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Document Title and Code: Policy for the Management of Communication Needs. NMA-MCN

Version 2

Author: Prepared by Nursing Matters & Associates.

Issue Date: August 2016

Review date: August 2019

Authorised by:

1.0Policy Statement:

It is the policy of The Centre to support each resident in meeting their individual communication

needs in an environment that facilitates effective communication.

2.0Purpose:

To ensure that residents’ communication patterns and needs are identified and addressed in a

person-centred plan of care and used to promote autonomy and informed decision making for

each resident.

3.0Objectives:

1.1 To ensure that residents’ communication needs are identified commencing at pre-

admission and on admission and throughout their care journey in the home.

1.2 To ensure that every resident identified as having specific communication needs receives

appropriate care and support to meet these needs.

1.3 To provide an environment that facilitates effective communication for all residents

1.4 To ensure that each resident receives the appropriate support with communication so as

to promote autonomy and informed decision-making in all aspects of their daily lives.

4.0Scope:

This policy applies to all staff in The Centre who are involved in assessment, care planning and

or delivery of care and services to residents. The policy does not address organization

arrangements for provision of information to resident.

This policy should be read in conjunction with the following:

■ The Centre Consent and Advocacy Policy■ The Centre Provision of Information to Residents Policy.

1 | P a g e M a n a g e m e n t o f R e s i d e n t s ’ C o m m u n i c a t i o n N e e d s 1 8 0 8 2 0 1 6

5.0Definitions:

5.1 Communication: Involves the combination of verbal and non-verbal behaviours and

involves openness to enquiry as well as the direction of attention, perception, receptivity

and empathy towards another person (McLeod-Clarke, J 1992; Heath, H. 1997).

5.2 Components of Communication:

5.2.1 Verbal: words that are spoken or written.

5.2.2 Paraverbal: the stress, pitch and intensity which give words extra meaning.

5.2.3 Paralinguistic: laughter, crying, coughing and spluttering.

5.2.4 Non-verbal: body and facial movements.

5.3 Communication disorders in the elderly: communication difficulties resulting from

hearing, visual, language and / or cognitive impairment affecting receptive, perceptual or

articulatory ability.

5.3.1 Receptive ability can be impaired due to hearing deficits; environmental distractions;

heightened anxiety; altered level of consciousness or neurological impairment such as

following a stroke.

5.3.2 Perceptual ability can be distorted by physiological imbalance; acute confusion;

depression or dementia.

5.3.3 Articulatory ability can be affected by respiratory disease; laryngeal disease; oral

disease; ill-fitting dentures; dysarthria or cerebral changes as in stroke.

5.3.4 Aphasia: a loss of the power to speech resulting from injury to the brain and leading to

difficulties understanding language (Receptive aphasia); organizing words and

meaningful expressions (expressive aphasia) or using inappropriate names to identify

objects/people (nominal aphasia). Mild forms of nominal aphasia can occur because of

anxiety or fatigue.

5.3.5 Dysarthria: difficulty articulating speech resulting from damage to the central or

peripheral nervous system affecting the muscles of speech.

5.3.6 Visual Impairment: can be defined as a visual acuity of 20/50 or worse (Hartford Institute

of Geriatric Nursing, 2008). In this policy visual impairment refers to any type of difficulty

in seeing / poor eyesight.

5.3.7 Hearing Impairment: In this policy refers to hearing loss associated with normal

degenerative changes or secondary to diseases / conditions affecting normal hearing.


6.0Hearing /Visual Changes Common in Older Adults.

6.1 Diseases that alter hearing seen more frequently as people age:

Central auditory processing disorder: An uncommon disorder that includes an inability to process incoming signals and is often found in stroke patients and older adults with Alzheimer Dementia. The person's hearing is intact but their ability to process the sound is impaired.

Tinnitus: Ringing in the ears may fluctuate can be due to damage to the hair receptors of the cochlear nerve and age related changes in the organs of hearing and balance. Patients with tinnitus should be referred to ENT

Meniere's Disease: characterized by fluctuating hearing loss, dizziness and tinnitus. Possible causes of Meniere's disease include: hypothyroidism, diabetes and neurosyphillis.

7.0Diseases that alter vision seen more frequently as people age:

Cataracts: Clouding of the crystalline lens presents as painless, progressive loss of vision can be unilateral or bilateral.

Macular Degeneration: The most common cause of legal blindness in the elderly. The development of drusen deposits in the retinal pigmented epithelium leading cause of central vision loss in older adults. More common in fair haired blue eyed individuals. Other risk factors include smoking and excessive sunlight exposure. There are wet and dry forms of macular degeneration.

Glaucoma: A potentially serious form of eye disease. The majority of cases of glaucoma are Open angle glaucoma (95%). Increased intraocular pressure causing atrophy and cupping of the optic nerve head causing visual field deficits that can progress to blindness. Vision changes include loss of peripheral vision, intolerance to glare, decreased perception of contrast and decreased ability to adapt to the dark.

Diabetic Retinopathy: End organ damage from diabetes causing retinopathy and spotty vision. Risk can be reduced by tight blood sugar control.

Hypertensive Retinopathy: End organ damage from poorly controlled hypertension causing background and eventual proliferative retinopathy. Usually treated with laser photocoagulation and tight blood pressure control.

Temporal Arteritis: Autoimmune disorder that causes inflammation of the temporal artery. It presents as malaise, scalp tenderness, unilateral temporal headache, jaw claudication, and sudden vision loss (usually unilateral). This vision loss is a medical emergency but is potentially reversible if identified immediately.

Detached Retina: Can occur in patients with cataracts or recent cataract surgery,

trauma or be spontaneous. Presents as a curtain coming down across vision. This should

be treated as a medical emergency

Source: Hartford Institute of Geriatric Nursing: Geriatric Nursing Resources for Care of Older Adults: Sensory Changes.


Actions Responsible Person.

This policy will be disseminated to and read by all staff involved in assessment and care planning for residents.

Person in Charge.

A record will be kept of all those who have signed the policy acknowledgement forms.

Person in Charge.

Where a new version of this policy is produced, the previous version will be removed and filed away.

Person in Charge.

Every new staff member who will have a role in assessment and care planning will be given an explanation of this policy as part of his/her induction.

Person in Charge.

Nurses will be provided with the opportunity to attend training /updates on communication and older people every three years or where there is a significant change to practice in this area.

. Person in Charge.

Each new resident will be screened for hearing, visual, language and cognitive related communication impairments on admission.

Admitting or designated nurse.

Any resident identified as having communication impairment on admission will have a comprehensive assessment of communication patterns and needs commenced within 48 hours or sooner if indicated by their admission assessment.

Admitting or named nurse.

Each resident who has communication impairment will have a written care plan developed in consultation with herself and /or the resident’s representative and other relevant healthcare personnel involved in the resident’s care.

Named nurse.

The resident’s plan of care to meet communication needs will be communicated to all those providing direct care to the resident.

Named nurse.

Nurses will maintain their competence in assessment and care planning for residents and communicate any competency / knowledge deficits to the Person in Charge.

All registered nurses

Care given to residents will be in accordance with the plan of care developed and agreed by the resident and / or representative and other healthcare professionals involved in the resident’s care.

All healthcare staff providing care to residents.

Changes in a resident’s communication patterns will be reported to the senior nurse in charge and changes to care will be communicated to all relevant healthcare professionals.

All nurses, care assistants and other healthcare professionals involved in the resident’s care.

Proactive management of the environment to optimize effective communication for resident’s with specific communication needs is part of the daily care for residents.

All staff.

8.0Responsibilities


9.0Quick Reference Guide: Management of Communication Needs.


Initial risk and immediate care needs assessed on admission. Resident assessed for presence of:◙ Speech/language impairments.◙ Visual Impairment.◙ Hearing impairment.◙ Cognitive impairment.Ask the resident and / or representative about any hearing, visual or speech difficulties

Resident observed for:

◙ Making efforts to hear, such as cupping the ear, leaning forward to hear.

◙ Having difficulty navigating the environment and /or finding objects

◙ Having difficulty understanding and providing adequate responses to questions

Communication difficulties identified –Focused Nursing Assessment.

◙ To assess cognitive function: Mini Mental State Exam.◙ To assess speech /language difficulties. ◙ To assess hearing difficulties. .◙ For visual difficulties.◙ Liaise with resident’s GP regarding further examination / evaluation

where hearing, visual or speech impairment suspected or identified.◙ Liaise with GP, resident and / or representative regarding any

referrals that might be needed.

Care Planning Process.Liaise with the resident and/or representative; resident’s GP and other healthcare personnel involved in the residents care and:◙ Identify and document specific communication difficulties.◙ Identify and document interventions and /or aids to maximise the

resident’s ability to communicate effectively.◙ Address environmental factors that may affect the resident’s ability to

communicate.◙ Agree review schedule to monitor the resident’s response to

interventions.◙ Care plan documented and communicated to other healthcare team

members involved in the resident’s care.

Monitoring.◙ Resident’s communication needs/problems reviewed and amended

according to specific review schedule.◙ Resident’s care and condition recorded in daily flow sheets.◙ Changes to care / condition recorded in progress notes.◙ Care plans for communication updated in accordance with the

resident’s changing needs.

Pre Admission.◙ Information regarding the resident’s communication patterns and needs

collected as part of the pre-admission process.

10.0 Assessment Protocol for Communication Patterns and Needs.

10.1 Pre-Admission Assessment.

10.1.1 Information regarding the resident’s communication patterns and needs should be

collected as part of the pre-admission process of The Centre Nursing Home, using the

designated pre-admission assessment form.

10.2 Admission assessment.

10.2.1 The admitting or named nurse should complete an assessment of the residents

communication needs through completion of the The Centre’s admission assessment

form and observation.

10.2.2 To assess for the presence of hearing difficulties the nurse should ask the resident

and/or representative questions such as:

Does the resident have any problem with hearing now?

Does the resident have any buzzing, ringing or roaring sounds in her ears?

Does the resident have any difficulties with hearing in specific situations, such as in a

noisy room, during normal conversation, on the telephone?

10.2.3 Observe the resident for signs of hearing impairment such as:

Does he/she cup her hand behind his/her ear?

Does he/she tilt his/her head towards another person when listening?

Does he/she keep the volume of the radio/television very high?

Does he/she misinterpret questions or not respond?

Does he/she look lost when a question is asked?

Does he/she ask for things to be repeated or say what, pardon and so on frequently?

10.2.4 Where a resident is identified as having a hearing impairment, the nurse should

gather information about any hearing / adaptive aids used, such as:

What, if any hearing aid devices are used?

Can the resident use these devices independently?

Has the resident got the device with them?

Do the resident / family have a maintenance leaflet / instructions for the device?

When did the resident last have a hearing test and what were the outcomes?

Was the resident prescribed any treatments for her hearing / ear care?

Is the resident currently taking this / these treatments?

Can the resident administer treatment independently?


When the last time was the resident had a hearing test and when is she due to have

another?

Has the resident a history of wax build up in her ears and if so what treatment is used?

10.2.5 To assess for the presence of visual impairment the nurse should ask the

resident/representative questions such as:

Does the resident have any difficulty with vision?

Can the resident have any difficulty reading signs or the newspaper?

Does the resident have any difficulty adapting from light to dark environments?

Does the resident have difficulty with very bright light?

10.2.6 The nurse should observe the resident for signs of visual impairment such as:

Difficulty navigating the environment.

Difficulty finding objects.

10.2.7 Where the resident and / or representative reports that the resident has a visual impairment, the nurse should obtain information regarding treatments, aids that have

been used such as:

History of eye problems / diseases.

Treatments.

Does the resident wear glasses?

Does the resident have more than one set of glasses?

Does the resident know when to wear these glasses?

Are the glasses present?

Are the glasses free of scratches?

Does the resident have any difficulty in locating the correct glasses when they are

needed?

What if any treatments have been prescribed for visual impairment?

Is the resident currently taking these treatments?

Can the resident take/administer these treatments independently?

How does the resident’s visual impairment impact on performance of daily activities,

including socializing and mood?


Does the resident have any wishes for improvement in visual functioning?

When did the resident last have an eye examination and what was the outcome?

When is the resident due to have a follow up eye examination?

How does the visual impairment affect the resident in everyday activities and quality of

life?

10.2.8 To assess for the presence of any receptive or expressive disorders the nurse

should observe the resident for difficulties understanding questions and/or verbal

instructions as well as the resident’s ability to respond appropriately to questions and/or

instructions.

10.2.9 To assess for communication difficulties related to cognitive impairment the nurse

should observe and assess for signs of cognitive impairment such as:

Memory loss.

Distortion of time and/or place perception.

Behavioral cues.

Difficulty understanding and / or repetition of words or sounds.

Difficulty in expressing emotions appropriately.

Inability to follow instructions.

Inability to make themselves understood by others which may be a trigger for challenging

behaviour.

Residents who have dementia may also have difficulty remembering, relating and sorting

out information, when they are spoken to and can retain or loose these skills in individual

ways.

10.2.10 The impact of dementia on language abilities varies greatly from one person to another,

thus an assessment of the resident’s particular communication patterns and needs is

essential.

10.2.11 The nurse should also observe for signs that the resident is having difficulty articulating

words which may be due to ill-fitting dentures or oral disease or as a result of neurological

impairment such as in Parkinson’s disease or following a stroke.

10.2.12 Where any or more of these signs are present, this prompts the need for further

assessment and evaluation, including identification of any aids used and how effective

these aids are in facilitating communication as well as medical examination by the

resident’s G.P.

10.2.13 Where more detailed assessment is required, the nurse should liaise with the resident

and /or representative as well as the resident’s GP regarding referrals or further tests.


10.2.14 Any immediate care needs or risks related to communication patterns and needs should

be documented on admission and communicated to all those involved in providing care

for the resident.

11.0 Care Planning Protocol for Resident’s with Communication Needs.

11.1.1 Care planning for meeting the communication needs of residents should be prepared by

the admitting within 48 hours or sooner if indicated by the findings of the admission

assessment and through observation of the resident and discussion with the resident

and/or his/her representative(s).

11.1.2 Care planning should involve the resident as far as is practicable, and / or his/her

representative as well as the resident’s G.P. and other healthcare personnel involved in

providing direct care to residents.

11.1.3 The care plan should include the resident’s preferences for sharing of information with

other healthcare professionals and next of kin / family. Where the resident is unable to

express his/her wishes regarding sharing of information this should be documented in the

care plan.

11.1.4 The resident’s communication abilities / strengths in relation to sight, speech and hearing

should also be included in the care plan. Where any needs or difficulties exist the care

plan should include the reason if known e.g. resident has no difficulty with sight, speech

and/or hearing or has poor sight/hearing/difficulty with speech due to CVA.

11.1.5 Document in the care plan the resident’s abilities or needs relating to being understood

and understanding others.

11.1.6 Where the resident cannot communicate verbally, the care plan should include any

specific cues can be used to interpret what the resident wants e.g. restlessness may

indicate …… etc?

11.1.7 The care plan should also take account of the level of help the resident needs with use or

maintenance of communication aids e.g. glasses; hearing aids etc.

11.1.8 The care plan should include any multidisciplinary team member recommendations

relating to communication e.g. speech and language therapist, audiologist,

ophthalmologist, etc.

11.1.9 In relation to cognitive impairment / dementia the care plan should contain information

relating to the resident’s abilities and any difficulties with orientation, and where the

resident has a tendency to become disoriented, the reason for this should be recorded if

known.


11.1.10 The care plan should include if the resident has memory difficulty, including whether this

relates to long term memory or short term memory or both and how it this affect the

resident on a day to day basis. Any assistance required should be outlined, for example

prompting; reminding; orientation and so on. If aids/equipment are used to support the

resident with communication, these must be recorded in the care plan, for example use of

a clock, labelling items, etc.

11.1.11 Document in the care plan the residents’ decision making ability – can they make

everyday decisions e.g. what to wear; what to eat etc. If not what assistance do they

need with making decisions, e.g. being shown items and allowing them to pick or perhaps

the resident can no longer make decisions but was able to tell staff preferences when

was first admitted so staff continue to provide care in keeping with this.

11.1.12 Document to what extent the resident can contribute to their care plan and if they are

unable to communicate their needs and preferences for care planning, the care plan

should identify any person who has been nominated to assist with or represent the

resident for care planning.

11.1.13 The care plan should identify person- centred, realistic and measurable goals that are

agreed with the resident as far as he/she is able.

11.1.14 The care plan should identify interventions required to address risks and /or prevent

complications and further decline that may result from communication difficulties. These

would include but are not limited to:

Safety issues.

Social isolation.

Withdrawal from others.

Anxiety and depressed mood.

11.1.15 The care plan should identify an appropriate review schedule.

11.1.16 All nurses should review and amend care plan as required in accordance with the

resident’s changing needs.

12.0 Care Planning for Residents with Hearing Impairment.

The following can be used as a guide when developing a plan of care, but should be adjusted to

reflect the uniqueness of each resident’s abilities, and known lifestyle, needs and preferences.

12.1.1 General Communication Tips.

Identify the residents preferred way of communicating.


Ensure there is sufficient lighting so that your face can be clearly seen. Alert the resident

of your presence touch if appropriate.

If worn, ensure the hearing aid is in situ, turned on and at an appropriate volume to meet

the resident’s needs.

Provide Information in a range of formats to meet the needs of the resident with complex

communication needs.

When communicating always be patient and friendly.

Look directly at the person and don’t turn away when talking. Maintain a distance of 1-2

metres.

Endeavour to minimise background noise and maintain eye contact.

Consider the use of personal communicators or a portable loop system if required.

Use a sign language chart and keep a pen or paper available.

Do not use medical terminology and avoid jargon.

Wherever possible provide information by writing it down or provide leaflets and booklets

so the resident can read the information at their own pace.

Only one person should talk at a time using facial expressions, body language and

gestures where appropriate.

13.0 Care Planning for Residents with Visual Impairment.

13.1.1 For residents presenting with visual impairment that has not been previously identified,

the named nurse should discuss same with the referring hospital / residents GP. Where a

treatment regimen is established, ensure continuation of same through care planning.


Ensure resident has access to aids for vision and that same are clean and well

maintained.

Ensure prescription/correction is correct and current

Lighting that can cause glare such as spot lights and reading lights should be avoided.

Use contrasting colours to identify important items in the resident’s environment.

Bright indirect lighting is the best approach for visual impairment.

Annual eye examinations should be arranged routinely and/or follow up examinations for

specific associated diseases such as diabetes.

Ensure adequate attention to touch (if appropriate) to alert the resident of your presence.

Provide illuminated magnifying glass/sheet to facilitate reading

Offer large print book and /or audio cassettes novels to resident.


14.0 Care Planning for Residents with Language and Cognitive Impairments.


Use a calm, friendly and non-demanding approach to help put the resident at ease.

Adopt a-non-threatening, non-challenging approach.

Smile and address the resident with their preferred name.

Give your full and undivided attention.

Communication needs to be short and simple.

Use short simple sentences, giving one message at a time.

Give one instruction or one piece of information at a time.

Give clear directions.

Speak slowly and clearly at the residents pace.

Use words that the resident can understand and avoid jargon.

Talk to the resident as an adult and not in a childlike manner.

Use language and words the resident is familiar with and can understand.

Ask questions that require a yes/no response.

Look at the resident’s body language.

Use Positive Body Language e.g. facial expressions, hand gestures, posture and touch.

Allow for a response.

14.1.2 Residents with cognitive impairment may communicate in highly individual ways

including through body language and behaviour; repeating words and sounds. Nurses

and healthcare workers should make every effort to recognise and understand individual

communication patterns and look for the meanings behind these patterns.

14.1.3 Reviewing life experiences such as the use of life stories should be included in care

planning for all residents with dementia so as to enhance understanding and

communication between the resident and nursing staff.

14.1.4 Life stories (biographical approach) should identify and acknowledge significant life

events which can be used as a basis for planning care.

15.0 Communication Strategies for Residents with Cognitive Impairment

15.1.1 Identify the resident’s individual need for stimulation, remembering that too much may

cause stress or too little may lead to boredom and / or facilitate disorientation.

15.1.2 Healthcare staff should always introduce themselves to the resident each time they are

carrying out care and explain what they are going to do.


15.1.3 Cards, labels, pictures may be useful to identify important items or to act as prompts for

care activities eg, picture of food may help prompt for mealtimes.

16.0 Communication Strategies for Residents who do not speak English as a first language.

16.1.1 Speak clearly and pronounce your words correctly. Exaggerated pronunciations will not

help the resident and may cause more confusion.

16.1.2 Do not speak louder than normal as this will not improve understanding. However, do not

speak too quietly either.

16.1.3 Do not cover or hide your mouth because the resident may want to watch you as you

pronounce your words as this may help her figure out what you are saying.

16.1.4 When possible, use simple words instead of ones that are complex. The more basic a

word is, the better the chance is that the resident will understand.

16.1.5 Develop a dictionary of frequently used words such as parts of the body, toilet, pain,

shower, tea, coffee, etc.

16.1.6 A picture book of commonly used words and equipment may also aid communication.

16.1.7 If you are having difficulty communicating consider drawing a picture or symbol.

16.1.8 If possible involve a family member/representative to aid with communicating with the

resident; however be aware of disclosing confidential information relating to the resident.

16.1.9 It may be necessary to source an interpreter on admission and for the initial settling in

period to The Centre Nursing Home.

16.1.10 Be aware of any cultural differences that the resident may have regarding touching, eye

contact and personal space.

16.1.11 Consideration should be given to the need for translating documents such as the

residents guide, the contract of care, the complaints procedure and other such essential

documents.


17.0 Creating an Environment Conducive to Effective Communication.

Create a calm and soothing environment by minimising distractions and noise.

Turn off background noise.

Avoid raising your voice.

Avoid competing noises, such as television and radio.

Provide a calming background e.g. music

Maintain regular routines.

Be consistent in your approach.

Appropriate lighting.

Use of signage.


‘Communication will be enhanced if nurses value older people as individuals, worthy of being alive and having lived.(Hughes, 1995).

The recognition of ‘person-hood’ can help to remove the ‘us’ and ‘them’ barriers that may exist between nursing staff and residents.(Kitwood, 1993).

18.0 References.

1. Health Information and Quality Authority (2016) National Standards for Residential Care

Settings for Older People in Ireland.

2. Health Information and Quality Authority (2014) Draft National Quality Standards for

Residential Care Settings for Older People in Ireland.

3. Health Information and Quality Authority (2015) Guidance on Dementia Care for

Designated Centre’s for Older People

4. Health Information and Quality Authority (2015) Guidance for providers of health and

social care services. Communicating in plain English

5. Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People

Regulations 2013 amended).

6. Cohen-Mansfield, D. Infeld (2003) Hearing aids for nursing home residents: Current

policy and future needs. Health Policy, Volume 79, Issue 1, Pages 49-56

7. Foreman, F; Mion, L; Trysgstad, L and Fletcher, K. (2003).Sensory Changes in Mezey,

M., Fulmer, T., Abraham, I., Zwicker, D.D., editors. Geriatric nursing protocols for best

practice 2nd edition. Springer Publishing Company. New York.

8. Heath, H. (1997) Communicating with Older People. Nursing Standard. Vol. 11 (16). Pp.

48-56.

9. Hartford Institute for Geriatric Nursing (2007) Communication Difficulties: Assessment

and Interventions in Hospitalised Older Adults. Accessed at www.hartfordign.org

10. National Trust Foundation (2004) The Royal Marsden Hospital Manual of Clinical Nursing

Procedures. Sixth Edition. Blackwell Publishing: Oxford

11. McLeod-Clarke, J. (1991) Communicating With Elderly People in Redfern, S. (1991)

Nursing Older People. Churchill Livingstone, London.


http://www.hartfordign.org/

12. Murphy, K; O’Shea, E.; Cooney, A.; Shiel, A. and Hodgkins, M. (2006). Improving Quality

of Life for Older People in Long-Stay Care Settings. National Council on Ageing and

Older People. Report N0.93.

13. Smith, M., Buckwalter, K. (2006) Effective Communication with Elders: HCGNE, Iowa.

14. Scottish Intercollegiate Network (2006) Management of Patients with Dementia: A

National Clinical Guideline. Accessed at www.sign.ac.uk.

15. NHS (2005) Best Practice Statement: Maximising Communication with older people who

have Hearing Disability: NHS, Scotland.

16. Tolson, D., McIntosh, J (1997) Listening in the care environment-chaos or clarity for the

hearing impaired elderly person. International Journal of Nursing Studies.34(3) 173-182

17. Wharrad,H.(2000) Prevalence and nursing awareness of hearing impairment in older

hospital patients. Journal of Clinical Nursing. 9(6) 834-841.

18. Wallhagen, M; Pettingill, E and Whiteside, O (2006) Sensory Impairment in Older Adults:

Part 1 Hearing Loss. American Journal of Nursing. Vol 106 (10) pp. 40-47.

19. Wallhagen, M; Pettingill, E and Whiteside, O (2006) Sensory Impairment in Older Adults:

Part 2 Vision Loss. American Journal of Nursing. Vol 106 (11) pp. 52-61


http://www.sign.ac.uk/

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