Chapter 3 Flashcards
Active Listening
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
Barrier
A block or an obstacle
Care conference
A meeting to share and gather info about a resident in order to develop a care plan
Body language
All of the conscious or unconscious messages a person’s body sends as she communicates, such as facial expressions and shrugging her shoulders
Care plan
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
Charting
The act of noting care and observations; documenting
Code
In health care, an emergency medical situation in which specially-trained responders provide the necessary care
Code status
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
Critical thinking
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
Culture
A set of learned beliefs, values, traditions, and behaviors shared by a social, ethnic, or age groups
Edema
Swelling in body tissues caused by excess fluid
Incident
An accident, problem, or unexpected event during the course of care
Incident report
A report documenting an incident and the response to the incident; also known as an occurrence, accident, or event report
Medical chart
Legal record of all medical care a patient, resident, or client receives
Minimum Data Set
A detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified
Nonverbal communication
Communication without using words, such as through gestures and facial expressions
Nursing process
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
Objective information
Factual information collected using the senses of sight hearing, smell, and touch; also called signs
Orientation
A person’s awareness of person, place, and time
Prefix
A word part added to the beginning of a root to create a new meaning
Prioritize
To place things in order of importance
Root
The main part of a word that gives it meaning
Rounds
Physical movement of staff from room to room to discuss or psychological injury
Subjective information
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
Suffix
A word part added to the end of a root or a prefix to create a new meaning
Verbal communication
Communication involving the use of spoken or written words or sounds
Vital signs
Measurements- temperature, pulse, respiration’s, blood pressure, pain level- that monitor the functioning of the vital organs of the body
sentinel event
An unexpected occurrence involving death or serious physical or psychological injury
Communication
The exchange of information with others, which involves sending and receiving messages
Roles during communication
Sender and receiver
Sender
The person who communicates first
Receiver
The person who receives the message
What is as important as the words used in communication?
The sound of the voice
Communication process
The sender sends a message to the receiver. The receiver receives the message. Then the receiver send feedback to the sender.
How would you feel when a teacher or supervisor sounds irritated when answering a question you have asked?
Answer the question for yourself
How might a resident fell when a nursing assistant sounds irritated when provided care?
Answer the question for yourself
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
Examples of negative nonverbal communication
Rolling eyes
Crossing arms in front of the body
Tapping feet
Pointing at someone while speaking
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
Be aware of what when communicating with residents?
Barriers and ways to avoid them
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
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
Aspects of communication influenced by culture
Eye contact
Touch
Language
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
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
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
Medical terms are made up of what?
Roots
Prefixes
Suffixes
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
Medical term example (thermometer) identify the prefix and suffix
Suffix- meter- measuring instrument
Prefix- thermo- heat
Thermometer definition- an instrument that measures body temperature
Prefix
A, An
Without, not, lack of
Analgesic= without pain
Prefix
Ante
Before, in front of
Antepartum= before delivery
Prefix
Bi
Two, twice, double
Bifocal= two lenses
Prefix
Brady
Slow
Bradycardia= slow pulse, heartbeat
Prefix
Contra
Against
Contraceptive= prevents pregnancy
Prefix
Dis
Apart, free from
Disinfected= free from microorganisms
Prefix
Dys
Bad, painful
Dysuria= painful urination
Prefix
Endo
Inner
Endoscope= instrument for examining the inside of an organ
Prefix
Epi
On, over, upon
Epidermis= outer layer of the skin
Prefix
Erytho
Erythrocyte= red blood cell
Prefix
Ex
Out, away from
Exhale= to breathe out
Prefix
Hemi
Half
Hemisphere= on or two parts of the brain
Prefix
Hyper
Too much, high
Hypertension= high blood pressure
Prefix
Hypo
Below, under
Hypotension= Low blood pressure
Prefix
Inter
Between, within
Interdisciplinary= between disciplines
Prefix
Leuk
White
Leukocyte= white blood cell
Prefix
Mal
Bad, illness, disorder
Malformed= badly made
Prefix
Micro
Small
Microscopic= too small for the eye to see
Prefix
Olig
Small, scant
Oliguria= small amount of urine
Prefix
Patho
Disease, suffering
Pathology= the study of disease
Prefix
Per
By, through
Perforate= to make a hole through
Prefix
Peri
Around
Pericardium= sac around the heart
Prefix
Poly
Many, much
Polyuria= much urine
Prefix
Post
After, behind
Postmortem= period after death
Prefix
Pre
Before, in front of
Prenatal= period before birth
Prefix
Sub
Under, beneath
Subcutaneous= beneath the skin
Prefix
Supra
Above, over
Suprapelvic= located above the pelvis
Prefix
Tachy
Swift, fast, rapid
Trachycardia= rapid heartbeat
Root
Abdomin
Abdomen
Abdominal= pertaining to the abdomen
Root
Aden
Gland
Adenitis= inflammation of the gland
Root
Angi
Vessel
Angioplasty
Surgical repair of a vessel using a balloon
Root
Arterio
Artery
Arteriosclerosis
Hardening of artery walls
Root
Arthr
Joint
Arthrotomy
Cut into the point
Root
Brachi
Arm
Brachial
Pertaining to the arm
Root
Bronchi, bronch
Arm
Brachial
Pertaining to the arm
Card, cardi
Heart
Cardiology
Study of the heart
Cerebr
Cerebrum
Cerebrospinal
Pertaining to the brain and spinal cord
Cephal
Head
Cephalalgia
Headache
Chole, chol
Bile
Cholecystitis
Inflammation of the gall bladder
Colo
Colon
Colonoscopy
Examination of the large intestine or colon with a scope
Cost
Rib
Costochondral
Pertaining to a rib
Crani
Skull
Craniotomy
Cutting into the skull
Cyan
Blue
Cyanosis
Blue, gray, or purple tinge to the skin due to lack of oxygen in the blood
Cyst
Bladder, cyst
Derm, derma
Skin
Dermatitis
Inflammation of the skin
Duoden
Duodenum
Duodenal
Pertaining to the duodenum, the first part of the small intestine
Encephal
Brain
Encephalitis
Inflammation of the brain
Gaster
Stomach
Gastritis
Inflammation of the stomach
Geron
Aged
Gerontology
Study of the aged
Gluco
Sweet
Glucometer
Device used to measure blood glucose
Glyco, glyc
Woman
Gynecology
Study of diseases of the female reproductive organs
Hems, hemato, hemo
Blood
Hematuria
Blood in the urine
Hepato
Liver
Hepatomegaly
Enlargement of the liver
Hyster
Uterus
Hysterectomy
Surgical removal of the uterus
Ile, ili
Ileum
Ileorrhaphy
Surgical repair of the ileum
Larying
Larynx
Laryngctomy
Excision of the larynx
Lymph
Lymph
Lymphocyte
Type of white blood cell
Mamm
Breast
Mammogram
X-ray of the breast
Mast
Breast
Mastectomy
Exicision of the breast
Melan
Black
Mening
Meninges; membranes covering the spinal cord and brain
Meningitis
Inflammation of the membranes of the spinal cord or brain
Melanoma
Mole or tumor, maybe cancerous
Necro
Death
Necrotic
Dead tissue
Nephr
Kidney
Nephrectomy
Removal of a kidney
Neur
Nerve
Neuritis
Inflammation of a nerve
Onc
Tumor
Oncology
Study of tumors
Ophthalm
Eye
Ophthalmologist
Eye doctor
Oste
Bone
Osteoarthritis
Disease if the joints
Ot
Ear
Otology
Science of the ear
Pharyng
Pharynx
Pharyngitis
Inflammation of the throat, sore throat
Phleb
Vein
Phlebitis
Inflammation of a vein
Pneo/ pnea
Breathing
Tachypnea
Rapid breathing
Pneum
Air, gas, respiration
Pneumonia
Inflammation of the lungs
Pod
Foot
Podiatrist
Foot doctor
Proct
Anus, rectum
Proctology
Study of the rectum
Pulm
Lung
Pulmonary
Relating to the lungs
Splen
Spleen
Splenomegaly
Englarged spleen
Stomat
Mouth
Stomatitis
Inflammation of mouth
Therm
Hot, heat
Thremoplegia
Heatstroke
Thorac
Chest
Thoracotomy
Incision into chest wall
Thromb
Blood clot
Thrombus
Blood clot blocking a vessel
Toxic, tox
Poison
Toxicology
Study of poisons
Trache
Trachea, windpipe
Tracheostomy
Incision to make an artificial airway
Urethr
Urethra
Urethritis
Inflammation of urethra
-cyte
Cell
Leukocyte
White blood cell
-ectomy
Excision, removal of
Splenectomy
Removal of spleen
-emesis
Vomiting
Hyperemesis
Excessive vomiting
-emia
Blood condition
Anemia
Lack of red blood cells
-ism
A condition
Hyperthyroidism
Condition caused by an excessive production of thyroid hormones
-itis
Inflammation
Stomatitis
Inflammation of the mouth
-logy
Study of
Hematology
Study of the blood
-megaly
Enlargement
Splenomegaly
Enlarged spleen
-oma
Tumor
Melanoma
Mole or tumor, may be cancerous
-osis
Condition
Halitosis
Bad breath
-ostomy
Creation of an opening
Ileostomy
Creation of an opening into the ileum
Otomy
Cut into
Laparotomy
Cutting into the abdomen
-pathy
Disease
Myopathy
Disease of the muscle
Penia
Lack
Leukopenia
A lack of white blood cells
-phagia
Speaking
Aphasia
A sense of speaking
-phobia
Exaggerated fear
Acrophobia
Fear of high places
-plasty
Surgical repair
Angioplasty
Surgical repair of a vessel using a balloon
-plegia
Paralysis
Paraplegia
Paralysis of the lower portion of the body
-rrhage
Excessive flow
Hemorrhage
Excessive flow of blood
-scope
Examination using a scope
-stomy
Creation of an opening
Colonoscopy
Examination of the large intestine of colon with a scope
Colostomy
Opening into the colon
-tomy
Incision, cutting into
Thoracotomy
Incision into chest wall
-uria
Condition of the urine
Dysuria
Painful urination
Why are abbreviations important?
They help healthcare workers communicate more efficiently.
Abbreviation
A
Before
AAROM
Active-assistive rage of motion
Abd
Abdomen
ABR
Absolute bedrest
ac, a.c.
Before meals
AD
Alzheimer’s disease
ADC
AIDS dementia complex
ad lib
As desired
adm.
Admission
ADLs
Activities of daily living
AED
Automated external defribrillator
AHA
American Heart Association
AIDS
Acquired immune deficiency syndrome
AIIR
Airborne infection isolation room
AKA
Above-knee amputation, also known as
am, AM
Morning
AMA
Against medical advice, American Medical Association
amb
Ambulate, ambulatory
AMD
Age-related macular degeneration
amt.
Anterior
a.p./ AP
Apical pulse
approx.
Approximately
AROM
Active range of motion
ASAP
As soon as possible
assist
Assistance
as tol
As tolerated
A, T, D
Admission, transfer, and discharge
ax
Axillary
BID, b.i.d.
Two times a day
BKA
Below-knows amputation
bld
Blood
BLS
Basic life support
BM
Bowl movement
BP, B/P
Blood pressure
BR
Bed rest
BPH
Benign prostatic hypertension
BPM
Beats per minute
BRP
Bathroom privileges
BSC
Bedside commode
BSE
Breast self examination
C
Centigrade, Celsius
c
With
Ca/CA
Calcium, cancer, carcinoma
CAD
Coronary artery disease
cal
Calorie
cath.
Catheter
CBC
Complete blood count
CBI
Continuous bladder irrigation
CBR
Complete bedrest
CCMS
Clean- catch midstream
CDC
Centers for Disease Control and Prevention
CDE
Certified diabetes educator
C. diff
Clostridium difficile
CEP
Competency evaluation programs
CEU
Continuing education unit
CHD
Coronary heart disease
CHF
Congestive heart failure
chol
Cholesterol
ck
Check
cl liq
Clear liquid
cm
Centimeter
CMS
Centers for Medicare and Medicaid Services
CNA
Certified Nurse Assistant
CNP
Certified Nurse Practitioner
CNS
Central Nervous System
c/o
Complaints of, in care of
CO2
Carbon dioxide
COLD
Chronic obstructive lung disease
COPD
Chronic obstructive pulmonary disease
CP
cerebral palsy
CPM
Continuous Passive Motion
CPR
Cardiopulmonary resuscitation
CRF
Chronic renal failure
C.S.
Central Supply
CSF
Cerebrospinal fluid
CVA
Cerebrovascular accident stroke
CVP
Central venous pressure
CVS
Cardiovascular system
CXR
Chest X-ray
DAT
Diet as tolerated
DJD
Degenerative flint disease
DKA
Diabetic ketoacidosis
DM
Diabetes mellitus
DNR
Do not resuscitate
DO
Doctor of osteopathy
DOA
Dead on arrival
DOB
Date of birth
DON
Director of nursing
Dr.
Doctor
DRG
Diagnostic Related Group
drug
Dressing
DVT
Deep Vein Thrombosis
Dx/dx
Diagnosis
ECG/EKG
Electrocardiogram
ED
Emergency department
EENT
Eye, ear, nose, and throat
e.g.
For example
EMS
Emergency medical services
ER
Emergency room
ESRD
End-stage renal disease
et al.
And other things
ETOH
Alcohol
Exam
Examination
F
Fahrenheit, female
FBS
Fast blood sugar
FDA
Food and Drug Administration
Fe
Iron
FF
Force fluids
FH
Family history
fld
Fluid
FS
Finger stick
FSBS
Finger stick blood sugar
ft
Foot
F/ U, f/u
Follow-up
FUO
Fever of unknown origin
FWB
Full weight-bearing
fx
Fracture
FYI
For your information
GAD
Generalized anxiety disorder
gal
Gallon
GB
Gall bladder
GERD
Gastroesophageal reflux disease
Geri chair
Geriatric chair
GI
Gastrointestinal
GP
General practitioner
Gm, gm
Gram
GSW
Gunshot wound
GTT
Glucose tolerance test
GU
Genitourinary
GYN/gyn
Gynecology
h, hr, hr.
Hour
H2O
Water
H2O2
Hydrogen Peroxide
H/A
Headache
HAART
Highly active anti-retroviral therapy
H&P
History and physical
HAV
Hepatitis A virus
HBV
Hepatitis B virus
HCV
Hepatitis C virus
HDV
Hepatitis D virus
HEV
hepatitis E Virus
Hg
Mercury
HHA
Home Health Aid
Hi-cal
High calorie
HIV
Human immunodeficiency virus
HMO
Human maintenance organization
HOB
Head of bed
HOH
Hard of Hearing
HPV
Human papilloma virus
HS/ hs
Hours of sleep
ht
Height
HTN
Hypertension
H.U.C.
Health unit coordinator
Hx
History
Hyper
Above normal, too fast, rapid
Hypo
Low, less than normal
I&D
Incision and drainage
I&O
Intake and Ouput
IBD
Irritable bowel disease
IBS
Irritable bowel syndrome
ICU
Intensive care unit
ID
Identification
i.e.
That is
IICU
Intermediate intensive care unit
IM
Intramuscular
In
Inch
inc
Incontinent
inf
Inferior
IQ
Intelligence Quotient
Irr/irrig
Irrigation
isol
Isolation
I.V., IV
Inteavaneous
K
Potassium
kg
Kilogram
KS
Kaposi’s sarcoma
l, L
Liter
L, lt
Left
lb
Pound
lab
Laboratory
LBP
Lower back pain
LE
Lower extremity
lg
Large
liq
Liquid
LLE
Left lower extremity
LLQ
Left Lower Quadrant
LOC
Level of consciousness, level of care
Low-cal
Low calorie
Low-fat/Low-cal
Low-fat, low calorie
Low- Na
Low sodium
LPN
Licensed Practical Nurse
LTC
Long-term care
LTCF
Long-term care
LUQ
Left upper quadrant
LVN
Licensed vocational nurse
M.D.
Medical doctor
MDRO’s
Multidrug- resistant organisms
MDR-TB
Multidrug-resistant Tuberculosis
MDS
Minimum Data Set
meds
Medications
mg
Milligram
MI
Myocardial infarction
min
Minute
mL
Milliliter
mm
Millimeter
mm Hg
Millimeter of Mercury
MO
Microorganisms
mod
Moderate
MRI
Magnetic resonance imaging
MRSA
Methicillin resistant staphylococcus aureus
MS
Multiple Sclerosis
MSD
Musculoskeletal disorder
MSDS
Material safety data sheet
MSW
Medical social worker
MUFA
Monosaturated fat
MVA
Motor vehicle accident
Na
Sodium
NaCl
Sodium chloride
NAS
No added salt
NATCEP
Nurse Aide Training and Competency Evaluation program
N/C
No complaints, no call
NCS
No concentrated sweets
neg
Negative
NF
Nursing facility
NG, ng
Nasogastric
NIBP
Non-invasive blood pressure
NKA
No known allergies
NKDA
No known drug allergies
no
No number
noc
Night
NPO
Nothing by mouth
NVD
Nausea, vomiting, diarrhea
NWB
Non-weight bearing
O2
Oxygen
O&P
Ova and parasites
OB
Obstetrics
ob/ gyn
Obstetrics and gynecology
OBRA
Omnibus Budget Reconciliation Act
occ
Occasionally
OCD
Obsessive Compulsive Disorder
OD
Overdose
O.D.
Right eye
OG
Orogastric
OOB
Out of bed
OPD
Outpatient department
O.R.
Operating room
ord.
Orderly, ordered
ORIF
Open reduction, internal fixation
ortho
Orthopedics
os
Mouth
O.S.
Left eye
OSHA
Occupational Safety and Health Administration
OT
Occupational Therapist/ therapy
OT
Over the counter
O.U.
Both eyes
oz
Ounce
P
After
P.A.
physician assistant
PAD
Peripheral artery assistant
pc, p.c.
After meals
PCA
Patient controlled anesthesia
PDR
Physician’s Desk Reference
PE
Pulmonary embolism
PEDS
Pediatrics
PEG
Percutaneous endoscopic gastrostomy
Peri care
Perineal care
per os
By mouth
PET
position emission tomography
pH
Parts hydrogen
PH
Past history
PHI
Protected Health Information
phy. ex.
Physical exam
RA
Rheumatoid arthritis
RBC
Reb blood cell
RDT
Registered Dietition
reg.
Regular
Rehab
Rehabilitation
REM
Rapid eye movement
req.
Requisition
resp.
Respiration
RF
Restrict fluids
RLE
Right lower extremity
RLQ
Right lower quadrant
RN
Registered Nurse
RNA
Restorative nursing assistant
R/O
Rule out
ROM
Range of motion
RR
Respiratory Rate
RT
Respiratory Therapy/therapist
RUE
Right upper extremity
RUQ
Right upper quadrant
Rx
Prescription
s
Without
S&A
Sugar and acetone
S&S
Signs and symptoms
S/S, s.c.
Subcutaneously
SCA
Sudden cardiac arrest
SCDs
Sequential compression devices
SIDS
Sudden infant death syndrome
sl
Sublingual ply
SLE
Systemic lupus erythematosis
SLP
Speech-language pathologist
sm.
Small
SNAFU
Situation normal, all fouled up
SNF
Skilled nursing facility
SNS
Somatic nervous system
SOB
Shortness of Breath
SP
Standard precautions
S.P.D.
Supply, Processing and Distribution
spec.
Specimen
SSE
Soap suds enema
ST.
Standard, speech therapy
staph
Staphylococcus
STAT
Immediately
Std prec
Standard precautions
STDs
Sexually transmitted diseases
STIs
Sexually transmitted infections
strep
Streptococcus
supp.
Suppository
surg.
Surgery
T., temp
Temperature
TB
Tuberculosis
tbsp.
Tablespoon
T, C, DB
Turn, cough, and deep breathe
THR
Total hip replacement
TIA
Transient ischemic attack
t.i.d/tid
Three times a day
TKR
Total knee replacement
TLC
Tender Loving Care
TPN
Total parenteral nutrition
T.P.R.
Temperature, pulse And respiration
trach.
Tracheostomy
tsp.
Teaspoon
TWE
Tap water enema
Tx/tx
Traction, treatment
U/A, u/a
Urinalysis
UE
Upper extremity
UGI
Upper gastrointestinal
UNK,unk
Unknown
URI
Upper respiratory infection
US
Ultrasound
USDA
United States Department if Agricultue
UTI
Urinary Tract Infection
vag.
Vaginal
VAP
Ventilator-acquired pneumonia
VD
Venereal disease
VRE
Vacomycin-restraint enterococcus
VS, vs
Vital signs
W/A, WA
While awake
WBC
White blood cell count
w/c
Wheelchair
WNL
Within normal limits
Yr.
Year
To change regular time to military time, between 1:00-11:59 pm, what do you do?
Add 12 to the regular time
Do minutes and seconds change?
No
Midnight may be written as what two things?
0000 or 2400
What is it called when NAs write down their observations and record the care they give?
Charting
What is written on the resident’s chart is considered what?
What actually happened
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
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
Is the info on resident charts confidential?
Yes
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
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
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
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
Objective info is based off of what?
What you see, hear, touch, smell.
How is subjective info collected?
They are collected from something that residents or families reported to you. Also called symptoms
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
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
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
Five steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
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.
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
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
If a nursing a assistant is injured on the job should she fill out an incident report?
Yes, even if it seems minor
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
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
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
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.
Where must the call light be before the NA leaves the room?
Within the resident’s reach
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
What do NAs do at the end of a shift?
Report info about the residents during their shift
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
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
Tips for organization and time management
Plan ahead Prioritize Make a schedule Combine activities Get help when needed
