1. Aphasia: impaired ability to understand or use commonly accepted words or symbols; interferes with ability to speak, write, or read; language center-usually left hemisphere (85% of population). Dysarthria is motor impairment-inability to articulate words.
    1. Types and pathophysiology:
      1. Receptive (sensory)-lesion usually Wernicke’s area of temporal lobe; difficulty understanding spoken word (auditory aphasia) or written word (visual aphasia).
      2. Expressive (motor)-difficulty expressing thoughts in speech or writing (motor aphasia); understands written and spoken words. Three types: anomic-fluent speech, but unable to name objects, qualities, and conditions; fluent-articulate and grammatically correct, but no content or meaning; nonfluent-unable to select, organize, and initiate speech (involves Brocas area of brain); may affect writing.
    2. Risk factors:
      1. Vascular disease of the brain (cerebrovascular accident).
      2. Alzheimer’s disease (degeneration).
      3. Tumor.
      4. Trauma.
    3. Analysis/nursing diagnosis:
      1. Impaired verbal communication related to cerebral cortex disorder.
      2. Powerlessness related to inability to express needs/concerns.
      3. Impaired social interaction related to difficulty communicating.
    4. Nursing care plan/implementation: Goal: assist with communication: patient does best when rested; small improvements will occur up to 1 year after injury (age is a factor). Strategies: Nonfluent -allow time to respond; support efforts to speak; acknowledge frustration of patient-anticipate needs when appropriate; use picture board or flashcards, pointing, to encourage communication; assess efforts to communicate with open-ended questions. Fluent-face the patient, speak slowly and distinctly, not loudly; use gestures, repeat instructions as needed; involve family in techniques to improve communication; acknowledge frustration.
    5. Evaluation/outcome criteria:
      1. Communication reestablished.
      2. Minimal frustration exhibited.
      3. Participates in speech therapy.

  2. Meniere’s disease: chronic, recurrent disorder of inner ear; attacks of vertigo, tinnitus, and vestibular dysfunction; lasts 30 minutes to full day; usually no pain or loss of consciousness.
    1. Pathophysiology: associated with excessive dilation of cochlear duct (unilateral) from overproduction or decreased absorption of endolymph (endolymphatic hydrops)-progressive sensorineural loss.
    2. Risk factors:
      1. Emotional or endocrine disturbance (diabetes mellitus).
      2. Spasms of internal auditory artery.
      3. Head trauma.
      4. Allergic reaction.
      5. High salt intake.
      6. Smoking.
      7. Ear infections.
    3. Assessment:
      1. Subjective data:
        1. Tinnitus (constant or intermittent).
        2. Headache; feeling of fullness or pressure in affected ear.
        3. True vertigo: sudden attacks; room appears to spin.
        4. Depression; irritability; withdrawal.
        5. Nausea with sudden head motion.
      2. Objective data:
        1. Impaired hearing, especially low tones.
        2. Change in gait; lack of coordination.
        3. Vomiting with sudden head motion.
        4. Nystagmus-during attacks.
        5. Diagnostic test: caloric (cold water in ear canal)-may precipitate attack; audiometry-loss of hearing.
    4. Analysis/nursing diagnosis:
      1. Risk for injury related to vertigo, lack of coordination.
      2. Auditory sensory/perceptual alteration related to progressive hearing loss.
      3. Anxiety related to uncertainty of treatment.
      4. Risk for activity intolerance related to sudden onset of vertigo.
      5. Sleep pattern disturbance related to tinnitus.
      6. Ineffective individual coping related to chronic disorder.
    5. Nursing care plan/implementation:
      1. Goal: provide safety and comfort during attacks.
        1. Activity: bed rest during attack; side rails up; lower to chair or floor if attack occurs while standing; assist with ambulation (sudden dizziness common).
        2. Position: recumbent; affected ear uppermost usually.
        3. Identify prodromal symptoms (aura, ear pressure, increased tinnitus).
      2. Goal: minimize occurrence of attacks.
        1. Give medications as ordered:
          1. Anticholinergics (oral or transdermal scopolamine, atropine, glycopyrrolate [Robinul]) to minimize GI symptoms.
          2. Antihistamines (dimenhydrinate [Dramamine], diphenhydramine HC1 [Benadryl]) to sedate vestibular system.
          3. Antiemetics and antivertigo agents (diazepam [Valium], meclizine HC1 [Antivert]).
          4. Diuretics may help (hydrochlorothiazide) to decrease endolymphatic fluid.
        2. Diet: low sodium (<2 g/day).
        3. Avoid precipitating stimuli: bright, glaring lights; noise; sudden jarring; turning head or eyes (stand in front of patient when talking).
      3. Goal: health teaching.
        1. No smoking (causes vasospasm) or alcoholic beverages (fluid retention, contraindicated with medications).
        2. Management of symptoms: play radio to mask tinnitus, particularly at night.
        3. Keep medication available at all times.
        4. Prepare for surgery if indicated (labyrinthectomy if hearing gone; or vestibular neurectomy to relieve vertigo and preserve hearing).
    6. Evaluation/outcome criteria:
      1. Decreased frequency of attacks.
      2. Complies with treatment regimen and restrictions (low-sodium diet, no smoking).
      3. Hearing preserved.