COMMUNICATION

CHAPTER III THE IMPLEMENTATION OF COMMUNICATION

AT EVERY STAGE

NURSING PROCESS, PATIENTS OF PHYSICAL, MENTAL

DISORDERS, AND SPECIAL NEEDS
PRELIMINARY

You have completed Chapters I and II well, CONGRATULATIONS I hope you also find it easy
to learn this Chapter III well too. In the previous chapter, it was explained that
communication is an important and fundamental thing that must be mastered by nurses in
carrying out nursing service activities. The application of communication in nursing care is
important for nurses because every nurse's activity, from assessment to evaluation of
nursing care, always uses communication as a work tool.

Every time she interacts with a patient in order to help and fulfil a disturbed need, or
conduct counselling, the nurse always applies therapeutic communication to achieve the
patient's goals. How communication applies in your field of work is important for you to
understand because it can provide an overview of the use of communication in nursing
services.

After studying Chapter III, students are expected to be able to apply therapeutic
communication in every stage of the nursing process, to patients with physical, mental and
special needs disorders.

Chapter III is entitled Application of Communication at Each Stage of the Nursing Process,
Patients with Physical, Mental Disorders, and Special Needs. This chapter consists of three
topics which are arranged sequentially as follows.

 Topic 1: Therapeutic Communication at Each Stage of the Nursing Process

 Topic 2: Communication to Patients with Physical and Mental Disorders
 Topic 3: Communication to Patients with Special Needs

Topic 1 Application of Therapeutic Communication on

Each Stage of the Nursing Process

Warm regards, hopefully you will always be given good health and keep the enthusiasm to
continue studying the topic in this Chapter III. As with Chapter I and Chapter II, start learning
sequentially from Topic 1. Topic 1 This Chapter III will explain the application of therapeutic
communication in nursing care and care using the stages of the nursing process starting

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from assessment, formulating nursing diagnoses, nursing planning, and implementing and
evaluating care. nursing.

After completing this topic, it is hoped that you will be able to apply therapeutic
communication at every stage of the nursing process from assessment, nursing diagnosis,
planning, and implementation and evaluation.

After completing Topic 1 in Chapter III, hopefully you will

1. implement communication at the assessment stage,

2. implement communication at the stage of nursing diagnoses,
3. implement communication at the planning stage,
4. implement communication at the implementation stage,
5. implement communication at the evaluation stage.

Based on the learning objectives in Topic 1, the subject matter will be

Described sequentially according to the stages of the nursing process is the application of
communication at the assessment stage, nursing diagnosis, planning, and implementation
and evaluation of nursing care.

Before discussing the application of communication at each stage of the nursing process, let
us first recall what is the nursing process.

The nursing process is a scientific and systematic method for solving client problems
through cooperation between nurse and client with the stages of assessment, nursing
diagnosis, planning, and implementation and evaluation. How is the application of
communication at each stage of the nursing process, study the following descriptions in
order.

A. THERAPEUTIC COMMUNICATION AT THE ASSESSMENT STAGE

Assessment is the first stage in the nursing process. This stage is an important stage in the
nursing process because the later stages in the nursing process will not work well if the
assessment stage is not carried out properly. At this stage the nurse uses

verbal or nonverbal skills in collecting client data. In the assessment, nurses are required to
be able to communicate well verbally and to observe nonverbal behaviour and interpret the
results of observations in the form of problems. After the data is collected, then
communicated in verbal language to clients or other health teams and communicated in
writing (documented) to be communicated to other health teams and as a legal aspect of
nursing care.

The forms of communication that nurses can use at the assessment stage of the nursing
process are interviews, physical examinations and observations, as well as data collection
through medical records / medical records and other relevant documents.

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1. Interview /interview
The interview is a transaction process between two people who have a purpose

specific, serious, and meaningful. Interviews are usually conducted in person through direct
meetings in face-to-face interactions (face to face). In this interview, the interviewer (nurse)
can use verbal or nonverbal communication skills to explore the interviewed data (client).
With direct contact, the interviewer (nurse) can obtain direct data that is shown in verbal or
nonverbal behaviour from the interviewee (patient).

The advantages of this in-person interview are as follows.

1. Increase the professional skills of nurses.

2. The data obtained is more specific and real in accordance with the actual situation.
3. It is more effective when compared to indirect interviews because you get it directly
feedback directly from the client.

This interview was conducted to obtain data about the client's medical history,

past medical history and treatment that has been done, main complaints, hopes, and so on.
In interviewing, the nurse uses the open question technique (broad opening) to dig up more
data about the client. Furthermore, the nurse can use other communication techniques to
clarify and provide feedback, rephrasing, focusing, or directing the client's answer to the
interview's objective.

The nurse's communication skills at the assessment stage will greatly determine the
.completeness of the data she gets and will determine the next process
Review and use the therapeutic communication techniques you learned in Chapter I, Topic
2

Example of Communication:

1. Orientation Phase:

Therapeutic greetings:

Evaluation and validation:

Contract:

2. Work Phase:
3. Termination Phase:

Subjective / objective evaluation:

Upcoming contract:

"Good morning, mom. I am nurse Tri who will be in charge of taking care of Mother today.
Thank you, Mother for entrusting us to help solve your problems.

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"How are you feeling now?" (wait for client's answer). “I see that the mother is very
depressed and suffering from this problem.” “At this time, I will collect data related to the
illness that the mother is suffering from, I need information about how the mother's
problem originated so that the mother cannot eat for several days. The time I need is 15-20
minutes, and mom still rest on this bed.

"What do you feel now?" "Explain how the origin of the disease that you feel now!" (wait for
client response).
"What are the medications or actions that have been done while the mother is at home?"
(wait for client response)

"How do you feel now?" (wait for patient response). "Based on the interview data, we can
identify together that mothers experience gastric pain and nausea when eating."

"Very well, ma'am. I will consult a doctor and in 10 minutes I will return to perform nursing
actions according to the agreement with the doctor”.

During the interview or during the assessment process to obtain client nursing data, in
addition to the communication techniques mentioned above, the nurse must also maintain
other therapeutic attitudes, namely maintaining eye contact, approaching and bending over
to the client, and listening to client answers actively. In every communication activity, use SP
communication according to the stages described in Chapter I about the basic concepts of
communication and therapeutic communication in nursing.

Follow-up Plan: “Mothers should keep trying to eat and drink through

mouth, drinking warm water or sweetened tea, and foods that do not cause nausea. Try
light biscuits to start”.

Figure 3.1 Application of Communication during Assessment through Interview

2. Physical examination and observation

The communication used by the nurse when the nurse collects data through physical
examination is in order to ask the client's permission, check, focus the examination carried
out in accordance with the complaints and instructions given by the client. The nurse also

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observes facial expressions (e.g., grinning in pain, crying, pale, etc.) as a form of nonverbal
communication and records them in the client's nursing status. When conducting physical
examinations and observations, the communication techniques used by nurses were
clarification and sharing of perceptions.

Physical examinations and observations are usually carried out at the same time as the
interview or after the interview is complete. Thus, the communication strategy
implementation (SP) can integrate with SP communication during the interview. The
following is an example of communication with a focus on the working phase of applying
clarification and sharing perceptions techniques.

Examples of work-phase communication:

1. While palpating the client's stomach, the nurse says, "Is there pain in this area that
causes the mother to feel nauseous and vomiting?"
2. "I see, you look very worried and depressed about your current condition."

3. Collecting data from other documents

The nurse uses medical records, laboratory, x-rays, etc. as a form of written communication
with other members of the health team to complete and clarify the data obtained from the
results of physical examination and observation.

B. COMMUNICATION ON NURSING DIAGNOSIS STAGE

At this stage of the nursing process, communication is carried out to clarify data and
conduct analysis before determining the client's nursing problem, then discussing with the
client. Problems or nursing diagnoses that have been defined are communicated /
communicated to the client so that he is cooperative and tries to work with the nurse to
solve the problem as well as to other nurses in person and in writing for documentation. The
technique used at the stage of nursing diagnosis is the technique of providing
information(informing).

Some examples of nursing diagnoses related to nutritional disorders are as follows.

 Inadequate nutrition (insufficient) due to disruption of the digestion process.

 Impaired nutritional needs are associated with metabolic disorders.

Examples of communication during the work phase:

"Based on the data I obtained through physical examination and information

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from the mother regarding the complaints that caused the mother to be admitted to the
hospital, I concluded that the mother had nutritional problems because there was a
problem in the digestion process. You have problems with your stomach, related to
problems with your stomach, I will collaborate with the doctor for treatment and further
actions. "

C. COMMUNICATION IN THE PLANNING STAGE

At this stage, the nurse's job is to formulate nursing goals and set success criteria, plan
nursing care, and collaborative actions to take. Communication that is important for nurses
to do in this phase is to discuss the plan that has been prepared by the nurse and with the
client to determine the success criteria to be achieved. In this phase, family involvement is
also important in relation to family participation in client care. Nursing care plans are then
written or documented in the client's status as a form of professional responsibility and
facilitate communication between health teams for ongoing nursing care.

Examples of communication during the work phase:

"Based on the nursing problems that we have determined together, then I collaborate with
the doctor regarding this problem. I convey that one of the actions that will be carried out
on the mother is the installation of an IV. The purpose of this infusion is to meet the
nutritional needs of the mother. For now, the mother's stomach must be rested for further
tests. This infusion is temporary; if the mother doesn't feel nauseous or vomiting anymore,
then we will let her go. "

D. COMMUNICATION AT THE IMPLEMENTATION STAGE

At this stage, communicating or discussing with other health professionals is important in

order to provide adequate treatment to the client. At this stage, nurses are very effective in
communicating with patients because nurses will use all abilities in communication when
explaining certain actions, providing health education, providing counselling, strengthening
support systems, helping to improve abilities. Coping, etc. Nurses use verbal or nonverbal
nursing actions to determine the patient's direct (spoken) or unspoken response. All nursing
activities / actions must be documented in writing to be communicated to other health
teams, identify follow-up plans, and legal aspects of nursing care.

The therapeutic communication technique used in this phase is to provide information

(informing) and maybe share perceptions.

Examples of communication during the work phase:

"I have already said that one of the actions I will take is to put in an IV. The purpose of
infusion is to meet the nutritional needs of the mother. During insertion, the mother will
feel a little pain when the IV needle is inserted into a vein. Are you ready? "

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Figure 3.2. Attitude and Communication of Nurses during Infusion

When performing nursing actions, in addition to verbal communication that is spoken in

words, the nurse must show a therapeutic attitude physically during communication,
namely:

1. pleasant facial expression, looks sincere,

2. approaching and bowing towards the client,
3. maintaining eye contact that shows an eagerness to help,
4. an open attitude that does not see the hands or feet when the interaction occurs,
5. stay relaxed.

E. COMMUNICATION IN THE EVALUATION STAGE

At this stage, the nurse assesses the success of the nursing care and actions that have been
carried out. All the results are recorded in the client's care progress logbook, discuss the
results with the client, ask the client for responses to the success or failure of the actions
taken, and together with the client to plan follow-up nursing care. If this has not been
successful, the nurse can discuss again with the client what is expected and how the client
or family's participation / involvement in achieving the client's new goals and plans for
nursing care.

At each phase in the care process, the nurse must use therapeutic communication
techniques and use the phases of the nurse-client therapeutic relationship, starting from the
orientation phase, the work phase, and the termination phase. For the pre-interaction
stage, you can do it by preparing by making a communication implementation strategy (SP).

Use the following SP communication format and prepare it before you interact with
patients. Write down conditions in accordance with the patient's condition, goals, and plans
that you will do. Every time you make SP communication, it means you have entered the
preorientation phase.

FORMAT

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 COMMUNICATIONS IMPLEMENTATION STRATEGY

Patient Condition:

Diagnosis of Nursing:

Nursing Plan:

Purpose:

SP Communications

Orientation Phase: Therapeutic greetings

Evaluation and validation
Contract
Work phase: (Write down the words according to the goals and plans to be achieved /
carried out)

Termination Phase: Subjective / objective evaluation Follow-up plans for future contracts

SUMMARY

1) All maintenance activities always use communication. The application of communication

is carried out at each stage of the nursing process starting from assessment, nursing
diagnosis, planning, and implementation and evaluation to solve client problems through
cooperation between nurse and client.

2) Therapeutic communication at the assessment stage is an important stage in the nursing

process because the later stages in the nursing process will not run well if the assessment
stage is not carried out properly. The nurse uses verbal or nonverbal skills in collecting data
and interpreting the results of the assessment to communicate to the client.

3) Communication at the nursing diagnosis stage is carried out to clarify the data and
analyse it before determining the client's nursing problem, then discussing with the client.
The problem or nursing diagnosis that has been determined is then communicated /
conveyed to the client so that he is cooperative and tries to work with the nurse to solve the
problem.

4) Communication at the planning stage is carried out when submitting the action plan and
discussing the plan that has been prepared by the nurse and with the client. Nursing care
plans are communicated in written form, that is, written or documented in the client's
status to be communicated to other members of the health team in order to provide
continuous nursing services, and as a form of nurse's professional responsibility.

5) Communication at the implementation stage is very effective when used by nurses when
explaining certain actions, providing health education, providing counselling, strengthening

8
support systems, helping to improve abilities coping, etc. Nurses use verbal or nonverbal
communication skills during nursing actions to determine the patient's direct (spoken) or
unspoken response. All nursing activities / actions must be communicated in writing.

6) Communication at the evaluation stage is important for nurses to do when assessing the
success of the care and nursing actions that have been taken. All evaluation results are
communicated verbally, namely when discussing the results with clients, asking clients for
responses to the success or failure of the actions taken, and planning follow-up nursing care
with the client. The results are also communicated in writing, that is, they are recorded in
the client's care progress logbook.

7) At each phase in the care process, the nurse must use therapeutic communication
techniques and use communication implementation strategies including phases of nurse-
client therapeutic relationships starting with the preorientation phase followed by the
orientation, work, and termination phases.

Topic: 2 Application of Therapeutic Communication in Patients with

Physical and Mental Disorders
Congratulations! You have successfully completed Topic 1 material in this Chapter III,
continue to study Topic 2. Topic 2 in this Chapter III covers the application of
communication at each stage of the nursing process, patients with physical, mental, and
special needs disorders.

Topic 2 provides knowledge and understanding of communication in patients with physical

and psychological / mental disorders that have an impact on the disruption of basic human
needs. The focus of this topic 2 is how to apply therapeutic communication in carrying out
nursing care for patients with disorders of basic human needs due to physical problems
(disorders of body systems) and mental disorders including anxiety.

After completing Topic 2, it is hoped that you will be able to apply therapeutic
communication in nursing care to clients with various disorders of basic human needs due
to physical problems (disorders of the body system) in order to meet basic human needs
and psychiatric disorders by using the stages of the nursing process starting assessment. ,
nursing diagnosis, planning, implementation, and evaluation.

After completing this Topic 2, it is hoped that you will be able to do the following.

1. Applying communication in nursing care to patients with physical disorders (disorders

of the body system) that have an impact on the disruption of basic human needs

1. Implement communication at the assessment stage of clients with disorders of basic

human needs (oxygen / nutrition / elimination / treatment).
2. Implementing communication at the stage of nursing diagnosis of clients with
impaired needs (oxygen / nutrition / elimination / treatment).

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 3. Implement communication at the planning stage of clients with impaired needs
(oxygen / nutrition / elimination / treatment administration).
4. Implement communication at the implementation stage of clients with impaired
needs (oxygen / nutrition / elimination / treatment).
5. Implement communication at the evaluation stage of clients with impaired needs
(oxygen / nutrition / elimination / treatment administration).

2. Implementing communication in nursing care for patients with psychiatric disorders.

1. Applying communication at the assessment stage of clients with psychiatric disorders

(anxiety).
2. Applying communication at the stage of nursing diagnosis of clients with psychiatric
disorders (anxiety).
3. Applying communication at the planning stage of clients with psychiatric disorders
(anxiety).
4. Applying communication at the implementation stage of clients with psychiatric
disorders (anxiety).
5. Applying communication at the evaluation stage of clients with psychiatric disorders
(anxiety).

In order to apply communication in nursing care to patients with physical disorders (body
systems) in order to meet basic human and psychiatric needs, you must continue to use
communication implementation strategies at every stage of the nursing process. In this
regard, mastery of the material in Chapters I and II is important.

How is the application of therapeutic communication in providing nursing care for clients
with various kinds of disorders of basic human needs due to physical problems (disorders of
the body system) and psychiatric disorders using the stages of the nursing process? Study
the following descriptions in order.

a) Applying communication in nursing care to patients with disorders of basic human needs
due to physical disorders (disorders of body systems).
Before discussing how the application of communication in nursing care for patients with
basic human needs disorders due to physical problems, we will first describe the system
disturbances that occur to provide insight to you regarding the problems that occur so that
you can direct the communication you will do. Disorders of demand which will be described
in Chapter III of Topic 2 are disruption of oxygen demand due to disturbances in the
respiratory system. For other distractions, you can do it yourself as an enrichment.

Impaired oxygen demand is a disorder of basic human needs caused by abnormalities or

disorders of the body system (physical problems) in the respiratory organ system. Disruption
in meeting oxygen demand can be related to a disturbance in the respiratory tract, oxygen
bonding with hemoglobin and oxygen diffusion to the alveoli. Some physical disorders
(diseases) that can cause disruption of oxygen demand include chronic obstructive
pulmonary disease (PPOM), upper respiratory tract infections (ARI), tuberculosis (TB),
pneumonia, and so on.

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1) Applying the assessment stage communication to clients with impaired basic human
needs (oxygen) We have understood that assessment is the first stage in carrying out
nursing care. In patients with impaired oxygen demand, the goal of nursing is to provide
oxygen to the body so that individuals can carry on their lives. Before applying therapeutic
communication to patients with oxygen disorders and for communication to be effective, it
is hoped that you will understand the aspects that are important to assess in patients. The
aspects that are important to assess in patients with impaired oxygen demand are medical /
treatment history, physical examination, and supporting examinations.

a) Health / care history to find out the history of health / care, an important data
collection technique to use is interviews. The data that need to be studied are
respiratory problems (breathlessness, intolerance of activity, wheezing), a history of
respiratory disease that has been experienced (bronchitis, asthma, etc.), lifestyle
(smoking), problems cardio pulmonal, and commonly used drugs. In connection with
this assessment to obtain medical history, the implementation of therapeutic
communication is very important.

b) Physical examination and support Physical examination of patients with impaired

oxygenation is carried out by means / techniques of inspection (seeing), palpation
(feeling), percussion (tapping), and auscultation (listening). This method of collecting
data using various techniques also requires the ability of nurses to carry out
therapeutic communication. Important investigations include collecting venous
blood, arterial blood, pulmonary function tests and sputum. All of these
examinations require the nurse's ability to communicate. Examples of
communication at the assessment stage are as follows.

Nurse:

1. 1) "Explain since when the mother felt the tightness got heavier."
2. 2) "At what time will the tightness occur."
3. 3) "Checking hemoglobin levels is important to find out

the bonding ability between Hb and oxygen. "

b. Applying the stage of nursing diagnosis communication to clients with impaired needs
(oxygen).
After collecting data, then they are grouped and analysed to determine the diagnosis or
nursing problem. It is important that the diagnosis / nursing problem has been assigned to
the patient so that they are cooperative in care. Some nursing diagnoses / problems that
often arise are ineffective airway clearance, ineffective breathing patterns, and impaired gas
exchange. Examples of communication at the stage of nursing diagnosis: Nurse:

 "Based on the results of the tests that have been done, it is known that the
maternal hb level is low so that the ability to carry oxygen to the tissues is less which
results in the mother feeling suffocated."

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  "The tightness that the mother experiences are due to interference with oxygen
transport."

c. Implementing the planning stage communication to clients with impaired needs (oxygen /
nutrition / elimination / treatment administration.)
An important activity in planning is setting goals and plans

nursing actions. Some activities that are planned and must be communicated include
positioning, breathing exercises and effective coughing, humidifier and nebulizer, as well
suctioning. This plan needs to be communicated to patients so that they are cooperative
and can give consent regarding the planned action.

Examples of planning stage communication:

Nurse:

 “Mother's airway is not clean, I planned to do

teaching about breathing exercises and coughing is effective. "

 "To thin mucus and clear the mother's airway, I would

To do nebulizer 2 times a day morning and evening. "

d. Implementing the implementation stage communication to clients with impaired needs

(oxygen).

In accordance with the plan, several actions were taken to patients with impaired oxygen
needs, including positioning, breathing exercises and effective coughing, humidifier and
nebulizer, as well suctioning.

Before taking this action, it is important for nurses to carry out therapeutic communication
to provide an explanation regarding the objectives and actions to be taken. Example of
communication in the implementation stage: Nurse:
 “I will start teaching how to breathe and cough effectively.

Are you ready? "

e. Applying evaluation stage communication to clients with impaired needs (oxygen).

The final stage of the nursing process is evaluation. This activity is carried out to measure
the achievement of successful care and actions that have been taken accordingly

standard. In patients with oxygen disorders, communication is necessary to determine the

patient's subjective response to meeting oxygen needs.

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Examples of evaluation phase communication:
Nurse:

"Once done nebulizer, Mother's airway has opened again so that no more breath sounds
out when you breathe. "

 Applying communication in nursing care to patients with psychiatric disorders.

Before discussing how the application of communication in nursing care for mental patients,
we will first describe the disorder to give your insight into the problems that occur so that
you can direct the communication you will do.

Many experts give their opinion about mental disorders. According to theorypsychoanalitic,
explained that mental disorders occur because of deviant behaviour in humans that can be
objectively observed through their mental structures, namely the id, ego, and superego. This
theory explains that the deviation (disorder) of behaviour in adulthood is associated with
problems in the developmental stage in early life. Each developmental phase has tasks to
complete. If many tasks are not completed, it will result in conflict. Psychological energy
(libido) is fixed, causing anxiety. This situation will give rise to neurotic symptoms in an
attempt to control the anxiety that occurs.

In this section, we will discuss the application of communication in nursing care for patients
with psychiatric disorders, especially anxiety. Anxiety is an emotional response that is
subjective and individual. Anxiety ranges from mild, moderate, severe, and panic. Prolonged
anxiety can cause serious mental disorders (depersonalization), namely the individual feels
alien to himself and in serious circumstances can occur exhaustion and death.

The application of communication to patients with mental disorders is the most essential
thing because communication is the nurse's main work tool to help patients improve their
adaptive behaviour / improve their behaviour.

a) Implementing communication at the assessment stage of clients with psychiatric

disorders

(anxiety) The assessment stage is an important stage in the nursing process because the
results of this assessment will determine the next steps in dealing with patient problems. An
important assessment for patients with mental disorders (anxiety) is behaviour, identifying
predisposing factors, stressor precipitation, extracting the sources coping, and mechanisms
coping used. A nurse must use communication skills in order to identify data about patients.

Examples of assessment phase communications:

 "I saw that the mother looked restless, explain what caused the mother to feel

not calm!"

 "What do you usually do when faced with such a problem?"

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b) Applying communication at the stage of nursing diagnosis of clients with psychiatric
disorders (anxiety)
After carrying out the assessment, the next step is to determine the nursing diagnosis or
problem. It is important that the diagnosis / nursing problem has been assigned to the
patient so that they are cooperative in care. Some of the nursing diagnoses / problems
relevant to anxiety are anxiety (moderate, severe, panic), ineffective individual coping, fear.

Examples of communication at the diagnosis stage: Nurse:

 "Based on data and analysis, it is known that the mother experiences anxiety

weight."

c) Implementing communication at the planning stage of clients with psychiatric disorders

(anxiety)

Nursing care plans are carried out in accordance with the nursing diagnosis and the level of
anxiety that occurs. Some action plans that require the nurse's ability to communicate are
building trusting relationships, increasing self-awareness, recognizing the patient's anxiety,
increasing relaxation, and protecting the patient. This plan needs to be communicated to
the patient so that they are cooperative and can work together as planned.

Examples of planning stage communication: Nurse:

 "To help reduce anxiety that occurs, I will

teaches relaxation techniques that mothers can do at any time if they feel anxious. "

d) Applying communication at the implementation stage of clients with psychiatric disorders

(anxiety)

An important activity in planning is setting goals and a plan of nursing action. Several
activities that are planned and must be communicated include positioning, breathing
exercises and effective coughing, humidifier and nebulizer, as well suctioning.

In accordance with the plan, several actions are taken to patients with impaired oxygen
needs, including positioning, breathing exercises and effective coughing, humidifier and
nebulizer, as well suctioning. Before doing this action, it is important for nurses to carry out
therapeutic communication to provide an explanation regarding the purpose and actions to
be taken.

Examples of implementation phase communication:

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 "Start by sharpening your eyes, calming your mind, making your body as relaxed as
possible."

 "Inhale through your nose and slowly out through your mouth."

e) Applying communication at the evaluation stage of clients with psychiatric disorders

(anxiety)

The final stage of the nursing process is evaluation. This activity is carried out to measure
the achievement of the success of care and the actions that have been taken. In patients
with anxiety, communication needs to be done to determine the patient's subjective
response to signs of decreasing anxiety levels with decreasing signs and symptoms that
appear.

Example of evaluation stage communication: Nurse:

 "How did you feel after doing deep breathing relaxation exercises?"
 "List the signs of less anxiety after doing regular exercise."

SUMMARY

1) Communication is the nurse's main work tool.

2) To carry out nursing care, each stage in the nursing process starts with
assessment, diagnosis, planning, implementation, and evaluation using
communication.

3) Therapeutic communication is carried out by nurses in providing nursing care to

patients with disorders of basic human needs due to physical disorders (body system
disorders) and mental disorders.

4) It is important for nurses to master various therapeutic communication

techniques to increase the effectiveness of nursing care carried out, both in order to
help patients overcome physical and mental problems.

5) Therapeutic communication at the assessment stage is an important stage

because the later stages in the nursing process will not work well if the assessment
stage is not carried out properly. The nurse uses verbal or nonverbal skills in
collecting data and interpreting the results of the assessment to communicate to the
client.

6) Communication at the nursing diagnosis stage is carried out to clarify the data and
analyse it before determining the client's nursing problem, then communicated /
conveyed to the client so that he is cooperative in overcoming the problem.

7) Communication at the planning stage is carried out when submitting the action
plan and discussing the plan that has been prepared by the nurse and with the client.

15
 Nursing care plans are communicated in writing, that is, written or documented in
the client's status.

8) Communication at the implementation stage is very effective when used by nurses

when explaining certain actions, providing health education, providing counselling,
strengthening support systems, helping to improve abilities coping, etc.

9) Communication at the evaluation stage is important for nurses to do when

assessing the success of the care and nursing actions that have been taken. All
evaluation results were communicated verbally, that is when discussing the results
with the client, and recorded in the patient's nursing status.

Nurse:

Mother:

"Explain to me how the behaviour happened to the mother's child that makes the mother
very restless." "In the last 3 months or so, my child has been less attentive to school, often
goes out at night and mingling with punk kids. I am worried that he will fall into
promiscuity”.

Topic: 3 Application of Communication to Patients with Special

Needs
Congratulations! You have successfully completed the Topic 1 and 2 material in this Chapter
III, continue to study Topic 3. Topic 3 in this Chapter III covers the application of
communication to patients with special needs. Topic 3 provides knowledge and
understanding of communication in patients with special needs including the concept of
communication for children with special needs, the characteristics of children with special

16
needs, types of communication disorders in children with special needs, and the application
of communication to patients with special needs.

After completing Topic 3 you will be expected to be able to apply therapeutic

communication to patients with special needs appropriately in nursing practice. After
completing Topic 3, hopefully you will

1. explain the concept of communication disorders in children with special needs,

2. identify characteristics of pediatric patients with special needs
3. identify types of communication disorders in children with special needs,
4. using communication techniques and strategies in children with special needs
(behavioural disorders: hyperactivity),
5. apply communication to patients with special needs. Based on the learning
objectives in Topic 1, the main points that will be described in order are the concept
of communication disorders in children with special needs, characteristics and types
and therapeutic communication techniques for patients with special needs, and how
to implement communication in patients with special needs.

A. WHAT ARE THAT SPECIFIC NEEDS?

Special needs are conditions that require special understanding and treatment of patients /
children who have certain limitations or disorders. In society, there are enough children or
adults with special needs that they have difficulty living in a normal society. Some of them
seem excluded / unacceptable because of their "disorder" or "disturbance" and do not get
adequate help or treatment. One of the factors that make patients with special needs
difficult for society to accept is their inability to communicate / language difficulties and
express opinions, as well as behaviour that is "strange" and difficult to understand.

To answer this question, then carefully study the communication disorders that often occur
in patients with special needs, respectively.

1. Communication disorders in children / clients with special needs

a. Case illustration:

Dody is a 2-year-old boy and still can't speak. He could say a few words, but he was far
behind his peers. This delay must be recognized immediately so as not to be late in dealing
with Dodi’s communication problems.

This case is a case that we commonly find among parents, namely the case of children
speaking late. Many parents hesitate to seek help because they try to convince themselves
that their children will be able to talk one day. Knowing what is normal and what is not in
the child's speech and language development can help you to pay more attention to
whether the child is still in normal speech ability or not.

b. What is a communication disorder?

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Communication disorders are speech disorders in children as one of the disorders often
experienced by children. This communication disorder is common in preschool age. This
includes speech disorders (3%) and stuttering (1%). Speech disorder that is handled late is if
there is a significant change in behaviour, psychiatric disorders, reading difficulties, and
academic achievement disorders including decreased achievement in school until drop-out.

Meanwhile, hearing loss varies about 5% of school-age children with hearing levels below
normal. Of this number, 10-20% require special education and about 1/3 of hearing-
impaired children attend regular schools, 2/3 of them enter special education or special
schools for the deaf.

2. Identifying Patient Characteristics of Children with Special Needs

Try to study the following illustration and understand the problem that occurred.

A 4-month-old baby seems unresponsive or babbling. Babies just look at a place without a
natural response. Try to learn and understand the following babies aged 12-24 months.

Think about what therapeutic communication might look like at each stage of the nursing
.process

1. Cannot use body language such as pointing or waving at 12 months of age.

2. Prefer to use body language over vocalization to communicate at 18 months of age.
3. Has difficulty imitating first sounds or words that do not appear at 18 months of age.

Are the child's communication skills normal? Recognize early communication

problems in children!

The following are characteristics of children over 2 years of age who are identified as
children with special needs due to communication problems.

1. Can only repeat words or sounds without being able to produce their own words or
sentences.
2. Just say a few words or sounds over and over.
3. Unable to follow simple instructions.
4. Has an unusual voice (nasal voice).
5. It is more difficult to understand than its peers.
6. Children with speech and language delays share a variety of characteristics, including
an inability to follow directions, slow speech, difficulty articulation, and difficulty
making sentences.

Other characteristics of children with special needs due to communication disorders

are as follows.

1. Stuttering is a speech disorder that occurs between the ages of 3 and 4 years and can
develop into a chronic case if not treated adequately. Stuttering can spontaneously
disappear in adolescence.

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 2. Children with hearing loss may present with reduced hearing ability. Early detection
and diagnosis of hearing loss should be carried out and treated promptly.

3. Various kinds of communication disorders in children with special needs

What kinds of disorders do you have a special need for?

In general, there are 4 types of communication disorders in patients with special needs,
namely language disorders, speech disorders, voice disorders, and rhythm disorders.

The following is a description of the various disorders. Study and understand the forms of
distraction that occur before you understand the application of therapeutic communication
to these specific circumstances.

a. Language disorders

Language is what is conveyed in words (speech) and not in writing. This is in accordance
with the first rule of language, namely as a symbol of sound. A speaker is always aware of
what he is going to say, but he is not aware of how he is saying it. However, not everyone
can use the language well and easily. There are some people who need special needs
because they have problems or experience problems in using language.

Language disorder is one type of disorder or disturbance in communication with an

indication that the client is experiencing difficulties or loss in the symbolization process. This
symbolization difficulty results in a person being unable to provide accepted symbols and
conversely unable to change the concept of meaning into symbols that can be understood
by others in their environment. This disorder is a form of client failure to reach the stage of
development in accordance with the language development of normal children his age.

Some forms of language disorders are delays in language development and aphasia as
described below.

1) Delay in language development

Delays in language development include mental intellectual delays, deafness,

congenital aphasia, autism, minimal brain dysfunction, and learning difficulties.
Children who experience these causes are late in developing language skills so that
the child experiences the transformation difficulties needed in communication.
These behavioural disorders greatly affect the language acquisition process,
including lack of attention and interest in the stimuli around them, attention that is
easily shifted, poor concentration, seems easily confused, quickly gives up, creativity
and imagination are lacking, and lack of conceptual ownership. self.

2) Aphasia

Aphasia is a type of language disorder caused by damage to the language centres in

cortex cerebri. Aphasia is clinically divided into the following.

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a) Sensory aphasia

Namely a disorder characterized by difficulty in giving meaning to the stimuli it receives.

Spontaneous speaking usually fluently only sometimes less relevant to the situation of the
conversation or the context of communication.

Example:
An adult aphasia will find it difficult to say the word book even though in front of him is
shown a book object. Clients with difficulty mention foam, fur, bubu. (The client looks
distressed and desperate). For auditory aphasia, the client is unable to give the meaning of
what he hears.

When asked, "have you eaten?" So, the answer is "plate, plate, table, yes, yes".

b) Motoric aphasia

This motoric aphasia is characterized by difficulty in coordinating or arranging

thoughts, feelings, and wills into symbols that are meaningful and understood by
others. Verbal speech is not fluent, intermittent, and is often not understood by
other people. If the sentences are short and monotonous. A person with this
disorder understands and can interpret the stimuli he receives, only to express them
having difficulty.

Example:
A 59-year-old adult aphasia, having difficulty answering, where is the house of the father,
pointing to the west and annoyed at the lack of ability in his speech. This type of aphasia is
also experienced in pouring into written form. This type is called dysgraphia (agraphia).

c) Conductive aphasia, which is a disorder characterized by difficulty in imitating the

repetition of language sounds. Short sentences are quite fluent in pronouncing, but long
sentences experience difficulties.

d) Amnestic aphasia, which is a disorder characterized by difficulty in choosing and using the
correct symbols. Generally, the symbols chosen are associated with names, activities, and
situations related to life activities.

Example:

 if you want to say chair, the patient will become the word sit.

b. Speech disorders

Language development cannot be separated from speech development. A person's

language development will affect speech development. Language development is influenced
by situations and environmental conditions when children are raised. Speech disorder is a
type of communication disorder or disorder characterized by an error in the speech sound
production process. Abnormalities in the production process cause articulation errors both

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in the point of articulation and in the way it is pronounced, as a result of which there are
errors such as replacement / substitution or omission.

Clinically, speech disorders in relation to the causes of the disorder can be divided into
several types, namely disaudia, dyslogia, dysarthria, dysplosia, and dyslalia.

Motoric aphasia patients understand and can interpret the stimuli they receive, but are
.unable to express their language

1) Disaudia

Disaudia is a type of speech disorder caused by hearing loss which causes difficulty in
receiving and processing tones both in intensity and quality of speech sounds. This
disturbance results in imperfect and possibly misleading voice messages. In children with
hearing impairment, these errors are often used in communication. Children with hearing
loss tend to have a monotonous voice and high pitch, do not recognize song sentences,
which are interrogative sentences, affirmative sentences, and do not recognize the meaning
of exclamation points in sentences. Example: word / copy /, he hears / hat /, word / ball /,
he hears / pattern /. Generally, children with a disaudia in communicating tend to use sign
language that they have mastered. However,

2) Dyslogia: Dyslogia is a form of speech disorder caused by the ability to think capacity or
the level of intelligence below normal. Spelling errors are caused by not being able to
observe differences in the sounds of objects, especially sounds that are almost the same.
Example: the word was replaced with but, coffee with a hat. The low ability to remember
causes the omission of syllables or words when pronouncing a sentence. For example: /eat /
pronounced / ‘’Ee’’/, / went / pronounced / we /, / mother went to market / pronounced /
ma ... we.... ma /.

3) Dysarthria

Dysarthria is defined as a type of speech disorder / inability that occurs due to paralysis,
weakness, stiffness or impaired coordination of the muscles of the speech organs or speech
organs due to damage to the central nervous system. This disorder is caused by several
conditions, namely the result of spasticity or stiffness of the speech muscles, weakness of
the muscles of the speech organs, impaired coordination of phonation movements,
articulation and resonance, decreased movement of the muscles of the speech organs to
stimuli from the center /cortex, and failure to speak due to involuntary movements. These
disturbances can result in speech difficulties, delays, dropouts, dropouts or no production of
sound or speaking in a monotone tone. This condition is difficult for the other person to
understand.

4) Dysglosia

Dysglosia means speech abnormalities that occur due to structural deformities of the
speech organs. This failure is due to deformities in the shape and structure of the
articulation organs, namely cleft palate, inappropriate construction of the upper and lower

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teeth, anomalous abnormalities, which are congenital abnormalities or deformities, such as
thick, non-growing tongue or short tongue straps.

5) Dyslalia

Dyslalia is a symptom of a speech disorder due to the inability to pay attention to speech
sounds received so that it is unable to form language concepts. For example / eat /
become / kaman / or / nakam /

c. Voice Interference

Voice disturbance, which is a type of communication disorder caused by a disturbance in the

sound production process.

The kinds of sound disturbances are as follows.

1) Abnormalities in tone: disturbances in the vibration frequency of the vocal cords

at the time of ponation which results in disturbances in the tone being spoken.

2) Abnormalities in sound quality: voice disturbances that occur due to imperfect

contact between the vocal cords at the time of adduction so that the sound
produced is not the same as the usual sound. Examples of disturbances: voice
becomes nasal, shrinks, or gets bigger.

3) Afonia, which is a voice disorder caused by the inability to produce sound or not
being able to make a sound at all due to vocal cord paralysis.

d. Rhythm Interference

Rhythm disturbance is a speech disorder characterized by fluency when speaking, including

stuttering, which is disruption in fluency in speaking in the form of repetition of sounds or
syllables, prolongation and inability to start pronouncing words, and fluency disorder
characterized by speaking very quickly resulting in errors articulation that is difficult to
understand and understand.

Speech difficulties in patients / children with special needs need to be recognized and
understood by nurses. The nurse should try to understand patient communication,

It is NOT the patient who has to understand nurse communication.

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Figure 4.1. Touch / Hugging as a form of Communication to Patients with Special Needs

4. Communication techniques and strategies for children with special needs (behavioral
disorders: hyperactivity)

The presence of specific disorders in the ability to interact and communicate in autistic or
hyperactive children requires the ability of nurses to select and use the right strategies to
improve the abilities of children with special needs (autistic or hyperactive). The nurse,
parent, or other adult must show patience when communicating and interacting.

What therapeutic communication techniques are effective for children with special needs
because of autism or hyperactivity?

Communication with children who experience impaired social relations or impaired verbal
communication due to autism or hyperactivity need to be selective in choosing techniques
because there are things that children don't like. Communication can be done verbally or
nonverbally. In principle, the purpose of communication is to maintain the comfort and
safety of clients as well as to maintain interaction and repair communication damage.

a. Nonverbal communication (body language) and attitude

1) Receiving children as a whole.

2) Maintain eye contact and maintain physical distance.

3) Stay relaxed, don't panic and always smile. Don't scold the child.

4) Use a soft tone of voice, especially if the client shows high emotions.

5) Hug the child even though he refuses and does not force a hug if the child refuses.

6) Avoid impatient body language such as rolling eyes, tapping feet, or sighing.

7) Exemplify the right behaviour.

8) Stay relaxed, calm, patient, and sincere.

9) Help the child's difficulties.

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 10) Keep the child safe from physical harm.

11) Helps improve adaptation and mechanisms coping child.

b. Verbal communication and communication techniques used

1) Simple or closed questions because the child / client is very uncooperative.

2) Repeating the conversation that is not clear.

3) Clarify the child's verbal expression.

4) Don't talk while walking.

5) Speak briefly and clearly according to children's ability to accept.

6) Focusing and others according to the child's condition.

c. Application of communication strategies in patients with special needs (behavioural

disorders: hyperactivity)
Communicating with children with special needs (behavioural disorders: hyperactivity) is not
easy. It is necessary to implement a communication strategy to achieve the expected
results. The following is an example of applying a communication strategy to a patient with
a special needs disorder (behavioural disorder: hyperactivity).

Case illustration:

A 7-year-old boy was escorted by his mother to the hospital for consultation because he
suspected a behavioural disorder in the child. According to the mother, her child could not
sit still, often ran to the road, climbed walls or trees without worrying, and seemed always
restless. During the assessment, the child was always nervous / unable to sit still, had no eye
contact and did not respond to calls.

Pre-interaction phase:

You as a nurse are ready to conduct meetings with parents and children. You already know
the child's problems and you have identified your own strengths and weaknesses.

(Students make SP communication before interaction)

Client Condition:

 Unable to sit still and always restless, no eye contact and no response when called his
name.

 According to the mother, the child often climbs walls, trees, or runs onto roads.

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Nursing Diagnosis:

1. Impaired verbal communication

2. Risk of physical injury

Nursing Plan:

1. Improve children's ability to recognize communication.

2. Increase the ability to control behaviour and prevent physical trauma / injury.

Nursing Care Objectives:

1. Able to know communication.

2. There was no physical injury.

Implementation (SP) Communication:

Orientation Phase: (therapeutic greetings, evaluation / validation, and contracts)

P: "Good morning dear, Assalamualaikum" (reached out, approached the child and sat
beside him).
K: Client response (no attention).
P: "What do you feel dear?" (while holding the child's shoulder)

K: Client response (no attention).

P: "Do you want to play with me?" "Which do you like?" (while showing the game selection)

K: Client response (choosing to play snake and ladder)

P: "Just play here, okay?"

K: Client response

Work Phase (related to the game together)

P: Observing the child's play behaviour while inviting him to play with his mother.

K: Client response regarding games.

P: "Did you like the game?"
K: Client response

P: "Continue when you're happy".

Termination Phase:

P: "How do you feel now?" (while holding the child's shoulder)

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K: Client response.
P: "Happy, huh?"
K: Client response.

P: “Your game is over, yes, now let's sit close to Mother. Then continue at home with
Mother. Good afternoon". (asking for handshakes with children)
K: Client response.

SUMMARY

1) Special needs are conditions that require special understanding and treatment of
patients / children who have certain limitations or disorders.

2) In general, there are 4 types of communication disorders, namely language

disorders, speech disorders, voice disorders, and rhythm disorders.

3) Language disorder is one type of disorder or disturbance in communication with

an indication that the client has experienced difficulties or losses in the
symbolization process which results in a person being unable to provide accepted
symbols and vice versa being unable to change the concept of meaning into symbols
that can be understood by others.

4) Aphasia is a type of language disorder caused by damage to the language centres

in cortex cerebri. Clinically, aphasia can be divided into sensory aphasia, motor
aphasia, conductive aphasia, and amnestic aphasia.

5) Speech disorders: language development cannot be separated from speech

development. The development of a person's language will affect speech
development. Speech disorder is a type of communication disorder or disorder
characterized by an error in the speech sound production process. Abnormalities in
the production process cause articulation errors both in the point of articulation and
in the way it is pronounced, as a result of which there are errors such as replacement
/ substitution or omission. Clinically, speech disorders can be divided into several
types, namely dysaudia, dyslogia, dysarthria, dysplosia, and dyslalia.

6) Voice disturbance, which is a type of communication disorder caused by a

disturbance in the sound production process, including tone disturbances, sound
quality abnormalities, and afonia.

7) Rhythm disorders, which are speech disorders characterized by non-fluency when

speaking, including stuttering and fluency in speech.

8) Behavioural disorders (hyperactivity) are disorders whose characteristics focus on

inattention / attention and communication disorders. The client is always on the
move and cannot stay still.

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 9) Disturbances in verbal or nonverbal communication in hyperactive children
include the inability to use words other people do not understand, use body
language, and can only communicate for a short time.

10) It is necessary to be selective in choosing the technique because there are things
that the child doesn't like. Communication can be done verbally or nonverbally. In
principle, the purpose of communication is to maintain the comfort and safety of
clients as well as to maintain interaction and repair communication damage.

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