Communicating with the patient who cannot speak: boards, yes/no signals, lip reading and reorientation
- Safe practice
An intubated patient who is awake can still communicate: closed questions, gestures, mouthed words, writing and boards give them a voice.
What it is
More than 80 % of ICU patients are affected by being unable to communicate at some point, because of a tube, weakness or sedation. Losing one's voice in an unfamiliar place causes fear, frustration, anxiety and a sense of powerlessness, and some patients stop trying. Simple unaided methods (yes/no questions, gestures, nods, mouthed words, eye contact, touch) are used most; aided methods (pen and paper, letter or picture boards, tablets) are used less, often for lack of training and materials. Planned communication, shared between shifts, helps the patient report pain and needs and take part in care.
What it requires
- Unaided methods: yes/no questions, pointing and gestures, thumbs-up or head shake, mouthed words, facial expressions, eye contact, touch.
- Aided methods: writing or drawing, alphabet boards, picture boards, electronic devices.
- Barriers: sedation, delirium, weakness, poor vision or hearing, language, noise, masks and protective equipment, lack of training and tools.
Components
- Assessment: is the patient awake and attentive enough? (sedation and delirium screens).
- The agreed method and signals, written in the record.
- The materials at the bedside, within the patient's reach.
- Reorientation and the family.
How it is applied (and why)
- Check alertness and attention before choosing a method: a delirious or very sleepy patient needs simpler methods.
- Introduce yourself, face the patient, and speak slowly in short sentences: it makes lip reading and understanding easier.
- Ask one closed question at a time and wait: patients need time to answer with gestures.
- Agree on yes and no signals and test them: an unreliable signal leads to wrong answers.
- Offer pen and paper or a board when the hands and attention allow: they let the patient start the conversation.
- Ask regularly about pain and other needs: the patient may not be able to raise them alone.
- Reorient with a clock, calendar and simple explanations: disorientation feeds fear and delirium.
- Write the method and signals that work in the handover and share them with the family: continuity avoids starting again.
In nursing practice
- Frustration or agitation in an intubated patient may come from not being understood: try to communicate and check for pain.
- Ask the family how the person usually expresses discomfort; relatives can often interpret cues.
- A speech and language therapist can help choose aids for patients with long ventilation.
- Masks hide facial expressions: use eye contact, gestures and touch to reassure.
Common mistakes
- Using only unaided methods when the patient could write or use a board.
- Asking several questions at once or open questions the patient cannot answer.
- Taking away glasses or hearing aids, or putting boards out of reach.
- Not passing on the method that works to the next shift.
Test yourself
Think of the answer, then tap the question to see it.
What kind of question works best with an intubated patient?
Closed questions answered yes or no, one at a time, with time to answer.
Which aided communication methods can be offered?
Pen and paper, alphabet or picture boards and electronic devices, when the patient's hands and attention allow.
Why are glasses and hearing aids important when the patient cannot speak?
Lip reading, gestures and boards need to be seen and heard; without them the patient is more disoriented and isolated.
How is communication kept consistent between shifts?
The method and signals that work are written in the record and the handover and shared with the family.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Communication with Mechanically Ventilated Patients: Nurses' Perspectives and Practice (Zeadnih RF et al.) (Nursing Reports, PubMed Central, 2025); Communicating with mechanically ventilated patients who are awake: a qualitative study on the experience of critical care nurses in Cyprus (Kyranou M, Cheta C, Pampoulou E) (PLoS One, PubMed Central, 2022); Delirium (Medical Encyclopedia) (MedlinePlus, U.S. National Library of Medicine, 2025).
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Representative model, for educational purposes only.