioral modification for agitation
4. Symptoms are exacerbated by:
a. Illness, disease
b. Increased temperature
c. Dehydration
d. Medications, including anesthesia
e. Tests, treatments
f. Changes in routine
g. Unfamiliar people, sights, sounds, smells
B. Preadmission and preoperative interview and management
1. Patient may not be able to provide information.
2. Determine the patient’s level of ability with input from family and caregiver.
3. Determine the patient’s and family’s understanding of AD.
4. Determine the family’s willingness and ability to participate in preoperative preparation and postoperative care.
5. Provide a safe, comfortable environment without distraction and allow enough time for interview and assessment.
a. Include family and caregiver to decrease anxiety and agitation and increase compliance.
b. Include the patient in discussions about his or her procedure.
(1) Establish eye contact, talk in a low-pitched, reassuring tone using patient’s name.
(2) Speak slowly and clearly using short, simple sentences with familiar words.
(3) Ask one question at a time.
(4) Ask yes or no questions.
(5) Allow 20 to 30 seconds for patient to answer question.
(6) Give simple directions, one step at a time.
(7) Because of patient’s short-term memory loss, be prepared to repeat information frequently.
(8) Patient may respond to mood of situation more than words spoken.
(9) Overstimulation of environment or pressure to answer questions may make patient more confused, agitated, aggressive.
(10) Be alert to patient’s nonverbal communication.
(11) Do not leave patient alone because he or she may wander away.
6. Assessment per protocol
a. Abilities and needs of the patient
(1) Caregiver’s and family’s successful management techniques
(2) Use of assistive devices
(3) Effective method of communication
(4) Normal daily routine for patient
b. Degree of disability
(1) Retains self-determination capabilities
(2) Family shares decision-making.
(3) Has durable power of attorney for health care
(4) Legal guardian appointed
7. Complete health history per protocol
a. Swallowing problems
b. History of aspiration
c. Triggers for agitation
8. Physical assessment per protocol
a. At risk for aspiration caused by:
(1) Decreased level of consciousness
(2) Decreased cough and gag reflexes
(3) Impaired swallowing mechanism
b. Patients treated with Ginkgo biloba or vitamin E may be at increased risk of bleeding.
(1) Observe for bruising.
(2) Consult with primary care physician about stopping or adjusting dosage before surgery.
9. Psychosocial assessment per protocol
a. Support system
(1) Possible lack of support system related to:
(a) Personality changes
(b) Altered behavior patterns
(c) Depression
(d) Inability to interact in an adult manner
(e) Delusions
(f) Socially unacceptable behavior
(2) Consider early referral to social services for discharge planning.
(3) Arrangements for safe transportation to and from the hospital
(4) Arrangements for willing, competent adult in home for postdischarge care
b. Anxiety—symptom for all stages of AD
(1) One nurse as much as possible for continuity of care and familiarity
(2) State name and purpose of encounter every time.
(3) Orient patient frequently.
10. Develop a plan of care based on patient’s and family’s and caregiver’s knowledge and needs.
11. Preoperative teaching per protocol
a. Include family and caregiver—patient is likely to forget instructions.
b. Present small amount of information at one time.
c. Give written as well as verbal instructions.
12. Complete preparation for admission per protocol.
a. Referrals as necessary
b. Preoperative tests as ordered
C. Admission for procedure (see Box 19-1)
1. Provide safe, calm, unhurried environment.
a. Use one nurse for care and approach as outlined in previous section.
(1) State name and what is happening every time.
(2) Orient patient to surroundings frequently.
(3) Explain actions before proceeding.
(4) If becomes agitated, pat or hold hand gently—avoid physical contact that could seem restraining.
b. Keep bed low, side rails up, family and caregiver at bedside.
2. Cognitive assessment
a. Memory loss
b. Confusion and disorientation
c. Agitation
D. Preoperative holding and intraoperative (see Box 19-2)
1. Use care when moving the patient.
a. Lift rather than pull to protect skin.
b. Protect bony prominences by positioning and use of padding.
2. Restraints are likely to cause agitation.
a. May need sedation before applying restraints necessary for procedure
b. Will need distraction from restraints if awake
3. Patient may be at risk for aspiration—more common in the later stages of AD.
a. Elevate the head of the bed if possible.
b. Suction as needed.
c. Position on side if possible.
4. May have an impaired cholinergic system. Avoid anticholinergic medicines such as atropine and scopolamine that may result in untoward behavioral activity.
E. Phase I (see Box 19-3)
1. Pain frequently undertreated because of cognitive disability
a. Pay attention to nonverbal clues.
b. Observe carefully for response to pain medication.
2. Increased risk of bleeding if has been taking Ginkgo biloba or vitamin E supplements
3. May be agitated, combative, confused
a. Repeated orientation to surroundings
b. Use one nurse for care.
c. Use nasal cannulas rather than mask.
d. Turn down sound from bedside monitors.
e. May need to wrap intravenous line in gauze or put on stockinette sleeve
f. If nasogastric tube in place, tape behind ear and fasten to gown’s shoulder.
g. Consider dehydration as contributing cause.
h. Observe for bladder distention.
i. Allow use of assistive devices as soon as possible.
j. Return to area with family and caretaker as soon as possible.
k. Avoid restraints if at all possible.
F. Phase II (see Box 19-4)
1. May be at risk for aspiration
a. May need to remind the patient to swallow
b. Elevate the head of the bed if possible.
c. Suction as needed.
d. Position on side if not contraindicated.
e. Use caution when giving liquids and solids.
2. Patient may be confused and/or combative.
a. Frequently orient patient to surroundings.
b. Allow family and caregiver to be with patient.
c. Allow use of assistive devices as soon as possible.
d. Provide safe environment, nursing interventions as listed in prior sections.
3. Pain is frequently undertreated because of cognitive disability.
a. Pay attention to nonverbal clues.
b. Observe carefully for response to pain medication.
4. Discharge
a. Patient will benefit from returning to familiar environment as soon as possible.
b. Verify safe transportation home.
G. Postdischarge (see Box 19-5)
IV. HEARING IMPAIRMENT
A. Background information
1. Estimated 28 million U.S. citizens have hearing impairments.
a. Leading disability in America
b. Affects 30% of patients 65 years and older
c. Affects more than 50% of those older than 75
2. Definitions
a. Deaf: unable to hear or understand oral communications with or without the aid of amplification devices
b. Hard of hearing: a hearing loss severe enough to necessitate use of amplification devices to hear oral communication
3. Types of hearing impairment
a. Conductive hearing loss—reduced ability of sound to be transmitted to middle ear
b. Sensorineural—reduced hearing resulting from damage to inner ear or neural brain pathways
c. Mixed—combination of conductive and sensorineural impairments
d. Central—auditory compromise at the level of the brain
4. Hearing deficit is not reflective of low intelligence.
5. Not all hearing impaired people can read lips or use sign language.
6. Only about 20% to 30% of words are readable on the lips.
B. Techniques for effective communication with the hearing impaired in any setting
1. Provide an environment for effective communication.
a. Provide a quiet, distraction-free area.
b. Provide adequate lighting.
c. Provide interpreter if necessary.
d. Supply a battery-powered microphone with earpiece if applicable.
e. Allow patient to choose appropriate seating arrangement.
2. Get patient’s attention before speaking.
a. Approach within the patient’s line of vision; face patient directly.
b. Wave hand.
c. Touch gently as to avoid startling the patient.
3. Determine the patient’s preferred method of communication.
a. Hearing aid
b. Lip reading
c. Sign language
d. Written messages
e. Alphabet, picture, word or phrase board
f. Combination of methods
4. For lip reading and/or hearing augmented by hearing aids
a. Sit or stand directly in front of the patient.
b. Keep mouth visible when speaking.
c. Do not chew gum or food.
d. Maintain comfortable voice volume.
e. Speak slowly and distinctly; do not exaggerate your pronunciation.
f. Use smallest number of words to convey the message.
g. Maintain eye contact.
5. Working with an interpreter
a. The interpreter is used to transmit information, not to explain information or give opinions.
b. Stand or sit across from the patient with the interpreter beside you.
c. Speak at a normal tone and face the patient directly.
d. Ask the patient, not the interpreter, to clarify information if not understood.
C. Preadmission and preoperative interview and management
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1. An in-person interview facilitates the patient’s participation, especially if he or she relies on lip reading or gestures.
a. Determine whether an interpreter for sign language will be needed to communicate with the patient.
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