Chapter 3 Flashcards
1
Q
Active Listening
A
A way of communicating that involves giving a person one’s full attention while he is speaking and encouraging him to give information and clarify ideas
2
Q
Barrier
A
A block or an obstacle
3
Q
Care conference
A
A meeting to share and gather info about a resident in order to develop a care plan
4
Q
Body language
A
All of the conscious or unconscious messages a person’s body sends as she communicates, such as facial expressions and shrugging her shoulders
5
Q
Care plan
A
A plan for each resident created by the nurse that outlines the tasks that team members must perform to help the resident reach his or her goals of care
6
Q
Charting
A
The act of noting care and observations; documenting
7
Q
Code
A
In health care, an emergency medical situation in which specially-trained responders provide the necessary care
8
Q
Code status
A
Formally written status of the type and scope of care that should be provided in the event of a cardiac arrest, other catastrophic organ failure, or terminal illness
9
Q
Critical thinking
A
The process of reasoning and analyzing in order to solve problems; for the nursing assistant, critical thinking means making careful observations and promptly reporting all potential problems
10
Q
Culture
A
A set of learned beliefs, values, traditions, and behaviors shared by a social, ethnic, or age groups
11
Q
Edema
A
Swelling in body tissues caused by excess fluid
12
Q
Incident
A
An accident, problem, or unexpected event during the course of care
13
Q
Incident report
A
A report documenting an incident and the response to the incident; also known as an occurrence, accident, or event report
14
Q
Medical chart
A
Legal record of all medical care a patient, resident, or client receives
15
Q
Minimum Data Set
A
A detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified
16
Q
Nonverbal communication
A
Communication without using words, such as through gestures and facial expressions
17
Q
Nursing process
A
An organized method used by nurses to determine residents’ needs, plan the appropriate care to meet those needs, and evaluate how well the plan of care is working; five steps are assessment, diagnosis, planning, implementation, and evaluation
18
Q
Objective information
A
Factual information collected using the senses of sight hearing, smell, and touch; also called signs
19
Q
Orientation
A
A person’s awareness of person, place, and time
20
Q
Prefix
A
A word part added to the beginning of a root to create a new meaning
21
Q
Prioritize
A
To place things in order of importance
22
Q
Root
A
The main part of a word that gives it meaning
23
Q
Rounds
A
Physical movement of staff from room to room to discuss or psychological injury
24
Q
Subjective information
A
Information collected from residents, their family members, and friends; information may or may not be true but is what the person reported; also called symptoms
25
Suffix
A word part added to the end of a root or a prefix to create a new meaning
26
Verbal communication
Communication involving the use of spoken or written words or sounds
27
Vital signs
Measurements- temperature, pulse, respiration’s, blood pressure, pain level- that monitor the functioning of the vital organs of the body
28
sentinel event
An unexpected occurrence involving death or serious physical or psychological injury
29
Communication
The exchange of information with others, which involves sending and receiving messages
30
Roles during communication
Sender and receiver
31
Sender
The person who communicates first
32
Receiver
The person who receives the message
33
What is as important as the words used in communication?
The sound of the voice
34
Communication process
The sender sends a message to the receiver. The receiver receives the message. Then the receiver send feedback to the sender.
35
How would you feel when a teacher or supervisor sounds irritated when answering a question you have asked?
Answer the question for yourself
36
How might a resident fell when a nursing assistant sounds irritated when provided care?
Answer the question for yourself
37
Examples of positive nonverbal communication
Smiling in a friendly manner
Leaning forward to listen
Nodding while a person is speaking
With permission, putting your hand over a resident’s hand
38
Examples of negative nonverbal communication
Rolling eyes
Crossing arms in front of the body
Tapping feet
Pointing at someone while speaking
39
Guidelines for proper communication
```
Use appropriate words
Be aware of your body language
Use a friendly and professional tone of voice
Wait for responses and let pauses happen
Practice active listening
Use mostly facts when communicating
```
40
Be aware of what when communicating with residents?
Barriers and ways to avoid them
41
Examples of communication barriers
Resident doesn’t hear, doesn’t hear correctly, or doesn’t understand
Resident is difficult to understand
NA, resident, or others use words that are not understood
NA uses slang or profanity
NA uses clichés
42
Examples of communication barriers (continued)
NA responds with ”why?”
NA gives advice
NA asks questions that only require yes/no answers
Resident speaks a different language
NA or resident uses nonverbal communication
43
Aspects of communication influenced by culture
Eye contact
Touch
Language
44
Examples of acceptable touch
Giving residents respectful personal care, such as bathing, dressing, feeding, and shaving
Hugging, if the resident permits or asks for it
Holding a resident’s hand when asked
45
Examples of unacceptable touch
Sitting on a resident’s lap or asking a resident to sit on your lap
Kissing a resident
Hugging a resident who pulls away
Inappropriately touching or rubbing against a resident or staff member
46
Who does a nursing assistant communicate with on the job?
```
Doctors, nurses, supervisors, and other staff members
Other departments
Residents
Families and visitors
The community
```
47
Medical terms are made up of what?
Roots
Prefixes
Suffixes
48
Medical term example (otoscope) identify the prefix and root
Root- scope- instrument to look inside
Prefix- oto- ear
Otoscope definition- an instrument used to examine the ear
49
Medical term example (thermometer) identify the prefix and suffix
Suffix- meter- measuring instrument
Prefix- thermo- heat
Thermometer definition- an instrument that measures body temperature
50
Prefix
| A, An
Without, not, lack of
| Analgesic= without pain
51
Prefix
| Ante
Before, in front of
| Antepartum= before delivery
52
Prefix
| Bi
Two, twice, double
| Bifocal= two lenses
53
Prefix
| Brady
Slow
| Bradycardia= slow pulse, heartbeat
54
Prefix
| Contra
Against
| Contraceptive= prevents pregnancy
55
Prefix
| Dis
Apart, free from
| Disinfected= free from microorganisms
56
Prefix
| Dys
Bad, painful
| Dysuria= painful urination
57
Prefix
| Endo
Inner
| Endoscope= instrument for examining the inside of an organ
58
Prefix
| Epi
On, over, upon
| Epidermis= outer layer of the skin
59
Prefix
| Erytho
Erythrocyte= red blood cell
60
Prefix
| Ex
Out, away from
| Exhale= to breathe out
61
Prefix
| Hemi
Half
| Hemisphere= on or two parts of the brain
62
Prefix
| Hyper
Too much, high
| Hypertension= high blood pressure
63
Prefix
| Hypo
Below, under
| Hypotension= Low blood pressure
64
Prefix
| Inter
Between, within
| Interdisciplinary= between disciplines
65
Prefix
| Leuk
White
| Leukocyte= white blood cell
66
Prefix
| Mal
Bad, illness, disorder
| Malformed= badly made
67
Prefix
| Micro
Small
| Microscopic= too small for the eye to see
68
Prefix
| Olig
Small, scant
| Oliguria= small amount of urine
69
Prefix
| Patho
Disease, suffering
| Pathology= the study of disease
70
Prefix
| Per
By, through
| Perforate= to make a hole through
71
Prefix
| Peri
Around
| Pericardium= sac around the heart
72
Prefix
| Poly
Many, much
| Polyuria= much urine
73
Prefix
| Post
After, behind
| Postmortem= period after death
74
Prefix
| Pre
Before, in front of
| Prenatal= period before birth
75
Prefix
| Sub
Under, beneath
| Subcutaneous= beneath the skin
76
Prefix
| Supra
Above, over
| Suprapelvic= located above the pelvis
77
Prefix
| Tachy
Swift, fast, rapid
| Trachycardia= rapid heartbeat
78
Root
| Abdomin
Abdomen
| Abdominal= pertaining to the abdomen
79
Root
| Aden
Gland
| Adenitis= inflammation of the gland
80
Root
| Angi
Vessel
81
Angioplasty
Surgical repair of a vessel using a balloon
82
Root
| Arterio
Artery
83
Arteriosclerosis
Hardening of artery walls
84
Root
| Arthr
Joint
85
Arthrotomy
Cut into the point
86
Root
| Brachi
Arm
87
Brachial
Pertaining to the arm
88
Root
| Bronchi, bronch
Arm
89
Brachial
Pertaining to the arm
90
Card, cardi
Heart
91
Cardiology
Study of the heart
92
Cerebr
Cerebrum
93
Cerebrospinal
Pertaining to the brain and spinal cord
94
Cephal
Head
95
Cephalalgia
Headache
96
Chole, chol
Bile
97
Cholecystitis
Inflammation of the gall bladder
98
Colo
Colon
99
Colonoscopy
Examination of the large intestine or colon with a scope
100
Cost
Rib
101
Costochondral
Pertaining to a rib
102
Crani
Skull
103
Craniotomy
Cutting into the skull
104
Cyan
Blue
105
Cyanosis
Blue, gray, or purple tinge to the skin due to lack of oxygen in the blood
106
Cyst
Bladder, cyst
107
Derm, derma
Skin
108
Dermatitis
Inflammation of the skin
109
Duoden
Duodenum
110
Duodenal
Pertaining to the duodenum, the first part of the small intestine
111
Encephal
Brain
112
Encephalitis
Inflammation of the brain
113
Gaster
Stomach
114
Gastritis
Inflammation of the stomach
115
Geron
Aged
116
Gerontology
Study of the aged
117
Gluco
Sweet
118
Glucometer
Device used to measure blood glucose
119
Glyco, glyc
Woman
120
Gynecology
Study of diseases of the female reproductive organs
121
Hems, hemato, hemo
Blood
122
Hematuria
Blood in the urine
123
Hepato
Liver
124
Hepatomegaly
Enlargement of the liver
125
Hyster
Uterus
126
Hysterectomy
Surgical removal of the uterus
127
Ile, ili
Ileum
128
Ileorrhaphy
Surgical repair of the ileum
129
Larying
Larynx
130
Laryngctomy
Excision of the larynx
131
Lymph
Lymph
132
Lymphocyte
Type of white blood cell
133
Mamm
Breast
134
Mammogram
X-ray of the breast
135
Mast
Breast
136
Mastectomy
Exicision of the breast
137
Melan
Black
138
Mening
Meninges; membranes covering the spinal cord and brain
139
Meningitis
Inflammation of the membranes of the spinal cord or brain
140
Melanoma
Mole or tumor, maybe cancerous
141
Necro
Death
142
Necrotic
Dead tissue
143
Nephr
Kidney
144
Nephrectomy
Removal of a kidney
145
Neur
Nerve
146
Neuritis
Inflammation of a nerve
147
Onc
Tumor
148
Oncology
Study of tumors
149
Ophthalm
Eye
150
Ophthalmologist
Eye doctor
151
Oste
Bone
152
Osteoarthritis
Disease if the joints
153
Ot
Ear
154
Otology
Science of the ear
155
Pharyng
Pharynx
156
Pharyngitis
Inflammation of the throat, sore throat
157
Phleb
Vein
158
Phlebitis
Inflammation of a vein
159
Pneo/ pnea
Breathing
160
Tachypnea
Rapid breathing
161
Pneum
Air, gas, respiration
162
Pneumonia
Inflammation of the lungs
163
Pod
Foot
164
Podiatrist
Foot doctor
165
Proct
Anus, rectum
166
Proctology
Study of the rectum
167
Pulm
Lung
168
Pulmonary
Relating to the lungs
169
Splen
Spleen
170
Splenomegaly
Englarged spleen
171
Stomat
Mouth
172
Stomatitis
Inflammation of mouth
173
Therm
Hot, heat
174
Thremoplegia
Heatstroke
175
Thorac
Chest
176
Thoracotomy
Incision into chest wall
177
Thromb
Blood clot
178
Thrombus
Blood clot blocking a vessel
179
Toxic, tox
Poison
180
Toxicology
Study of poisons
181
Trache
Trachea, windpipe
182
Tracheostomy
Incision to make an artificial airway
183
Urethr
Urethra
184
Urethritis
Inflammation of urethra
185
-cyte
Cell
186
Leukocyte
White blood cell
187
-ectomy
Excision, removal of
188
Splenectomy
Removal of spleen
189
-emesis
Vomiting
190
Hyperemesis
Excessive vomiting
191
-emia
Blood condition
192
Anemia
Lack of red blood cells
193
-ism
A condition
194
Hyperthyroidism
Condition caused by an excessive production of thyroid hormones
195
-itis
Inflammation
196
Stomatitis
Inflammation of the mouth
197
-logy
Study of
198
Hematology
Study of the blood
199
-megaly
Enlargement
200
Splenomegaly
Enlarged spleen
201
-oma
Tumor
202
Melanoma
Mole or tumor, may be cancerous
203
-osis
Condition
204
Halitosis
Bad breath
205
-ostomy
Creation of an opening
206
Ileostomy
Creation of an opening into the ileum
207
Otomy
Cut into
208
Laparotomy
Cutting into the abdomen
209
-pathy
Disease
210
Myopathy
Disease of the muscle
211
Penia
Lack
212
Leukopenia
A lack of white blood cells
213
-phagia
Speaking
214
Aphasia
A sense of speaking
215
-phobia
Exaggerated fear
216
Acrophobia
Fear of high places
217
-plasty
Surgical repair
218
Angioplasty
Surgical repair of a vessel using a balloon
219
-plegia
Paralysis
220
Paraplegia
Paralysis of the lower portion of the body
221
-rrhage
Excessive flow
222
Hemorrhage
Excessive flow of blood
223
-scope
Examination using a scope
224
-stomy
Creation of an opening
225
Colonoscopy
Examination of the large intestine of colon with a scope
226
Colostomy
Opening into the colon
227
-tomy
Incision, cutting into
228
Thoracotomy
Incision into chest wall
229
-uria
Condition of the urine
230
Dysuria
Painful urination
231
Why are abbreviations important?
They help healthcare workers communicate more efficiently.
232
Abbreviation
| A
Before
233
AAROM
Active-assistive rage of motion
234
Abd
Abdomen
235
ABR
Absolute bedrest
236
ac, a.c.
Before meals
237
AD
Alzheimer’s disease
238
ADC
AIDS dementia complex
239
ad lib
As desired
240
adm.
Admission
241
ADLs
Activities of daily living
242
AED
Automated external defribrillator
243
AHA
American Heart Association
244
AIDS
Acquired immune deficiency syndrome
245
AIIR
Airborne infection isolation room
246
AKA
Above-knee amputation, also known as
247
am, AM
Morning
248
AMA
Against medical advice, American Medical Association
249
amb
Ambulate, ambulatory
250
AMD
Age-related macular degeneration
251
amt.
Anterior
252
a.p./ AP
Apical pulse
253
approx.
Approximately
254
AROM
Active range of motion
255
ASAP
As soon as possible
256
assist
Assistance
257
as tol
As tolerated
258
A, T, D
Admission, transfer, and discharge
259
ax
Axillary
260
BID, b.i.d.
Two times a day
261
BKA
Below-knows amputation
262
bld
Blood
263
BLS
Basic life support
264
BM
Bowl movement
265
BP, B/P
Blood pressure
266
BR
Bed rest
267
BPH
Benign prostatic hypertension
268
BPM
Beats per minute
269
BRP
Bathroom privileges
270
BSC
Bedside commode
271
BSE
Breast self examination
272
C
Centigrade, Celsius
273
c
With
274
Ca/CA
Calcium, cancer, carcinoma
275
CAD
Coronary artery disease
276
cal
Calorie
277
cath.
Catheter
278
CBC
Complete blood count
279
CBI
Continuous bladder irrigation
280
CBR
Complete bedrest
281
CCMS
Clean- catch midstream
282
CDC
Centers for Disease Control and Prevention
283
CDE
Certified diabetes educator
284
C. diff
Clostridium difficile
285
CEP
Competency evaluation programs
286
CEU
Continuing education unit
287
CHD
Coronary heart disease
288
CHF
Congestive heart failure
289
chol
Cholesterol
290
ck
Check
291
cl liq
Clear liquid
292
cm
Centimeter
293
CMS
Centers for Medicare and Medicaid Services
294
CNA
Certified Nurse Assistant
295
CNP
Certified Nurse Practitioner
296
CNS
Central Nervous System
297
c/o
Complaints of, in care of
298
CO2
Carbon dioxide
299
COLD
Chronic obstructive lung disease
300
COPD
Chronic obstructive pulmonary disease
301
CP
cerebral palsy
302
CPM
Continuous Passive Motion
303
CPR
Cardiopulmonary resuscitation
304
CRF
Chronic renal failure
305
C.S.
Central Supply
306
CSF
Cerebrospinal fluid
307
CVA
Cerebrovascular accident stroke
308
CVP
Central venous pressure
309
CVS
Cardiovascular system
310
CXR
Chest X-ray
311
DAT
Diet as tolerated
312
DJD
Degenerative flint disease
313
DKA
Diabetic ketoacidosis
314
DM
Diabetes mellitus
315
DNR
Do not resuscitate
316
DO
Doctor of osteopathy
317
DOA
Dead on arrival
318
DOB
Date of birth
319
DON
Director of nursing
320
Dr.
Doctor
321
DRG
Diagnostic Related Group
322
drug
Dressing
323
DVT
Deep Vein Thrombosis
324
Dx/dx
Diagnosis
325
ECG/EKG
Electrocardiogram
326
ED
Emergency department
327
EENT
Eye, ear, nose, and throat
328
e.g.
For example
329
EMS
Emergency medical services
330
ER
Emergency room
331
ESRD
End-stage renal disease
332
et al.
And other things
333
ETOH
Alcohol
334
Exam
Examination
335
F
Fahrenheit, female
336
FBS
Fast blood sugar
337
FDA
Food and Drug Administration
338
Fe
Iron
339
FF
Force fluids
340
FH
Family history
341
fld
Fluid
342
FS
Finger stick
343
FSBS
Finger stick blood sugar
344
ft
Foot
345
F/ U, f/u
Follow-up
346
FUO
Fever of unknown origin
347
FWB
Full weight-bearing
348
fx
Fracture
349
FYI
For your information
350
GAD
Generalized anxiety disorder
351
gal
Gallon
352
GB
Gall bladder
353
GERD
Gastroesophageal reflux disease
354
Geri chair
Geriatric chair
355
GI
Gastrointestinal
356
GP
General practitioner
357
Gm, gm
Gram
358
GSW
Gunshot wound
359
GTT
Glucose tolerance test
360
GU
Genitourinary
361
GYN/gyn
Gynecology
362
h, hr, hr.
Hour
363
H2O
Water
364
H2O2
Hydrogen Peroxide
365
H/A
Headache
366
HAART
Highly active anti-retroviral therapy
367
H&P
History and physical
368
HAV
Hepatitis A virus
369
HBV
Hepatitis B virus
370
HCV
Hepatitis C virus
371
HDV
Hepatitis D virus
372
HEV
hepatitis E Virus
373
Hg
Mercury
374
HHA
Home Health Aid
375
Hi-cal
High calorie
376
HIV
Human immunodeficiency virus
377
HMO
Human maintenance organization
378
HOB
Head of bed
379
HOH
Hard of Hearing
380
HPV
Human papilloma virus
381
HS/ hs
Hours of sleep
382
ht
Height
383
HTN
Hypertension
384
H.U.C.
Health unit coordinator
385
Hx
History
386
Hyper
Above normal, too fast, rapid
387
Hypo
Low, less than normal
388
I&D
Incision and drainage
389
I&O
Intake and Ouput
390
IBD
Irritable bowel disease
391
IBS
Irritable bowel syndrome
392
ICU
Intensive care unit
393
ID
Identification
394
i.e.
That is
395
IICU
Intermediate intensive care unit
396
IM
Intramuscular
397
In
Inch
398
inc
Incontinent
399
inf
Inferior
400
IQ
Intelligence Quotient
401
Irr/irrig
Irrigation
402
isol
Isolation
403
I.V., IV
Inteavaneous
404
K
Potassium
405
kg
Kilogram
406
KS
Kaposi’s sarcoma
407
l, L
Liter
408
L, lt
Left
409
lb
Pound
410
lab
Laboratory
411
LBP
Lower back pain
412
LE
Lower extremity
413
lg
Large
414
liq
Liquid
415
LLE
Left lower extremity
416
LLQ
Left Lower Quadrant
417
LOC
Level of consciousness, level of care
418
Low-cal
Low calorie
419
Low-fat/Low-cal
Low-fat, low calorie
420
Low- Na
Low sodium
421
LPN
Licensed Practical Nurse
422
LTC
Long-term care
423
LTCF
Long-term care
424
LUQ
Left upper quadrant
425
LVN
Licensed vocational nurse
426
M.D.
Medical doctor
427
MDRO’s
Multidrug- resistant organisms
428
MDR-TB
Multidrug-resistant Tuberculosis
429
MDS
Minimum Data Set
430
meds
Medications
431
mg
Milligram
432
MI
Myocardial infarction
433
min
Minute
434
mL
Milliliter
435
mm
Millimeter
436
mm Hg
Millimeter of Mercury
437
MO
Microorganisms
438
mod
Moderate
439
MRI
Magnetic resonance imaging
440
MRSA
Methicillin resistant staphylococcus aureus
441
MS
Multiple Sclerosis
442
MSD
Musculoskeletal disorder
443
MSDS
Material safety data sheet
444
MSW
Medical social worker
445
MUFA
Monosaturated fat
446
MVA
Motor vehicle accident
447
Na
Sodium
448
NaCl
Sodium chloride
449
NAS
No added salt
450
NATCEP
Nurse Aide Training and Competency Evaluation program
451
N/C
No complaints, no call
452
NCS
No concentrated sweets
453
neg
Negative
454
NF
Nursing facility
455
NG, ng
Nasogastric
456
NIBP
Non-invasive blood pressure
457
NKA
No known allergies
458
NKDA
No known drug allergies
459
no
No number
460
noc
Night
461
NPO
Nothing by mouth
462
NVD
Nausea, vomiting, diarrhea
463
NWB
Non-weight bearing
464
O2
Oxygen
465
O&P
Ova and parasites
466
OB
Obstetrics
467
ob/ gyn
Obstetrics and gynecology
468
OBRA
Omnibus Budget Reconciliation Act
469
occ
Occasionally
470
OCD
Obsessive Compulsive Disorder
471
OD
Overdose
472
O.D.
Right eye
473
OG
Orogastric
474
OOB
Out of bed
475
OPD
Outpatient department
476
O.R.
Operating room
477
ord.
Orderly, ordered
478
ORIF
Open reduction, internal fixation
479
ortho
Orthopedics
480
os
Mouth
481
O.S.
Left eye
482
OSHA
Occupational Safety and Health Administration
483
OT
Occupational Therapist/ therapy
484
OT
Over the counter
485
O.U.
Both eyes
486
oz
Ounce
487
P
After
488
P.A.
physician assistant
489
PAD
Peripheral artery assistant
490
pc, p.c.
After meals
491
PCA
Patient controlled anesthesia
492
PDR
Physician’s Desk Reference
493
PE
Pulmonary embolism
494
PEDS
Pediatrics
495
PEG
Percutaneous endoscopic gastrostomy
496
Peri care
Perineal care
497
per os
By mouth
498
PET
position emission tomography
499
pH
Parts hydrogen
500
PH
Past history
501
PHI
Protected Health Information
502
phy. ex.
Physical exam
503
RA
Rheumatoid arthritis
504
RBC
Reb blood cell
505
RDT
Registered Dietition
506
reg.
Regular
507
Rehab
Rehabilitation
508
REM
Rapid eye movement
509
req.
Requisition
510
resp.
Respiration
511
RF
Restrict fluids
512
RLE
Right lower extremity
513
RLQ
Right lower quadrant
514
RN
Registered Nurse
515
RNA
Restorative nursing assistant
516
R/O
Rule out
517
ROM
Range of motion
518
RR
Respiratory Rate
519
RT
Respiratory Therapy/therapist
520
RUE
Right upper extremity
521
RUQ
Right upper quadrant
522
Rx
Prescription
523
s
Without
524
S&A
Sugar and acetone
525
S&S
Signs and symptoms
526
S/S, s.c.
Subcutaneously
527
SCA
Sudden cardiac arrest
528
SCDs
Sequential compression devices
529
SIDS
Sudden infant death syndrome
530
sl
Sublingual ply
531
SLE
Systemic lupus erythematosis
532
SLP
Speech-language pathologist
533
sm.
Small
534
SNAFU
Situation normal, all fouled up
535
SNF
Skilled nursing facility
536
SNS
Somatic nervous system
537
SOB
Shortness of Breath
538
SP
Standard precautions
539
S.P.D.
Supply, Processing and Distribution
540
spec.
Specimen
541
SSE
Soap suds enema
542
ST.
Standard, speech therapy
543
staph
Staphylococcus
544
STAT
Immediately
545
Std prec
Standard precautions
546
STDs
Sexually transmitted diseases
547
STIs
Sexually transmitted infections
548
strep
Streptococcus
549
supp.
Suppository
550
surg.
Surgery
551
T., temp
Temperature
552
TB
Tuberculosis
553
tbsp.
Tablespoon
554
T, C, DB
Turn, cough, and deep breathe
555
THR
Total hip replacement
556
TIA
Transient ischemic attack
557
t.i.d/tid
Three times a day
558
TKR
Total knee replacement
559
TLC
Tender Loving Care
560
TPN
Total parenteral nutrition
561
T.P.R.
Temperature, pulse And respiration
562
trach.
Tracheostomy
563
tsp.
Teaspoon
564
TWE
Tap water enema
565
Tx/tx
Traction, treatment
566
U/A, u/a
Urinalysis
567
UE
Upper extremity
568
UGI
Upper gastrointestinal
569
UNK,unk
Unknown
570
URI
Upper respiratory infection
571
US
Ultrasound
572
USDA
United States Department if Agricultue
573
UTI
Urinary Tract Infection
574
vag.
Vaginal
575
VAP
Ventilator-acquired pneumonia
576
VD
Venereal disease
577
VRE
Vacomycin-restraint enterococcus
578
VS, vs
Vital signs
579
W/A, WA
While awake
580
WBC
White blood cell count
581
w/c
Wheelchair
582
WNL
Within normal limits
583
Yr.
Year
584
To change regular time to military time, between 1:00-11:59 pm, what do you do?
Add 12 to the regular time
585
Do minutes and seconds change?
No
586
Midnight may be written as what two things?
0000 or 2400
587
What is it called when NAs write down their observations and record the care they give?
Charting
588
What is written on the resident’s chart is considered what?
What actually happened
589
What is included on a resident’s chart?
```
Admissions forms
Residents history and results of exams
Care plans
Doctors orders and progress notes
Nursing assessments
Notes from nurses and other specialists
```
590
Other info found on a resident’s chart
```
Flow sheets
Graphic record
Intake and output record
Consent forms
Lab and test results
Surgery reports
Advance directives
```
591
Is the info on resident charts confidential?
Yes
592
Guidelines for charting
Keep all info confidential
Document care immediately after it is given. Never document care before it is given
Use black ink when documenting by hand
Sign each note you make
593
More guidelines for charting
Use only facts when documenting
If an error is made, draw one line through it, initial it, and date it. Write correct info.
Use only facility’s accepted abbreviations and terms
Use comparisons to describe size
594
General rules for computer use
Do not share your password or log in ID with anyone
Do not access personal email or inappropriate websites from work
Log off and/or exit the web browser when done with charting or using the computer
Be careful about who can see PHI on the screen, as HIPPA guidelines apply to computer use
595
MDS facts
Assessment tools developed by the government
Detailed form for assessing residents
Completed for each resident with 14 days of admission and again each year
Must be reviewed every 3 months
New MDS are completed when there is any major change in resident’s condition
596
Objective info is based off of what?
What you see, hear, touch, smell.
597
How is subjective info collected?
They are collected from something that residents or families reported to you. Also called symptoms
598
Other ways to observe residents accurately
Note changes in orientation
Check vital signs
Report any changes in ability
Report other important changes, such as appetite, ability to go to the bathroom, and mood
599
Signs and symptoms that should be immediately reported
```
Falls
Wheezing
Difficulty breathing
Chest pain and pressure
Pain in calf of leg
Blurred vision
Slurred speech
```
600
Signs and symptoms reported immediately
```
Vomiting
Sudden limp or change in ability to walk
Numbness or loss of feeling in one side of body or in arms or legs
Abdominal pain
Change in vital signs
Severe headache
```
601
Five steps of the nursing process
```
Assessment
Diagnosis
Planning
Implementation
Evaluation
```
602
Should NAs be afraid to share observations in care planning meetings, and what should they do if they are?
No, they should check with the nurse before meeting.
603
Do HIPPA guidelines apply to care plans?
Yes, team members should not share a resident’s Information with anyone not directly involved with the resident’s care
604
What is considered an incident?
An accident or problem during the course of care
An error in care
A fall in injury to a resident of staff member
An accusation against staff members
605
If a nursing a assistant is injured on the job should she fill out an incident report?
Yes, even if it seems minor
606
When completing an incident report, the NA should....
Include exactly what she saw
State the time and the mental and physical condition of the person
Describe the person’s reaction to the incident
State the facts; the NA should not give her opinion
Non include “Incident report filed” in the resident’s medical record
Not make any photocopies of the incident report
607
Rules for telephone etiquette
Cheerfully greet callers
Identify your facility, yourself, and your position
Listen closely to the caller’s request and write down any messages
Get a telephone number if needed
Thank the caller and say goodbye
608
Rules for telephone use
Do not give out staff or resident information over the phone
Ask before placing a caller on hold
Ask for training to transfer calls
Follow facility policy regarding personal phone calls and cell phone use
609
Why would ignoring a call light be considered abuse?
The call light is the resident’s life line. If it is not answered something could happen to them.
610
Where must the call light be before the NA leaves the room?
Within the resident’s reach
611
Start-of-shift guidelines
Arrive on time
Listen to your assignment and for information about all residents on your area
Listen carefully to information from the prior shift
Ask any questions you have about your residents
612
What do NAs do at the end of a shift?
Report info about the residents during their shift
613
What is typically found on an assignment?
```
Resident’s names and room numbers
Medical diagnosis
Code status
Activity level
Range of motion exercises
Bathing info
```
614
Info typically found on an assignment sheet
```
Diet orders
Fluid orders
Bowel and bladder info
How often to measure vital signs
Test and procedures to be performed
```
615
Tips for organization and time management
```
Plan ahead
Prioritize
Make a schedule
Combine activities
Get help when needed
```
