promoting effective communication for patients receiving

Irene Grossbach, Sarah Stranberg and Linda ChlanPromoting Effective Communication for Patients Receiving Mechanical Ventilation

originally published online August 31, 2010Published online http://www.cconline.org © 2011 American Association of Critical-Care Nurses

2011, 31:46-60. doi: 10.4037/ccn2010728Crit Care Nurse

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Critical care staff whomanage intubatedpatients often experiencedifficulties with one ofthe most basic human

functions: communication. Patientswith endotracheal or tracheostomytubes are unable to communicateverbally because of the placement ofthe tube and inflation of the tube’s

cuff, which prevents passage of airacross the vocal cords. Despite theinability to produce speech, thesepatients can communicate effectivelyvia other methods. Intubated patientscommunicate with nurses, other cli-nicians, and family members prima-rily through gestures, head nods,mouthing of words, and writing.1

Other communication methodsinclude letter/picture boards, listsof common words or phrases tailoredto meet individual patients’ needs,

Promoting Effective Communication for Patients Receiving Mechanical Ventilation

and high-tech alternative communi-cation devices. Various options forpatients with a tracheostomy tubeinclude partial or total cuff defla-tion and use of a speaking valve incertain patients who are in stablecondition. Specially designed tra-cheostomy tubes are also availableto allow speaking while the cuff ofthe tracheostomy tube is inflated.

Although communication withpatients in the intensive care unit(ICU) is usually focused on basicneeds related to physical comfortsuch as positioning or suctioning,communication is often an impor-tant component of end-of-life deci-sion making. Patients may need toexpress their final wishes to family,friends, and providers.2 The goal isto enhance a patient’s ability toexpress their needs and wishes tostaff and to their loved ones fullyand effectively. Various sophisticatedmethods are available for complexcases. In this article, we review vari-ous strategies to promote effectivecommunication between patients

Irene Grossbach, RN, MSNSarah Stranberg, MA, CCC-SLPLinda Chlan, RN, PhD

Feature

©2010 American Association of Critical-Care Nurses doi: 10.4037/ccn2010728

Communicating effectively with ventilator-dependent patients is essential so thatvarious basic physiological and psychological needs can be conveyed and decisions,wishes, and desires about the plan of care and end-of-life decision making can beexpressed. Numerous methods can be used to communicate, including gestures,head nods, mouthing of words, writing, use of letter/picture boards and commonwords or phrases tailored to meet individualized patients’ needs. High-tech alterna-tive communication devices are available for more complex cases. Various optionsfor patients with a tracheostomy tube include partial or total cuff deflation and useof a speaking valve. It is important for nurses to assess communication needs; iden-tify appropriate alternative communication strategies; create a customized careplan with the patient, the patient’s family, and other team members; ensure that thecare plan is visible and accessible to all staff interacting with the patient; and con-tinue to collaborate with colleagues from all disciplines to promote effective com-munication with nonvocal patients. (Critical Care Nurse. 2011;31[3]:46-61)

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receiving mechanical ventilation,health care staff, and patients’ familymembers.

Challenge of Effective Communication With Nonvocal Patients ReceivingMechanical Ventilation

Determining an alternative, effec-tive communication system requirescollaboration between staff, a patient’sfamily, and the patient. Difficultieswith communication often causeanxiety, frustration, and fear inpatients.3,4 Increased respiratory ratecan create breathing discomfort andthe need to make ventilator adjust-ments promptly to match the fasterbreathing pattern or provide optimalventilation support.4 Directing thepatient to calm down and breathewith the machine is inappropriateand usually ineffective.

Patients who have been emer-gently intubated may need initialreminders and short explanationssuch as “you have a tube in your throatto help you breathe” and “you can-not speak when the tube is in place.”Other simple words of encourage-ment and support may include “youare doing well,” “everything is OK—we are helping you get better,” and“your breathing will feel better.” Thepatient may be able to communicate

basic responses more effectively ifstaff ask one question at a time toelicit a yes/no response and givesimple directions such as “nod yourhead” or “squeeze my hand.” Acalming reassuring voice, confidentapproach, and therapeutic touchmay help alleviate this anxiety-pro-ducing situation.

More time is available to prepareelectively intubated patients andtheir family members. These patientscan be provided with detailed infor-mation about the location of theendotracheal or tracheostomy tube,why the patient will not be able tocommunicate verbally, and whatmethods to communicate can beused while receiving mechanicalventilation. An educational pam-phlet about the endotracheal or tra-cheostomy tube, the ventilator, andhow to communicate can be givento the patient’s family and the patientas appropriate (Table 1).

Nursing staff can improve apatient’s experience, frustration level,and outcome by using strategies toimprove communication3 with non-vocal patients and by creating orcustomizing a plan that meets thepatient’s needs. The patient careplan and specific methods shouldbe readily available for use by allmembers of the health care team

who interact with the patient. It isalso essential to involve and educatethe patient’s family members so thatthey can communicate effectively.These efforts may help the patientand the patient’s family feel lessanxious and fearful.

Families want to be included ascaregivers when patients are in anICU. A familiar voice and touch canhave a calming effect on a frightenedor upset patient. Relatives have empa-thy for the patient and recognize thepatient’s nonverbal cues such asfacial expressions of fear and restlessphysical movements. They have adeep understanding of the patient’sneeds, which can be helpful to thehealth care team.5 However, whenrelatives experience difficulties com-municating with their loved one, theymay feel a sense of loss because ofthe lack of response from the patient.6

Appropriate, warm physical touchmay provide some benefit.7

Communication StrategiesNumerous strategies are avail-

able for improving communicationwith patients in the ICU. Many ofthese techniques are simple and/orinvolve very basic materials at thebedside. The following 6 strategiesfacilitate successful communicationwith patients receiving mechanicalventilator support: (1) Establish acommunication-friendly environ-ment. (2) Assess functional skillsthat affect communication. (3)Anticipate patients’ needs. (4) Facili-tate lipreading. (5) Use alternativeand augmentative communicationdevices. (6) Educate the patient, thepatient’s family, and staff aboutcommunication strategies. Thesestrategies are addressed in detail inthe following sections.

Irene Grossbach practiced as a pulmonary clinical nurse specialist for 28 years and is anadjunct assistant professor in the School of Nursing at the University of Minnesota inMinneapolis.

Sarah Stranberg is a speech-language pathologist and a clinical specialist at the Universityof Minnesota Medical Center, Fairview, in Minneapolis.

Linda Chlan is an associate professor in the School of Nursing at the University of Minnesotain Minneapolis.Corresponding author: Irene Grossbach, RN, MSN, 3043 East Calhoun Pkwy, Minneapolis, MN 55408 (e-mail:[email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

Authors

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Table 1 Patient Education Pamphlet: Ventilator

Your doctor has ordered a ventilator for you. This booklet will help answer questions you and your family may have.

What is a ventilator?A ventilator is a machine that helps your breathing. It is also called a respirator or a breathing machine. It is a large square machine that sits

at your bedside. The ventilator gives you a certain number of breaths every minute. The machine does the work your lungs usually do.

Why do I need a ventilator?You may need a ventilator if you do not have enough oxygen or if you have too much carbon dioxide in your bloodstream. It can help

decrease your shortness of breath and work of breathing so you feel more comfortable. If you are having surgery, the anesthesia mayprevent your breathing muscles from working. When the anesthesia wears off, normal breathing will return and you will not need theventilator. People may need the help of a ventilator for a variety of problems, including pneumonia, emphysema, asthma, and diseasesthat cause breathing muscles to become weak or paralyzed. You need a ventilator because ______________________________ ___.

How does the ventilator work?The doctor guides a tube into your main airway (trachea)

through either your nose or mouth (Figure 1). This tube con-nects to the ventilator, which is set to give you the air andoxygen that you need to help your breathing. Your lungs fillwith air similar to gently blowing up a balloon. A chest x-rayis done to make sure the tube is in the best position. Clothties or tape or special holders keep the tube in place.

Some people have a hole placed in their neck and a tra-cheostomy or “trach” tube is in place. In this case, the venti-lator is connected to the tracheostomy tube (Figure 1).

How will you know if I am getting the right amount of air?You may be hooked up to a monitor that measures your oxygen

level in your blood or “O2 saturation.” A blood sample, calledarterial blood gas or ABG, may be drawn from an artery tocheck your oxygen and carbon dioxide levels. Ventilator set-tings will be changed as needed to meet your breathingneeds.

Will I be able to talk?You can speak because air passes by and vibrates your vocal

cords or voice box. When the breathing tube is in, you willnot be able to talk because of the tube position. The tubepasses through your vocal cords and a balloon is inflated sothat no air can go past your vocal cords for speaking. Youwill be able to speak when the tube is removed. One of themajor frustrations for you can be the decreased ability to talk.There are ways to help you and your family communicate.

• Write: Your nurse will keep a pencil, clipboard, and paper at the bedside for you.• Nod your head up and down: Visitors should ask simple yes/no questions and only one question at a time. Avoid asking

questions that require long answers, detailed conversation, or more than one answer.• Use hand or facial gestures to convey what you need, • Have people read your lips as you mouth words. This method does not work as well if the tube is in your mouth.• Point to letters or pictures or common phrases on a letter, picture, or phrase board. The intensive care unit has a supply of these for

you to use, if needed.• Write down common needs (Suction me, Turn me, I am having pain, I am uncomfortable, I can’t breathe, How am I doing? Please

untie my hands, Where is my family? How long will the tube be in? When is the tube coming out?)• If you know you may be on a ventilator after surgery, discuss ways to communicate with your family.• Wear your glasses and hearing aid, if needed, for reading, writing, and hearing.

Your nurse will work with you to understand what you want to communicate. There are many other methods of communicating for peoplewho need the ventilator for long periods of time.

Can I eat?The position of the breathing tube may make it hard to swallow. You will not be able to eat solid food. You may be able to keep your

mouth moist by having it swabbed with a small mouth sponge or ice chips, depending on your situation. How long you are on theventilator will affect how you are fed. Most people are fed by liquids given through a needle in a vein or through a feeding tube placedin the stomach. If you have a tracheostomy, you may be evaluated to determine whether you can eat food and drink liquids.

Continued

Figure 1 A tube is placed in the nose or mouth. Some peoplemay need a tracheostomy tube.

Tube placedin nose

Windpipe (trachea)

Tracheostomy tube

Voice box

Tube placedin mouth



Establish a Communication-Friendly Environment

Staff working in a critical careenvironment often become accus-tomed to the abundant sensorystimulation. Most critical care nurseshave mastered the ability to focusattention on a specific task or inter-action despite a multitude of distrac-tions. Patients and their families maynot be familiar with this environ-ment, which can significantly affectcommunication. The followingadaptations may be helpful.

Adjust your proximity and posi-tion so that you are visible to thepatient. Staff often attempt commu-nicating with patients when theyare across the room or behind otherequipment, such as ventilators.

Speak directly to the patient. Itis often easy to look up and speakfacing family members who are ableto participate in conversations eas-ily. Facing the patient directly may

require repositioning the patient ifmedically possible.

Ensure that the lighting is ade-quate for the patient to see thespeaker and/or communicationboards. Improve lipreading bymaking light fall on the patient’sface. Reduce background noise andactivity, perhaps by turning off thetelevision or radio, decreasing addi-tional conversations occurring inthe room, and closing the door.

Assess Functional Skills ThatAffect Communication

In addition to their current con-ditions, patients enter the ICU withpersonal characteristics and func-tional abilities that can affect theirability to communicate and interactin this challenging environment.Areas to assess include auditory andvisual acuity, whether the person isright- or left-handed, musclestrength for writing, and language

for speaking and literacy. Table 2presents a user-friendly and compre-hensive communication assessmenttool we developed for use with non-vocal patients.

Auditory Acuity. The acute careunit is a difficult environment forpatients with any degree of hearingimpairment because of the variedbackground noises emitted by equip-ment. Although necessary equipmentcannot be eliminated, it is importantto establish a communication-friendly environment. Determine ifthe hearing-impaired patient wearshearing aids and whether the hear-ing aids are at the hospital and work-ing properly. Ensure that thehearing aid that is in place has noaudible feedback, a common prob-lem due to patients’ positioning.Hearing aid batteries and basic sup-plies for cleaning should be readilyavailable. If the hearing loss is newand unexplained, the attending

Table 1 Continued

Will I feel pain?Some people are given medication so they do not remember the tube being put in. Other people may be uncomfortable while the

breathing tube is being put in. A medicated spray will numb your nose and mouth before the breathing tube is placed. This spray willhelp make you more comfortable. Your doctor may order a sedative or pain medication for you while you are on the ventilator.

Can I get out of bed?You should stay in bed. Your position will be changed at least every 2 hours or more often if you desire. You may sit up in bed and turn

from side to side. Sometimes people can get out of bed, stand, walk, and sit on a chair.

Will I be able to cough?You will be able to cough but will need help clearing secretions. The nurse or respiratory therapist will put a catheter (a small flexible tube)

into the breathing tube and suction out the secretions. This may need to be done often, depending on the amount of secretions in the tube.

Can I wear dentures?If the breathing tube is in your mouth, you cannot wear your dentures. If the breathing tube is in your nose, you can wear your dentures

if wearing them makes you feel better.

How long will I need the ventilator?This depends on your condition. Some people need ventilator support for only a few hours, while other people need support for days or

weeks or months. The nurses, respiratory therapists, and doctors will work to improve your condition so you spend as little time aspossible on the ventilator. When your condition improves, a process of discontinuing the ventilator or “weaning” is done. The machineis set so you are doing the breathing on your own. If your breathing is comfortable and your arterial blood gas looks good, thebreathing tube is removed.

Being on a ventilator may cause anxiety, fear, and discomfort. If needed, the doctor will order a sedative or pain medication for you.Understanding why you are on the ventilator, what to expect when you are on the ventilator, and how to communicate your needs canbe very helpful to calm and reassure you. Your nurses and doctors will try to make this a less frightening experience for you. Pleaseshare this booklet with your family. Feel free to ask your doctor or nurse any questions you may have.



physician and pharmacist should benotified to determine whether thepatient is experiencing ototoxiceffects from prescribed medications.The ear canal should be inspectedand cleaned of wax.

Most hospitals have basic ampli-fier equipment, or assistive listen-ing devices, to improve hearing. Acommon assistive listening device isthe Pocketalker Personal Amplifier(Williams Sound Corp, Eden Prairie,Minnesota), which consists of head-phones for the hearing-impaired

person to wear and a microphonedevice that can amplify the speechof the other talker (Figure 2).

Visual Acuity. Glasses may beessential to visualize items on acommunication device. Evaluatewhether the patient wears glassesfor reading and if they are available.Clean and position properly, espe-cially if a patient requires bifocallenses. Screen patients for neuro-logical deficits such as field cuts orvisual neglect, which may interferewith their ability to communicate.

Handedness. Determine whichhand is used for writing or use of acommunication board. If the patienthas a new hemiparesis affecting thedominant hand, it can affect the abil-ity to point to items on some boards.

Assess Muscle Strength. Commu-nication boards may need to bemodified to accommodate theselimitations, including locating themost common needs at an “easy-topoint-at” spot on the board. Use ofrestraints on a patient’s dominanthand will hinder their ability to write,

Table 2 Communication Assessment Tool for nonvocal patients

Directions: Communication plan should be kept at the bedside and/or designated computer location so it is readily available to all healthcare team members and the patient’s family. Update as needed.

Date assessed: ______ with patient ______ with family member _______ both _____

Mental status: alert, appropriate----lethargic, confused----comatoseLanguage: English: Yes No Other (List) ____________Hearing: Normal Impaired (R,L) Hearing aid: Yes NoVision: Normal Impaired Needs glasses for reading: Yes NoWriting: Right Left Grasps writing device: Yes No Unable due to hands: weak--- swollen---paralyzedLiteracy (reads, spells): Yes No Aphasia: Yes No (If yes, consult speech therapy)Neuromuscular weakness, paralysis: Yes (Explain) _________________ NoAble to use standard call light system Yes No (Select adaptive system)_______________________________________________________________Effective communication system(s) for this patient:____Nods head up, down to yes/no questions____Clipboard, pad, pencil _____hand____Lip-read____Picture board____Letter board____Word board____Regular call light system____Needs adaptive call light system. Proper placement for use __________________

Severe weakness, paralysis_____Blinks eyes 1 blink = yes, 2 blinks = no_____Moves eyes toward head for yes, closes eyes for no_____Needs advanced system; speech consult sent________________________________________Details of effective communication system for Mr/Ms ____________________Example:12/6/08 Mr L communicates by nodding head to yes/no questions, needs glasses for reading and writes with right hand-elevate HOB at

least 40°, points to picture board—usual issues have been pain, needs frequent position change, likes ROM to legs and wants radioon (AM 1500 or FM 100)

12/10 Update—same communication system as 12/6 except patient unable to write because hands swollen, weak, can’t grasp. Discon-tinue pad, pencil for now

12/13 Bilateral hearing loss—MD notified, no ear wax—use Pocketalker in room12/15 No change

Abbreviations: HOB, head of bed; L, left; R, right; ROM, range of motion exercises.



gesture, or point to items on a com-munication board.

Language. If a patient does notspeak/understand English, a hospi-tal interpreter can be extremelyhelpful for developing communica-tion tools. Picture boards may workbetter than word/phrase/letterboards for non-native English speak-ers or aphasic patients because pic-tures do not rely on language skills.

Literacy. A patient’s impairedability to read/spell can be a com-plicating factor if staff membersattempt to use a letter board orphrase lists. In these situations, useof pictures may be more appropri-ate to facilitate communication.

Anticipate Patients’ NeedsGestures have been identified as

the communication method usedmost often by ventilator-dependentpatients.2 Gestures can be misinter-preted as anxiety8 when the patientis really just attempting to convey amessage and be understood. A rest-less, diaphoretic, and grimacingpatient with a high respiratory ratemay be in pain. A frustrated patienttrying to communicate becomesmore anxious.

The nursemay administera sedativeand/or applyrestraints whenthe more appro-priate manage-ment would beto identify andimplementcommunicationstrategies thatmeet the partic-ular needs ofthat patient and

enable the patient to communicateeffectively. The following strategiesare helpful in resolving problems toensure successful communication.

Use of Inquiry. When routinelyassessing patients, anticipate basiccare needs by asking simple questionsrelated to personal care and comfort,such as: “Do you want to be turned?”“Do you need to be suctioned?” “Doyou need to use the bedpan?” “Uri-nal?” “Do you have pain?”

Ask yes/no questions rather thanopen-ended questions. Instead ofasking “Where are you having pain?”ask “Are you having pain in yourchest?” “Do you have a headache?”or “Does your back hurt?” Staff canalso use pictures of the body or havethe patient point to the area of pain.Accurate assessment and pain man-agement are essential to qualitycare. A nonverbal pain scale at thebedside or taped to the head of thebed reminds nurses of the rating scaleand the policy for pain assessment.9

Ask only one question at a time.For example, do not ask “Are youhaving pain in your chest or inyour hip?”

Implement a consistent methodfor yes/no responses and communi-

cate the plan to all staff. Consistencyis particularly important for patientswith neuromuscular impairment orparalysis, where eye blinks, headmovements, and gestures are com-monly their “lifeline” to communi-cate needs effectively. Identify thetopic if the patient’s communicationis unclear. “Are you asking about theventilator?” “Are you talking aboutyour family?” Knowing a specifictopic/context of the patient’s mes-sage may significantly increaseunderstanding of the message andimprove questions that you ask inefforts to resolve the problem.

Identification and Validation ofNonverbal Responses. Identify andvalidate the meaning of facial expres-sions and other nonverbal commu-nication. For example, you couldverbalize to the patient your obser-vation that he appears angry, upset,scared, sad, or happy. Empathizeand attempt to identify possiblecauses for feelings and solutions.

Maintain eye contact, preferablyat the patient’s level. Be aware ofcultural factors that may precludeeye contact.

Convey a calm, confident, reas-suring manner. Maintain patienceif the patient is angry or frustratedat not being able to communicateneeds. Empathize with the patientand convey willingness to under-stand. Allow time for the patient toconvey a message. Obtain additionalassistance, if needed, in situationswhere time is limited.

Facilitate LipreadingReading lips is a specialized skill

and may be difficult, particularly ifthe tube is orally placed. The tube,tube holder, and/or tape over themouth limit lip movement and visu-

Figure 2 Pocketalker Personal Amplifier. Courtesy Williams Sound Corporation, Eden Prairie, Minnesota.



alization. Becoming skilled at lipread-ing takes practice, and some peopleare naturally better at decipheringmouthed words. Persons with hear-ing loss generally are expert lip-readers,9 and it is especially helpfulif they are health care professionals,because they understand the healthissues. Identify other methods tocommunicate needs effectively. Alip-reader translating service elicitedpositive responses from patients andallowed health care providers tospend more time providing patient-centered care and less time attempt-ing to decipher patients’ messages.10

Several steps can be taken toimprove lipreading. Make sure thelight falls on the patient’s mouth, notin the patient’s eyes. Look for keywords, a pattern of words or phrasesthat give the sentence meaning andprovides clues so you can ask focusedquestions. Allow the patient to mouthwords in a full sentence to givethem context; do not isolate words.Avoid interruptions that break thethought process and distract youfrom focusing on what the patientis saying. Obtain assistance fromskilled colleagues to help translatemouthed words.11

Use Alternative and AugmentativeCommunication Devices

Alternative and augmentativedevices to aid communicationrange from the basic to the high-tech. Patients can have success withstandard, generic tools, such as analphabet board, but patients mayfurther benefit from other assistivedevices. Identifying and implement-ing alterative and augmentativecommunication requires collabora-tion among nurses, respiratory ther-apists, and speech pathology staff.

An effective communication systemincludes use of basic communicationtools and consultation with stafffrom the speech-language pathologyservice as needed.

Basic Communication Tools. Pro-vide each patient with basic suppliesfor note writing, including paper ona clipboard and a dark lead pencilfor easy visualization. Removerestraints as needed for writing.Table 3 lists the essential contentsfor communication tool kits. Maketools and supplies easily accessibleto all staff.

Provide basic communicationboards. These may include a letterboard, a picture board, and a list ofcommon phrases/messages as shownin Figure 3. Involve the patient, ashe or she is able, the patient’s fam-ily, and staff in determining a listof patient-specific needs or mes-sages and the best order of place-ment on the individualized board.Word/phrase boards can reduce

overall frustration with communica-tion.3 Boards can be laminated forlong-term use. Messages may varydepending on the clinical situationand the duration of intubation.Messages for a patient with neuro-muscular disease who is able onlyto blink eyes include the following:Suction, Urinal, Bedpan, Brushteeth, I am hot, I am cold, I can’thear you, I am biting my tongue,Mouth guard, Bend elbows, Dorange of motion, Turn me, Raise myhead, Change position of head,Reposition shoulders, Adjust myear, There’s a lump under me, Washaround eyes, Push eyelashes out ofeyes, Readjust pillow, Lower myhead, Reposition my arms, Needpills (Valium, Tylenol, sleeping pill),Tube feeding running too fast, Brushhair, Turn on TV, Turn off TV, Turnup volume, Turn down volume,Change channels, Turn on radio,Pull out earplug, Push in earplug,Favorite channel is___, Gaze board.

52 CriticalCareNurse Vol 31, No. 3, JUNE 2011 www.ccnonline.org

Table 3 Essentials to include in a communication kit

Communication supplies should be readily available for all ventilator-dependentpatients. These supplies can be easily assembled and placed in clear plastic bags orplastic containers for individual use. Letter, word, and picture boards should belaminated for durability and trouble-free use. Adaptive call light systems and otheraids for hearing impairment (eg, the Pocketalker) should be readily available in adesignated location. Speech pathologists should be consulted as needed to assistin determining effective communication systems for patients with complex commu-nication problems or for seemingly simple cases where the nurse is unable toestablish an effective communication system.

Communication kit contentsClipboard 81⁄2 x 11 writing pad Pencil (#2)Washable fine-tip markerLetter boardWord board Picture boardPain rating scaleShortness of breath/dyspnea rating scaleAnxiety rating scale Communication Assessment Tool (Table 2)

A Pocketalker for hearing impaired patients and a magnifying glass should be readilyavailable for use.

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Fowler et al12 identified commonmessages for surgical patients expe-riencing short-term intubation: Iam having pain, I am uncomfort-able, I can’t breathe, and How longwill the tube be in? When is thetube coming out? Please untie myhands, Where is my family? Howam I doing? Please suction me toremove secretions.

Pain rating scales provide amethod for the patient to communi-cate pain level by pointing or ges-turing. Patients who are unable towrite may be able to trace with afinger the letters of a message on asheet of paper or palm of a hand.

Try out eye gaze or specific eyemovements for communicationwith a patient who has paresis that

prevents hand or head motion. Eyemovements can be used for a reliablemeans of yes/no responses. Blink-ing eyes for responses can often bedifficult to distinguish from reflex-ive blinking. Lateral or horizontaleye gaze can be used for basic mes-sages such as “look up for yes, downfor no”, and so on. Eye gaze can alsobe used with simple communicationboards to expand responses or usedwith advanced computerized com-munication devices that involvetyping or manipulating of movement-sensitive switches.

Save messages that the patientwrites (Figure 4), particularly notesexpressing needs, wants, and feel-ings. Saving such notes allows thepatient to communicate more effec-

tively, prevents frustration resultingfrom needing to rewrite commonneeds, and helps the health careteam more effectively understandand meet the physical and psycho-logical needs of the patient. A magicslate or dry erase board may not bethe best choice because everythingthe patient writes is usually erased.

Collaborate with the patient onhand signaling to convey basic needsor information. Communicate thisinformation in writing so that allstaff can interpret hand signals.

Make sure the call light is ineasy reach before leaving the room.Consult with the appropriate hospi-tal department as needed for modi-fied call light systems for weak orparalyzed patients. These include“easy-touch” switches and switchesthat patients can activate withmouth movement.

Consultation With the Speech-Language Pathology Service. Consultwith the speech-language pathologyservice for more complex alternativecommunication systems. Voice out-put communication aids are smallelectronic, computerized devicesthat can be used by typing or manip-ulating movement-sensitive switches.The cost of these devices usuallyprohibits most facilities from hav-ing a supply for use in the ICU.

An electronic larynx (electro -larynx) can enhance communica-tion for patients with temporary orpermanent voice loss. This hand-held device is easily operated bypressing the instrument to the neckto transmit sound into the pharynx,where the lips and tongue use it toform words. It is commonly used bypeople who have had a laryngec-tomy because it produces a “sound”that replaces the voice component of

Figure 3 Picture communication symbols. ©1981-2009 by Mayer-Johnson LLC. All rights reserved worldwide. Used with permission. Boardmaker isa trademark of Mayer-Johnson LLC, P O Box 1579, Solana Beach, CA 92075 (www.mayer-johnson.com).

Change position Adjust bed down Adjust bed up Sit in chair

I want to rest Quiet please! Television Fan

Suction Mouth swab Cool cloth Blanket

ItchCool downHotPAIN

Chest pain Stop I need help Headache



speech. Patients with a tracheostomycould be considered for use of thedevice if they are able to articulateor mouth words to produce intelli-gible speech. Patients with weakspeech muscles are poor candidates.

Ewing13 reported that patientsrate use of an electronic larynxmore favorably than they rate useof pad and pencil, lip movement,and sign language, indicating thatthe electronic larynx was the leaststressful method, the easiest to use,and the clearest for self-expression.Use of the electronic larynx withcritically ill patients is often chal-lenging because manual dexterity isrequired to place the electrolarynxagainst the neck and to coordinatethe on/off modes with speechattempts. The nurse commonlymanipulates the device in these sit-uations. The speech- languagepathologist should be consultedfor instruction on correct use.

Consult with a speech-languagepathologist and a respiratory thera-pist to determine if a stable patientwith a tracheostomy is a candidatefor speech. Procedures include par-tial or total cuff deflation, use of a1-way speaking valve, and a special-ized tracheostomy tube with talkattachments, as discussed in thenext section.

Educate the Patient, the Patient’sFamily, and Staff in Communica-tion Strategies

The patient, the patient’s family,and staff must be educated on thecommunication strategies developedfor that specific patient. Communi-cation can be extremely frustrating,inefficient, and inaccurate if staffare each using different strategies.Such inconsistency can profoundlyaffect even simple movements foryes/no questions. A severely impairedpatient may be cued by one staff to

“blink once for yes and blink twicefor no,” whereas a second staffmember may cue the patient in theopposite “blink once for no andblink twice for yes.”

Successful strategies includenoting the patient-specific commu-nication plan on the care plan andplacing it in an easily recognizedlocation for caregiver implementa-tion. Keep the patient-specific com-munication system at the bedsideon a clipboard for easy use. Be awareof patient privacy regulations thatmay limit postings. Assist anddemonstrate to the patient’s familyhow to communicate effectivelywith their loved one. Provide preop-erative education on the causes ofimpaired verbal communicationwhen a patient is intubated. Workwith the patient and the patient’sfamily members to identify effectivecommunication methods and ensurethat information is written on the

54 CriticalCareNurse Vol 31, No. 3, JUNE 2011 www.ccnonline.org

Figure 4 One patient’s written notes communicate his physical and psychological needs.



care plan. Table 4 summarizes thecommunication problem, causes,and management.

Speech With a Tracheostomy

Many patients with a tra-cheostomy, whether receivingmechanical ventilation support orbreathing spontaneously, can achievespeech with the tracheostomy tubein place. Determining a patient’scandidacy for speech should be acollaborative effort between mem-bers of the multidisciplinary team.Facilities vary in their practice, but

typically the physician orders anevaluation by the speech-languagepathologist, the pulmonary clinicalnurse specialist, and/or the respira-tory therapist.

Several methods are available forachieving speech with a tracheostomy,and selection of the most effective,safe, efficient method should bebased on the patient’s clinical status.Five common methods are partialor complete cuff deflation, pluggingor capping the tube, use of a 1-wayspeaking valve, use of a tracheostomytube with a talk attachment, and useof a fenestrated tracheostomy tube.

Partial or Total Cuff Deflation Partial or total deflation of the

cuff is an option for clinically stabletracheostomy patients who arereceiving mechanical ventilation. Atracheostomy with the cuff inflatedprevents air from passing throughthe larynx for speech (Figure 5). Ifthe tracheostomy cuff is deflated byonly a few milliliters or completely,air leaks around the tube and passesthrough the larynx and out of themouth (Figure 6). The speech pro-duced with this technique is oftenreferred to as “leak speech.” Patientsoften need to work on coordination

Table 4 Communication problem, causes, and management

Problem: Impaired ability to communicate verbally

Causes: Endotracheal tube, tracheostomy tube placement results in no air flowing past larynx when cuff is inflated, decreased ability toread lips if orally intubated, and tube-securing method occludes the patient’s mouth.

ManagementInitial evaluation/plan

1. Evaluate appropriate communication method(s) for client based on type and degree of physical disability and use of arms and hands,mental status, comprehension, language background, hearing, and vision. Refer to Table 2 (Communication Assessment Tool).

2. Communicate patient-specific plan on care plan and at bedside for easy implementation by caregivers. 3. Assist/Demonstrate effective communication methods to staff and patient’s family.

Interventions4. Maintain eye contact, preferably at patient’s eye level. Provide adequate room light. Make sure patient has glasses and hearing aid

if needed. 5. Ask yes/no questions one at a time, use pad/pencil, gestures, and word and alphabet board as appropriate. 6. Anticipate needs, ask questions related to personal care and comfort on a regular basis. Questions include the following: Do you

want to be turned? Do you need to be suctioned? Do you need to use the bedpan? Urinal? Do you have pain? 7. Initiate use of word board/phrase board appropriate for patient and tailored to meet individualized needs. Place in bold print on

communication board. Laminate if intended for long-term use.

Sample communication board for complex patient, total paralysisSuction, Urinal, Bedpan, Brush teeth, I am hot, I am cold, I can’t hear you, I am biting my tongue, Mouthguard, Bend elbows, Do

range of motion, Turn me, Raise my head, Change position of head, Reposition shoulders, Adjust my ear, There’s a lump underme, Wash around eyes, Push eyelashes out of eyes, Readjust pillow, Lower my head, Reposition my arms, Need pills (Valium,Tylenol, sleeping pill), Tube feeding running too fast, Brush hair, Turn on TV, Turn off TV, Turn up volume, Turn down volume,Change channels, Turn on radio, Pull out earplug, Put in earplug, Favorite channel is___, Gaze board.

Common messages of surgical patients experiencing short-term ventilator supportI am having pain, I am uncomfortable, I can’t breathe, How long will the tube be in?, When is the tube coming out?, Please untie

my hands, Where is my family? How am I doing? Please suction me to remove secretions.8. Convey calm, confident, reassuring approach. Maintain patience if patient gets frustrated or angry at not being able to communi-

cate needs. Empathize with patient.9. Seek assistance from other colleagues to help determine what the patient is trying to communicate. Avoid communicating your

frustration or blaming the patient for the problem. 10. Identify, validate meaning of nonverbal communication. Empathize with patient. 11. Involve family/significant other in plan of care as much as possible.12. Make sure call light is easy to reach before leaving room. Obtain modified call light system if patient is weak or paralyzed.13. Provide preoperative education about what to expect regarding impaired verbal communication when intubated. Identify effective

communication methods with patient/family and communicate specific information on care plan.14. Consult with speech therapy as needed to assist in providing effective communication methods.



of verbalizations with the inhalation/exhalation timing of the ventilatorin order to initiate speech/voiceduring the exhalation phase. Theycan learn how to control air leakagethrough the mouth by occludingthe posterior pharynx area with thetongue and pharyngeal structure.

Plugging orCapping theTube

Anotheroption forpatients with atracheostomywho are in sta-ble conditionand do notrequiremechanicalventilation isplugging orcapping thetube. Patientswho are breath-ing sponta-neously orrequire partialventilator sup-port can beevaluated todeterminewhether plug-ging the tube isappropriate.Because thetube takes upspace in the tra-chea, pluggingit creates vari-ous degrees ofairway obstruc-tion dependingupon tube size,tracheal size,and other pos-sible upper air-

way problems. Increased airwayresistance causes anxiety, respira-tory distress, and potential car-diopulmonary deterioration.

Before the tube is plugged, thecuff must always be completelydeflated. Larger tracheostomytubes cannot be continuously

plugged because of the increasedairway resistance that results.Instead, the patient may tolerateintermittent plugging of the tubewith a finger during the exhalationphase. Initiate plugging after thepatient takes a breath, and discon-tinue plugging the tube if thepatient cannot exhale, speak, orcomplains of shortness of breathand difficulty breathing. Teachcapable patients how to fingerocclude the tracheostomy tube forspeaking. In order to plug the tubesuccessfully and continuously, thetube must be changed to a smallerdiameter to decrease airway resist-ance by allowing more space for air-flow in the trachea. Changing to atracheostomy tube with a cuff thattightly collapses to the shaft of thetube may also improve space forairflow in the trachea. Change to anuncuffed tube if a cuffed tube is nolonger needed. A 1-way speakingvalve may be attached to the tubeopening for speech.

1-Way Speaking ValveUse of a 1-way speaking valve is

a common method for achievingspeech with a clinically stablepatient with a tracheostomy who isbreathing spontaneously or receiv-ing mechanical ventilatory support.Although they are available fromseveral different manufacturers, 1-way valves have similar character-istics and functions. The Passy-Muir Speaking Valve (Passy-MuirInc, Irvine, California) is an exam-ple of a 1-way valve that attaches tothe 15-mm hub of the tra-cheostomy tube. The plastic valveopens on inspiration, allowing airto enter the lungs. On exhalation,the valve closes off and all air must

Figure 5 When the cuff of the tracheostomy tube is inflated,air cannot pass through the larynx to generate speech. Reprinted with permission from Tippett and Siebens.14 Copyright 1995 by AmericanSpeech-Language-Hearing Association. All rights reserved.

Figure 6 When the cuff of the tracheostomy tube is partially orcompletely deflated, air can pass around the cuff and throughthe larynx, so speech is possible. Reprinted with permission from Tippett and Siebens.14 Copyright 1995 by AmericanSpeech-Language-Hearing Association. All rights reserved.



exit through the upper airway (Fig-ure 7). As it exits, exhaled air passesbetween the vocal cords to producethe voice for speech.

The cuff of the tracheostomytube must be completely deflatedfor all patients, regardless ofwhether they are receiving mechan-ical ventilation, before attachmentof the 1-way valve. Placing a 1-wayvalve on a tracheostomy tube withan inflated cuff would allow apatient to inhale but not exhale, amajor error that can immediatelylead to acute respiratory distress,

barotrauma,and other life-threateningcomplications.Also, an improp-erly deflatedcuff with 1-wayvalve placementcan cause animmediate andundesirableincrease in lungpressures andtrauma due todifficulty exhal-ing air throughthe narrowedairway.

Use of the 1-way valve typi-

cally involves the collaboration of amultidisciplinary team that includesthe nurse, physician, speech-languagepathologist, respiratory therapist,and patient. It is essential that thehealth care team thoroughly under-stand the indications, contraindi-cations, correct procedure, andmonitoring that are required with useof a 1-way valve. Table 5 summarizescontraindications to use of the 1-wayspeaking valve. Patients unable to usethe Passy-Muir Speaking Valve maytolerate partial cuff deflation as dis-cussed earlier.

Procedure for Use of the Tracheostomy 1-Way Speaking Valve

Health care providers must pos-sess the knowledge and skills todetermine appropriate candidatesfor use of the 1-way speaking valve.They also must be able to makeappropriate assessments and venti-lator adjustments and to imple-ment other strategies for successfuluse of this communication tech-nique. Table 6 lists a specific proce-dure for successful and safe use ofa Passy-Muir Speaking Valve.

Specialized Tracheostomy Tube With Feature Designed for Speaking

Many critically ill patients arenot in stable enough condition totolerate cuff leaks with tidal volumeloss or tracheal occlusion. Severalmanufacturers of tracheostomytubes have produced tubes with afeature to allow speaking (Figure 8).These tubes have dimensions simi-lar to the dimensions of other cuffedtracheostomy tubes. The unique fea-ture of these specialty tubes is that asmall section of tubing with an open-ing for airflow is attached above thecuff. This tubing exits the stomaand can be attached to an additionalsource of airflow with the flow rate

Table 5 Contraindications to use of a 1-way speaking valve

Patient in medically unstable condition and/or requiring significant ventilator support (high respiratory rate and minute ventilationrequirements, high fraction of inspired oxygen, positive end-expiratory pressure greater than 5 cm H2O, respiratory distress, fre-quent bronchospasm and air-trapping problems)

Pneumothorax with air leak and without air leak if there is any potential for increase in lung pressuresLarger diameter tracheostomy tubeTracheostomy tube with inflated cuff Tracheostomy tube with foam cuffAirway above tracheostomy not patent: obstruction can be caused by numerous factors including bilateral vocal cord paralysis, severe

tracheal or laryngeal stenosis, tumor obstruction, or secretionsCopious, excessive, or thick secretionsParalysis of lips, tongue, and other muscles involved in speechLaryngectomy

Figure 7 A 1-way speaking valve.

Larynx

Trachea

1-way valve



regulated on awall flowmeteraccording to themanufacturer’srecommenda-tions. Thepatient or staffmemberoccludes a porton the externalairflow tubingso that the addi-tional airflow isrouted throughthe airflow tub-

ing and exits into the trachea justabove the inflated tracheostomycuff. This airflow can then passthrough the vocal cords for speech.The air used for speaking is not theair being used for ventilation.

The main barrier to successfuluse of the speaking tube is obstruc-tion of the small holes of the tubingwith secretions, which blocks theairflow. The hole above the cuff isonly several millimeters large andcan easily be occluded by the copi-ous secretions that accumulate abovean inflated cuff. These secretions

Table 6 Procedure for placement of a 1-way speaking valve

1. Evaluate the patient to determine whether the device is appropriate. The patient should be awake, attempting to communicate, andshould not have contraindications to use. Collaborate with the physician, speech pathologist, and respiratory therapist.

2. Explain the plan to the patient. Gather the necessary clinicians at the bedside, often including the bedside nurse and respiratory therapist and/or speech pathologist.

3. Verify that all equipment is readily available, including suction catheter, suction, manual resuscitation bag.4. Position patient for breathing comfort, usually with head of bed elevated.5. Deflate cuff completely.

a. Suction oral cavity and tracheostomy tube if needed.b. Completely deflate the cuff.c. Be ready to immediately suction the trachea and mouth of any secretions that may have pooled above the cuff and are forced

into the mouth with coughing or ventilator airflow.6. Attach valve to tracheostomy tube. If patient is ventilator dependent, attach flex tube adapter or swivel valve adapter; reattach venti-

lator tubing.7. Adjust, as needed, the ventilator tidal volume higher to compensate for leakage around tube, reset volume and pressure alarms, and

make other ventilator adjustments including turning off PEEP to prevent machine self-cycling.8. Monitor tolerance including breathing comfort and ability to exhale easily. Immediately remove the valve if the patient complains of

respiratory distress, breathing discomfort, or shortness of breath or if observations show difficulty with air exchange, inadequatechest deflation indicating impaired exhalation, the appearance of “air trapping,” increased respiratory rate, increased respiratorymuscle use, and various other signs of increased work of breathing. Readjust the ventilator to ensure adequate ventilation andreassess the patient for contraindications.

9. Caution: If the patient has difficulty exhaling, vocalizing will be difficult for the patient. The patient most likely is not a good candi-date for the valve because of significant airway resistance from the tube or other problems. Avoid placing the patient in a situationof uncomfortable breathing, which may affect future communication interventions.

10. Instruct ventilator-dependent patient to “notice that air fills your lungs with air when the machine gives you the breath of air. Breath-ing out will be through your nose and mouth.” Coach the patient to “take a breath in first, then speak.” Initially try vocalizing withsimple sounds like “Ahhhh…..” or count “1,2,3,4….” Provide direction and reassurance as needed.

11. Provide adequate oxygenation and monitor oxygenation status with pulse oximetry. Maintain SpO2 at 90% or greater or be alert toacute problems if SpO2 starts decreasing from the patient’s baseline level while on the ventilator.

12. Remove the valve and suction as needed to maintain a patent airway. Provide ventilation support as needed. Note: Secretions canobstruct air passage outside the tube, causing respiratory distress and valve intolerance. Although a 1-way speaking valve canimprove the strength of the cough, it may be difficult for the patient to cough secretions up to the mouth with the valve in placebecause of the small space between the tube and the trachea, thicker secretions, inability to take deep breaths, and the weak cough.

13. Provide an oral suction system for patients who can to suction the oral cavity.14. Remove the valve before starting nebulizers/ aerosol treatments to prevent damage of the valve. Remove the valve when the patient

is sleeping.15. Readjust the ventilator to previous settings after valve removal, and recheck the patient/ventilator system to ensure optimal ventilation.16. Spontaneously breathing patient: Provide ventilation assistance as needed with a manual resuscitation bag to assist with deep

breaths and secretion clearance.

Abbreviations: PEEP, positive end-expiratory pressure; SpO2, oxygen saturation as determined by pulse oximetry.

Figure 8 A tracheostomy tube with the feature that allowsspeaking while the cuff is inflated.Reprinted from Dikeman and Kazandjian,15 with permission from Delmar Learning,a part of Cengage Learning, Inc. ©1996.

Ventilator air

Speaking air

Air source



should be removed by applying asuction source to the airflow tubingand suctioning out the secretions.The tube may also not fit properly inthe patient’s trachea, causing block-age of the airflow port and an inef-fective tube for speaking. Patientswith hand weakness or paralysis areunable to occlude the port for initi-ating voice and must rely on thenurse for assistance and adjustmentof the wall airflow. This optionshould be considered for patientswho have not had success with themore common techniques for speechand need the cuff to remain inflatedfor optimal ventilation.

Fenestrated Tracheostomy Tubefor Patients Who Do Not RequireMechanical Ventilation

If the plan is to plug a tra-cheostomy tube for speaking, a fenes-trated tracheostomy tube may beplaced to allow more airflow throughthe trachea and thereby help decreaseairway resistance. The fenestration isa hole located on the outside of thetube that allows air to travel throughthe tube if the inner cannula isremoved and the fenestration is prop-erly located in the trachea (Figure 9).Before the tube is plugged, the cuffmust be completely deflated.

Some fenestrated tubes do notfit properly in certain patient’sanatomies, and the hole may beblocked by the tracheal wall tissue.Such blockage can affect breathingand also place the patient atincreased risk for granulation tissueformation at the site of the fenestra-tion. The tube should always beevaluated for proper position of thefenestration by visual inspectionwith an endoscope by a specialisttrained to evaluate the tube prop-erly. Potential for this problem may

be evaluated simply by removingthe inner cannula and looking witha flashlight into the tracheostomytube to observe for an open holeversus a hole blocked by trachealwall tissue. If the hole is against thetracheal wall, it can be a source oftracheal irritation or tissue growthinto the fenestration and trachea.The tube should not be used if thefit is improper.

It may be difficult for somepatients, even patients with strongcoughs, to cough secretions throughthe narrow space in the trachea andthrough the fenestration, especiallyif secretions are thick and tenacious.The tracheostomy plug should beremoved and secretions suctionedas needed if sounds of secretions areaudible or the patient complains ofneeding suctioning, feels short ofbreath, or has respiratory distress.Reevaluate the patient’s respiratorystatus after the tube is plugged. Close

monitoring throughout tube plug-ging is essential as most patients areunable to remove tracheostomy plugson their own. When the patient needsto receive mechanical ventilation, theinner cannula is replaced, the cuff isinflated, and the ventilator adapteris reattached to the ventilator, whichis properly set up and functioning.

Suggested Research Priorities for Effective Communication

Loss of speech is a frighteningexperience16 and can cause anxiety,agitation, and various other adversephysiological effects as well as adverseventilator effects. Although ICUnurses commonly care for patientswith complex communication needs,nurses may receive little or no train-ing in facilitating or interpretingcommunication for ventilator-dependent patients or in usingdevices to improve the effectivenessof communication.15,16 Assistive andaugmentative devices are availableto improve communication; how-ever, it is not surprising that theyare rarely used.2 It is essential toassess the patient’s ability to com-municate, establish an effective careplan with strategies customized forthe patient’s needs, and ensure thatall staff can effectively interact withthe patient to determine needs andconcerns.17,18 The American ThoracicSociety Statement on Research Pri-orities in Respiratory Nursing16 rec-ommends the following:

Studies are needed toimprove nurse-patientcommunication, includinginterpretation of non-vocalbehaviors. In addition,studies are needed to deter-mine ways of best assistingpatients to use available

Figure 9 Fenestrated tracheostomytube for patients who do not requiremechanical ventilation.



communication devices.Strategies need to be tested toimprove health care pro -vider communication skills.

Testing combinations of alterna-tive augmentative technologies, con-sultation, and training of caregiversmay create effective communicationoptions for nonspeaking patients.Systematic research may assist indetermining the differential effectsof these treatments and profiles ofsuccessful users of alternative aug-mentative communication systems.19

It is common for neuropsychologi-cal and functional deficits to occur inICU patients receiving mechanical ven-tilation because of the various sedativemedications commonly used. Studiesare needed to test the frequency, sever-ity, and potential causes of thesedeficits with the goal of testing inter-ventions to decrease the impact of thedeficits.16 One example is a study of theeffect of implementing effective com-munication strategies on decreasingthe need for sedative medicationsand thereby minimizing adverseneuropsychological consequences.

Communication assessmenttools should be evaluated to deter-mine whether they are user-friendlyand meet the desired outcome ofdetermining and implementingeffective communication strategies.The assessment tool (Table 2) devel-oped and presented in this articlerequires clinical evaluation.

Various types and sizes of letterboards, word boards, and phrase

boards are available to enhancecommunication. Few descriptive orempirical studies have addressed thecontent and format of these tools orpatients’ perspectives on decreasingfrustration with communication.Research is needed to test the effectsof communication boards and vari-ous other methods used to facilitatecommunication on outcomes, includ-ing patients’ anxiety and satisfaction,adequate pain management, andduration of mechanical ventilation.3

Research is also needed to determinethe types of communication toolsthat are most effective for individualtypes or categories of patients.

SummaryCommunicating effectively with

ventilator-dependent patients isessential for the provision of qualitycare. Cases presented in Table 7 (avail-able online only at www.ccnonline.org) summarize a variety of clinicalsituations and highlight useful com-munication strategies that effectivelymeet the needs of patients and theirfamilies. It is important for nurses toassess communication needs; identifyappropriate alternative communica-tion strategies; create a customizedcare plan with the patient, family,and other team members; ensurethat the care plan is visible and acces-sible to all staff interacting with thepatient; and continue to collaboratewith colleagues from all disciplinesto promote effective communicationwith nonvocal patients. Patients’ fam-ily members also need to be educatedand supported in their efforts to com-municate and care for their lovedones. CCN

Financial DisclosuresNone reported.

References1. Happ MB, Tuite P, Dobbin K, Divirgilio-Thomas

D, Kitutu J. Communication ability, method,and content among nonspeaking nonsurvivingpatients treated with mechanical ventilation inintensive care unit. Am J Crit Care.2004;13(3):210-222.

2. Happ MB. Communicating with mechanicallyventilated patients: state of the science. AACNClin Issues. 2001;12(2):247-258.

3. Patak L, Gawlinski A, Fung NI, et al. Commu-nication boards in critical care: patients’ views.Appl Nurs Res. 2006;19(4):182-190.

4. Grossbach I. Ventilator troubleshooting guide.In: Chulay M, Burns S, eds. AACN Essentials ofProgressive Care Nursing. New York: McGraw-Hill; 2007:487-497.

5. Dreyer A, Nortvedt P. Sedation of ventilatedpatients in intensive care units: relatives’ expe-riences. J Adv Nurs. 2008;61:549-556.

6. Engstrom A, Soderberg S. The experiences ofpartners of critically ill persons in an intensivecare unit. Intensive Crit Care Nurse. 2004;20(5):299-308.

7. Happ MB, Swigart VA, Tate JA. Family presenceand surveillance during weaning from prolongedmechanical ventilation. Heart Lung. 2007;36(1):47-57.

8. Jablonski RS. The experience of being mechani-cally ventilated. Qual Health Res. 1994;4:186-207.

9. Kabes AM, Graves JK, Norris J. Further valida-tion of the nonverbal pain scale in intensive carepatients. Crit Care Nurse. 2009;29:59-66.

10. Carroll SMC. Lip-reading translating for non-vocal ventilated patients. J Assoc Med ProfHearing Losses. 2003;1(2). www.amphl.org/articles/carroll2003.pdf. 2003. Accessed July27, 2010.

11. Lawless CA. Helping patients with endotra-cheal and tracheostomy tubes communicate.Am J Nurs. 1975;75(12):2151-2153.

12. Fowler SB. Impaired verbal communicationduring short-term oral intubation. Nurs Diagn.1997;8(3):93-98.

13. Ewing DM. Electronic larynx for aphonicpatients. Am J Nurs. 1975;(12):2153-2156.

14. Tippett DC, Siebens AA. Preserving oral com-munication in individuals with tracheostomyand ventilator dependency. Am J Speech-Lan-guage Pathol. 2005;4(2):56-57.

15. Dikeman KJ, Kazandjian MA. Communicationand Swallowing Management of Tracheostomizedand Ventilator-Dependent Adults. San Diego, CA:Singular Publishing Group, Inc; 1995:188.

16. Larson JL, Ahijevych K, Gift A, et al. ATS State-ment: American Thoracic Society statement onresearch priorities in respiratory nursing. Am JRespir Crit Care Med. 2006;174(4):471-478.

17. Finke EH, Light J, Kitko L. A systematic reviewof the effectiveness of nurse communicationwith patients with complex communicationneeds with a focus on the use of augmentativeand alternative communication. J Clin Nurs.2008;17(16):2102-2115.

18. Consortium for Spinal Cord Medicine. Respi-ratory Management Following Spinal Cord Injury:A Clinical Practice Guideline for Health-CareProfessionals. Washington, DC: Paralyzed Vet-erans of America; 2005. www.guidelines.gov/summary/summary.aspx?doc_id=7198&nbr=004301&string. Accessed July 27, 2010.

19. Happ MB, Garrett KL, Roesch T. AAC in theICU: Critical Issues and Preliminary Research.Aac.unl.edu/drb/as03/aac-icu .pdf. 2003.Accessed July 27, 2010.

Now that you’ve read the article, create or contribute toan online discussion about this topic using eLetters. Justvisit www.ccnonline.org and click “Submit a Response”in either the full-text or PDF view of the article.

To learn more about patients receivingmechanical ventilation, read “Not-so-TrivialPursuit: Mechanical Ventilation RiskReduction” by Mary Jo Grap in the Ameri-can Journal of Critical Care, 2009;18:299-309. Available at www.ajcconline.org



www.ccnonline.org CriticalCareNurse Vol 31, No. 3, JUNE 2011 61

CCN Fast Facts CriticalCareNurseThe journal for high acuity, progressive, and critical care

Promoting Effective Communication for Patients Receiving Mechanical Ventilation

and use of a speaking valve. It is important for nurses to assesscommunication needs (see Table); identify appropriate alterna-tive communication strategies; create a customized care planwith the patient, the patient’s family, and other team members;ensure that the care plan is visible and accessible to all staffinteracting with the patient; and continue to collaborate withcolleagues from all disciplines to promote effective communica-tion with nonvocal patients.

FactsCommunicating effectively with ventilator-dependent

patients is essential so that various basic physiological andpsychological needs can be conveyed and decisions, wishes,and desires about the plan of care and end-of-life decisionmaking can be expressed. Numerous methods can be used tocommunicate, including gestures, head nods, mouthing ofwords, writing, use of letter/picture boards, and high-techalternative communication devices. Various options for patientswith a tracheostomy tube include partial or total cuff deflation

Grossbach I, Stranberg S, Chlan L. Promoting Effective Communication for Patients Receiving Mechanical Ventilation. Crit Care Nurse. 2011;31(3):46-61.

Table Communication Assessment Tool for nonvocal patients

Directions: Communication plan should be kept at the bedside and/or designated computer location so it is readily available to all healthcare team members and the patient’s family. Update as needed.

Date assessed: ______ with patient ______ with family member _______ both _____

Mental status: alert, appropriate----lethargic, confused----comatoseLanguage: English: Yes No Other (List) ____________Hearing: Normal Impaired (R,L) Hearing aid: Yes NoVision: Normal Impaired Needs glasses for reading: Yes NoWriting: Right Left Grasps writing device: Yes No Unable due to hands: weak--- swollen---paralyzedLiteracy (reads, spells): Yes No Aphasia: Yes No (If yes, consult speech therapy)Neuromuscular weakness, paralysis: Yes (Explain) _________________ NoAble to use standard call light system Yes No (Select adaptive system)_______________________________________________________________Effective communication system(s) for this patient:____Nods head up, down to yes/no questions____Clipboard, pad, pencil _____hand____Lip-read____Picture board____Letter board____Word board____Regular call light system____Needs adaptive call light system. Proper placement for use __________________

Severe weakness, paralysis_____Blinks eyes 1 blink = yes, 2 blinks = no_____Moves eyes toward head for yes, closes eyes for no_____Needs advanced system; speech consult sent________________________________________Details of effective communication system for Mr/Ms ____________________Example:12/6/08 Mr L communicates by nodding head to yes/no ?, needs glasses for reading and writes with right hand-elevate HOB at least

40°, points to picture board—usual issues have been pain, needs frequent position change, likes ROM to legs and wants radio on(AM 1500 or FM 100)

Abbreviations: HOB, head of bed; L, left; R, right; ROM, range of motion exercises.



promoting effective communication for patients receiving

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