1. Define important words in this chapter

3Communication Skills

1. Define important words in this chapter

active listening a way of communicating that involves giving a person your full attention while he is speaking and encouraging him to give information and clarify ideas; includes nonverbal communication.

barriera block or an obstacle.

body language all of the conscious or unconscious messages your body sends as you communicate, such as facial expressions, shrugging your shoulders, and wringing your hands.

care conferencea meeting to share and gather information about residents in order to develop a care plan.



care plana written plan for each resident created by the nurse; outlines the steps taken by the staff to help the resident reach his or her goals.

charting the act of noting care and observations; documenting.

codein health care, an emergent medical situation in which specially-trained responders provide resuscitative measures to a person.



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 failure, or terminal illness; terms and acronyms are used to identify the care desired by the person, such as “DNR” (do not resuscitate) and “no code.”

critical thinkingthe process of reasoning and analyzing in order to solve problems; for the nursing assistant, critical thinking means making good observations and promptly reporting all potential problems.

culturea set of learned beliefs, values, traditions, and behaviors shared by a social, ethnic, or age group.



edemaswelling in body tissues caused by excess fluid.

incidentan 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 report or event report.

medical chart written legal record of all medical care a patient, resident, or client receives.



Minimum Data Set (MDS)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 making 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 informationfactual 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 each resident and his or her care plan.

sentinel event an unexpected occurrence involving death or serious physical or psychological injury.

subjective informationinformation 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, respirations, blood pressure, pain level—that monitor the functioning of the vital organs of the body.


2. Explain types of communication

Define the following terms:verbal communication

communication involving the use of spoken or written words or sounds.

nonverbal communicationcommunication without using words, such as making gestures and facial expressions.



Define the following terms:body language

all of the conscious or unconscious messages your body sends as you communicate, such as facial expressions, shrugging your shoulders, and wringing your hands.

active listening a way of communicating that involves giving a person your full attention while he is speaking and encouraging him to give information and clarify ideas; includes nonverbal communication.



Communication is the exchange of information with others which involves sending and receiving messages.

People have different roles during communication. For example, a person can be the “sender” or the “receiver.” The person who communicates first is the “sender.” The person who receives the message is the “receiver.”

3 Communication Skills

Transparency 3-1: Communication Process



The process shown in Transparency 3-1 occurs over and over, with the sender and receiver switching roles during a conversation.

Communicating verbally means using words. Verbal communication includes the way words are spoken or written.How the voice sounds when someone speaks is as important as the words he uses.



Think about these questions:• How do you feel when a teacher or supervisor sounds irritated

when answering a question you have asked? • Try to imagine how residents feel when nursing assistants

seem annoyed in the tone of their voice.



Body language has to do with all of the conscious or unconscious messages your body sends as you communicate. It includes posture, body movements, facial expressions, and gestures. It can be positive or negative.


Transparency 3-2: Body Language



Think about this question:What signals are the two people on Transparency 3-2 sending to each other through their body language?



Body language can be positive or negative.

Examples of positive nonverbal communication:• Smiling in a friendly manner• Leaning forward to listen• With permission, putting your hand over a resident’s hand



Examples of negative nonverbal communication:• Rolling your eyes • Crossing your arms in front of you• Tapping your foot• Pointing at someone while speaking



Think about this question:Can you think of other examples of either positive or negative nonverbal communication?



Remember these guidelines for good communication:• Use appropriate words.• Be aware of your body language.• Use an acceptable tone of voice.• Wait for responses and let pauses happen.• Practice active listening. • Use mostly facts when communicating.


3. Explain barriers to communication

Define the following term:barrier

a block or an obstacle.



As a nursing assistant (NA), you will encounter various barriers to communication with your residents.

It is important to be aware of these barriers and ways to avoid them.


Transparency 3-3: Barriers to Communication


Barriers to communication:• Resident does not hear, does not hear correctly, or does not

understand you.• Resident is difficult to understand.• NA, resident, or others use words that are not understood.• NA uses slang or profanity.• NA uses clichés.




Barriers to communication (cont'd.):• 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.


4. List ways that cultures impact communication

Define the following term:culture

a set of learned beliefs, values, traditions, and behaviors shared by a social, ethnic, or age group.



The following aspects of communication are influenced by culture and are important to understand when caring for residents:

• Eye contact• Touch• Language

Touch is an important way to communicate, and there are differences among cultures and among individual personalities, in terms of how comfortable they are with touch.



Examples of acceptable touch include the following: • 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 she asks you to



Examples of unacceptable touch include the following: • Sitting on a resident’s lap or asking a resident to sit on your

lap • Kissing a resident • Hugging a resident who pulls away from you • Inappropriately touching or rubbing against a resident or

staff member



Think about this question:Can you think of other examples of acceptable and unacceptable touch?



Discussion:• Describe how your culture influences your own

communication and use of touch. • Are there are any other cultural considerations when working

with residents from different cultures than your own which you can think of that would be useful in your job?


5. Identify the people you will communicate with in a facility

There are many different people you will communicate with on the job. This is another reason why understanding communication and communicating clearly are so important.

Remember that you will communicate with the following while on the job:

• Doctors, nurses, supervisors, and other staff members• Other departments• Residents• Families and visitors• The community


6. Understand basic medical terminology and abbreviations

Define the following terms:edema

swelling in body tissues caused by excess fluid.root

the main part of a word that gives it meaning.prefix

a word part added to the beginning of a root to create a new meaning.

suffix a word part added to the end of a root or a prefix to create a new meaning.



In order to communicate well with other members of the care team, you need to learn medical language. You will use medical terms for specific conditions.

Medical terms are made up of these word parts:

• roots • prefixes• suffixes


A root is the main part of the word that gives it meaning.

A prefix comes at the front of the word. It works with a word root to make a new term. For example, the root “scope” means an instrument to look inside. The prefix “oto” means ear. An otoscope is an instrument used to examine the ear.



Handout 3-1: Prefixes

a, an: without, not, lack ofanalgesic = without pain

ante: before, in front ofantepartum = before delivery

bi: two, twice, doublebifocal = two lenses

brady: slowbradycardia = slow pulse, heartbeat

contra: againstcontraceptive = prevents pregnancy

dis: apart, free fromdisinfected = free from microorganisms

dys: bad, painfuldysuria = painful urination

endo: inner endoscope = instrument for examining the inside of an organ

epi: on, upon, overepidermis = outer layer of skin

erythro: red erythrocyte = red blood cell


Handout 3-1: Prefixes (cont’d.)

ex: out, away from exhale = to breathe out

hemi: half hemisphere = one of two parts of the brain

hyper: too much, high hypertension = high blood pressure

hypo: below, underhypotension = low blood pressure

inter: between, within interdisciplinary = between disciplines

leuk: white leukocyte = white blood cell

mal: bad, illness, disorder malformed = badly made

micro: small microscopic = too small for the eye to see

olig: small, scant oliguria = small amount of urine

patho: disease, suffering pathology = study of disease


Handout 3-1: Prefixes (cont’d.)

per: by, through perforate = to make a hole through

peri: around pericardium = sac around the heart

poly: many, much polyuria = much urine

post: after, behind postmortem = period after death

pre: before, in front of prenatal = period before birth

sub: under, beneathsubcutaneous = beneath the skin

supra: above, oversuprapelvic = located above the pelvis

tachy: swift, fast, rapidtachycardia = rapid heartbeat


Handout 3-2: Roots

abdomin (o): abdomenabdominal = pertaining to the abdomen

aden (o): gland adenitis = inflammation of a gland

angi (o): vessel angioplasty = surgical repair of a vessel using a balloon

arterio: artery arteriosclerosis = hardening of artery walls

arthr (o): jointarthrotomy = cut into a joint

brachi (o): arm brachial = pertaining to the arm

bronchi, bronch (o): bronchusbronchopneumonia = inflammation of lungs

card, cardi (o): heart cardiology = study of the heart

cerebr (o): cerebrum cerebrospinal = pertaining to the brain and spinal cord

cephal (o): head cephalalgia = headache


Handout 3-2: Roots (cont’d.)

chole, chol (o): bile cholecystitis = inflammation of the gall bladder

colo: colon colonoscopy = examination of the large intestine or colon with a scope

cost (o): rib costochondral = pertaining to a rib

crani (o): skull craniotomy = cutting into the skull

cyan (o): blue cyanosis = blue, gray, or purple tinge to the skin due to lack of oxygen in the blood

cyst (o): bladder, cyst cystitis = inflammation of the bladder

derm, derma: skin dermatitis = inflammation of the skin

duoden (o): duodenum duodenal = pertaining to the duodenum, the first part of the small intestine

encephal (o): brain encephalitis = inflammation of the brain

gaster (o), gastro: stomach gastritis = inflammation of the stomach



geron: aged gerontology = study of the aged

gluco: sweet glucometer = device used to measure blood glucose

glyco, glyc: sweet glycosuria = glucose (sugar) in the urine

gyneco, gyno: woman gynecology = study of diseases of the female reproductive organs

hema, hemato, hemo: blood hematuria = blood in the urine

hepato: liver hepatomegaly = enlargement of the liver

hyster (o): uterus hysterectomy = surgical removal of the uterus

ile (o), ili(o): ileum ileorrhaphy = surgical repair of the ileum

laryng (o): larynx laryngectomy = excision of the larynx

lymph (o): lymph lymphocyte = type of white blood cell



mamm (o): breast mammogram = x-ray of the breast

mast (o): breast mastectomy = excision of the breast

melan (o): black melanoma = mole or tumor, may be cancerous

mening (o): meninges; membranes covering the spinal cord and brainmeningitis = inflammation of the membranes of the spinal cord or brain

necro: death necrotic = dead tissue

nephr (o): kidney nephrectomy = removal of a kidney

neur (o): nerve neuritis = inflammation of a nerve

onc (o): tumor oncology = study of tumors

ophthalm (o): eye ophthalmologist = eye doctor

oste (o): bone osteoarthritis = disease of the joints



ot (o): ear otology = science of the ear

pharyng (o): pharynx pharyngitis = inflammation of the throat, sore throat

phleb (o): vein phlebitis = inflammation of a vein

pneo (a): breathing tachypnea = rapid breathing

pneum: air, gas, respiration pneumonia = inflammation of the lung

pod (o): foot podiatrist = foot doctor

proct (o): anus, rectum proctology = study of the rectum

pulm (o): lung pulmonary = relating to the lungs

splen (o): spleen splenomegaly = enlarged spleen

stomat (o): mouth stomatitis = inflammation of mouth



therm (o): hot, heat thermoplegia = heatstroke

thorac (o): chest thoracotomy = incision into chest wall

thromb (o): blood clot thrombus = blood clot blocking a vessel

toxic (o), tox (o): poison toxicology = study of poisons

trache (o): trachea, windpipe tracheostomy = incision to make an artificial airway

urethr (o): urethra urethritis = inflammation of urethra



A suffix is found at the end of a word. A suffix by itself does not form a full word. When you add a prefix or a root, the suffix turns it into a working medical term.

For example, the suffix “meter” means measuring instrument. The prefix “thermo” means heat. A thermometer is an instrument that measures body temperature.


Handout 3-3: Suffixes

-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


Handout 3-3: Suffixes (cont’d.)

-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: to eat dysphagia = difficulty swallowing

-phasia: speaking aphasia = absence 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 lower portion of the body

-rrhage: excessive flow hemorrhage = excessive flow of blood


Handout 3-3: Suffixes (cont’d.)

-scopy: examination using a scopecolonoscopy = examination of the large intestine or colon with a scope

-stomy: creation of an opening colostomy = opening into the colon

-tomy: incision, cutting into thoracotomy = incision into chest wall

-uria: condition of the urine dysuria = painful urination



Abbreviations help healthcare workers communicate more efficiently, and many abbreviations are used in healthcare. Two examples of a common medical abbreviations are “BP” for blood pressure and “temp” for temperature.


Handout 3-4: Abbreviations

a beforeAAROM active-assistive range of motionabd abdomenABR absolute bedrestac, a.c. before mealsAD Alzheimer’s diseaseADC AIDS dementia complexad lib as desired adm. admissionADLs activities of daily livingAED automated external

defribrillatorAHA American Heart AssociationAIDS acquired immune deficiency

syndromeAIIR airborne infection isolation

roomAKA above-knee amputation, also

known as

am, AM morningAMA against medical advice,

American Medical Associationamb ambulate, ambulatoryAMD age-related macular

degenerationamt. amountant. anteriorANS autonomic nervous systema.p./AP apical pulseapprox. approximatelyAROM active range of motionASAP as soon as possibleassist assistanceas tol as toleratedA, T, D admission, transfer, and

dischargeax axillaryBID, b.i.d. two times a day


Handout 3-4: Abbreviations (cont’d.)

BKA below-knee amputationbld bloodBLS basic life supportBM bowel movementBP, B/P blood pressureBPH benign prostatic hypertrophyBPM beats per minuteBR bedrestBRP bathroom privilegesBSC bedside commodeBSE breast self examinationC centigrade, Celsiusc withCa/CA calcium, cancer, carcinomaCAD coronary artery diseasecal caloriecath. catheterCBC complete blood countCBI continuous bladder irrigation

CBR complete bedrestCCMS clean-catch midstreamCDC Centers for Disease Control

and PreventionCDE certified diabetes educatorC-diff clostridium difficile CEP competency evaluation (testing) programsCEU continuing education unitCHD coronary heart diseaseCHF congestive heart failurechol cholesterolck checkcl liq clear liquidcm centimeterCMS Centers for Medicare and Medicaid ServicesCNA certified nursing assistantCNP certified nurse practitioner



CNS central nervous systemc/o complains of, in care ofCO2 carbon dioxide

COLD chronic obstructive lung disease

COPD chronic obstructive pulmonary disease

CP cerebral palsyCPM continuous passive motionCPR cardiopulmonary resuscitationCRF chronic renal failureCSF cerebrospinal fluidC.S. Central SupplyCVA cerebrovascular accident,

strokeCVP central venous pressure CVS cardiovascular systemCXR chest x-rayDAT diet as toleratedDKA diabetic ketoacidosis

DJD degenerative joint diseaseDM diabetes mellitusDNR do not resuscitateDO doctor of osteopathyDOA dead on arrivalDOB date of birthDON director of nursingDr. doctorDRG diagnostic related groupdrsg dressingDVT deep vein thrombosisDx/dx diagnosisECG/EKG electrocardiogramED emergency departmentEENT eye, ear, nose and throate.g. for exampleEMS emergency medical servicesER emergency roomESRD end-stage renal disease



et al. and other thingsETOH alcoholexam examinationF Fahrenheit, femaleFBS fasting blood sugarFDA Food and Drug AdministrationFe ironFF force fluidsFH family historyfld fluidFS fingerstickFSBS fingerstick blood sugarft footFUO fever of unknown originFWB full weight-bearingFYI for your informationF/U, f/u follow-upfx fractureGAD generalized anxiety disorder

gal gallonGB gallbladderGERD gastroesophageal reflux

diseasegeri chair geriatric chairGI gastrointestinalGP general practitionerGm, gm gramGSW gunshot woundGTT glucose tolerance testGU genitourinaryGYN/gyn gynecologyh, hr, hr. hourH20 water

H202 hydrogen peroxide

HAART highly active anti-retroviral therapy

H/A headacheHAV hepatitis A virusHBV hepatitis B virus



HCV hepatitis C virusHDV hepatitis D virusHEV hepatitis E virusHg mercuryHHA home health aideHi-cal high calorie HIPAA Health Insurance Portability

and Accountability ActHIV human immunodeficiency virusH&P history and physicalHOB head of bedHOH hard of hearingHMO health maintenance organizationHPV human papillomavirusHS/hs hours of sleepht heightHTN hypertensionH.U.C. Health Unit CoordinatorHx history

hyper above normal, too fast, rapidhypo low, less than normalIBD irritable bowel diseaseIBS irritable bowel syndromeICCU intermediate intensive care unitICU intensive care unitID identificationI&D incision and drainagei.e. that isIM intramuscular In inchinc incontinentinf inferiorI&O intake and outputIQ intelligence quotientIrr/irrig irrigationI.V., IV intravenousisol isolationK+ potassium



kg kilogramKS Kaposi’s sarcomal literL leftlab laboratorylb poundLBP low back painLE lower extremityLLE left lower extremitylg largeliq liquidLLQ left lower quadrantLOC level of consciousness, level of careLow-cal low calorieLow Fat low fatLow cal low calorieLow Na low sodiumLPN Licensed Practical Nurselt left

LTC long-term careLTCF long-term care facilityLUQ left upper quadrantLVN Licensed Vocational NurseM.D. medical doctorMD muscular dystrophyMDROs multidrug-resistant organismsMDR-TB multidrug resistant tuberculosisMDS minimum data setmeds medicationsmed-surg medical-surgicalmg milligramMI myocardial infarctionmin minutemL millilitermm millimetermm Hg millimeters of mercuryMO microorganismmod moderate



MRI magnetic resonance imagingMRSA methicillin-resistant

staphylococcus aureus MS multiple sclerosisMSDs musculoskeletal disordersMSDS material safety data sheetMSW medical social workerMUFA monounsaturated fatMVA motor vehicle accidentNa sodiumN/A not applicableNA nursing assistantNaCl sodium chlorideNAS no added saltNATCEP Nurse Aide Training and

Competency Evaluation Program

N/C no complaints, no callNCS no concentrated sweetsneg negative

NF nursing facilityNG, ng nasogastric NIBP non-invasive blood pressure

monitoringno numberNKA no known allergiesNKDA no known drug allergiesnoc nightNPO nothing by mouthNVD nausea, vomiting, and diarrheaNWB non-weight-bearingO2 oxygen

OB obstetricsob/gyn obstetrics and gynecologyOBRA Omnibus Budget Reconciliation

Act OCD obsessive-compulsive

disorderOG orogastric



OOB out of bedocc occasionallyOCD obsessive compulsive disorderOD overdoseO.D. right eyeO&P ova and parasitesOPD outpatient departmentO.R. operating roomord. orderly, orderedORIF open reduction, internal

fixation ortho orthopedicsos mouthO.S. left eyeOSHA Occupational Safety and

Health AdministrationOT occupational therapist,

occupational therapyOTC over-the-counter (medication)O.U. both eyes

oz. ounceP afterP.A. physician’s assistantPAD peripheral artery diseasepc, p.c. after mealsPCA patient-controlled anesthesiaPDR Physician’s Desk ReferencePE pulmonary embolismPeds pediatricsPEG percutaneous endoscopic

gastrostomyper os by mouthPET positron emission tomographyperi care perineal carepH parts hydrogenPH past historyPHI protected health

informationphy. ex. physical exam



PID pelvic inflammatory diseasePM/pm afternoonPMH past medical historyPNS peripheral nervous systemPO (per os) by mouthpost op after surgeryPPD purified protein derivative (test for tuberculosis)PPE personal protective equipmentpos. positivepre op before surgeryprep preparationprn when necessaryprog. progressPROM passive range of motionPt/pt patientpt. pintP.T. physical therapist, physical

therapyPTH parathyroid hormone

PTSD post-traumatic stress disorderPUFA polyunsaturated fatPVD peripheral vascular diseasePWB partial weight-bearingq everyQ&A questions and answersQA quality assuranceqam every morningqd every dayqh, qhr every hourqhs every night at bedtimeQ2h every two hours Q3h every three hours q4h every four hoursq.o.d. every other dayqt. quartquad quadrant, quadriplegicR respirations, rectal R, rt. right



RA rheumatoid arthritisRBC red blood cellRDT registered dieticianreg. regularrehab rehabilitationREM rapid eye movementreq. requisitionres. residentresp. respirationRF restrict fluidsRLE right lower extremityRLQ right lower quadrantRN registered nurseRNA restorative nursing assistantR/O rule outROM range of motionRR respiratory rateR/rt. rightRT respiratory therapy/therapist

RUE right upper extremityRUQ right upper quadrantRx prescription, treatments withoutS&A sugar and acetones.c. subcutaneouslySCA sudden cardiac arrestSCDs sequential compression devicesSIDS sudden infant death syndromesl sublinguallySLE systemic lupus erythematosisSLP speech-language pathologistsm. smallSNAFU situation normal, all fouled up

(slang)SNF skilled nursing facilityspec. specimenSOB shortness of breath



SNS somatic nervous systemSP Standard PrecautionsS.P.D. Supply, Processing and

DistributionSs one-halfS&S, S/S signs and symptomsSSE soapsuds enemaST. standard, speech therapystaph staphylococcusSTAT/stat immediatelyStd prec Standard PrecautionsSTDs sexually-transmitted diseasesSTIs sexually-transmitted infectionsstrep streptococcussupp. suppositorysurg. SurgeryT., temp temperatureTB tuberculosis

tbsp. tablespoonT,C, DB turn, cough, and deep breatheTHR total hip replacementTIA transient ischemic attackt.i.d., tid three times a dayUTI urinary tract infectionvag. vaginalVAP ventilator-acquired pneumoniaVD venereal diseaseVRE vancomycin-resistant

enterococcus VS, vs vital signsW/A,WA while awakeWBC white blood cell/countw/c wheelchairWNL within normal limitswt. weightyr. year



TKR total knee replacementTLC tender loving careTPN total parenteral nutritionT.P.R. temperature, pulse, and

respirationtrach. tracheostomytsp. teaspoonTWE tap water enemaTx, tx traction, treatmentU/A, u/a urinalysisUE upper extremityUGI upper gastrointestinalunk unknownURI upper respiratory infectionUS ultrasoundUSDA United States Department of

Agriculture



Review the information in the book and handouts about medical terminology and abbreviations.

Think about this question:In what ways would it be more difficult for healthcare workers (doctors, nurses, nursing assistants, etc.) to communicate if there were no medical terminology or abbreviations?

3Communication Skills7. Explain how to convert regular time to military time

Facilities may use the 24-hour clock, or military time, to document information. Regular time uses numbers 1 through 12. In military time, the hours are numbered from 00 to 23.

• To change the regular hours between 1:00 p.m. to 11:59 to military time, add 12 to the regular time.

• Minutes and seconds do not change.• Midnight may be written as 0000 or 2400; follow your

facility’s policy.


Transparency 3-4: 24-hour Clock


8. Describe a standard resident chart

Define the following terms:medical chart

written legal record of all medical care a patient, resident, or client receives.

chartingthe act of noting care and observations; documenting.



Your responsibility as a nursing assistant is to gather information and report it to the nurse. You will write down your observations and record the care you give. This is called charting.

Some facilities allow nursing assistants to chart in a medical record. Others limit nursing assistants’ charting to certain forms.


REMEMBER: A resident’s chart is the legal record of a resident’s care. What is written on the chart is considered to be what actually happened.



Information found on a resident’s chart:• Admission forms• Resident’s history and results of exams• Care plans• Doctor’s orders and progress notes• Nursing assessments• Notes from nurses and other specialists



Information found on a resident’s chart (cont'd.):• Flow sheets• Graphic record• Intake and output record• Consent forms• Lab and test results• Surgery reports • Advance directives



REMEMBER:All information in a resident’s chart is confidential.



9. Explain guidelines for documentation

Nursing assistants chart, or document, all resident care that they provide. They also document their observations. It is very important to document accurately because documentation is a legal record of all resident care.



Remember these guidelines for accurate documentation:• Keep all information confidential.• Document care immediately after it is given. Never

document care before it is given.• Use black ink.• Sign each note you make.


Guidelines for accurate documentation (cont'd.):• Use only facts when documenting.• If an error is made, draw one line through it and initial it

and write the date. Write the correct information.• Use only your facility’s accepted abbreviations and terms.• Use comparisons to describe size.



10. Describe the use of computers in documentation

Your facility may use computers to document information. Computers can easily store information that can be retrieved when it is needed.

Remember these general rules for computer use:• Do not share your password or log-in ID with anyone.• Do not access personal e-mail 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 HIPAA

guidelines apply to computer use.


11. Explain the Minimum Data Set (MDS)

Define the following term:Minimum Data Set (MDS)

a detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified.


The Minimum Data Set (MDS) manual is an assessment tool developed by the federal government. It gives long-term care facilities a structured, standardized approach to care.

Here are some facts about the MDS:• Assessment tool developed by the federal government• Detailed form for assessing residents• Details what to do if problems are identified• Completed for each resident within 14 days of admission

and again each year



Facts about the MDS (cont'd.):• Must be reviewed every three months• New MDS is done when there is any major change in

resident’s condition



REMEMBER: Your reports on changes in the condition of residents you care for is extremely important. When you report any changes right away, a new MDS assessment can be done if needed.



12. Describe how to observe and report accurately

Define the following terms:care plan

a written plan for each resident created by the nurse; outlines the steps taken by the staff to help the resident reach his or her goals.

objective informationfactual information collected using the senses of sight, hearing, smell, and touch; also called signs.

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.



Define the following terms:orientation

a person’s awareness of person, place, and time.vital signs

measurements—temperature, pulse, respirations, blood pressure, pain level—that monitor the functioning of the vital organs of the body.

critical thinkingthe process of reasoning and analyzing in order to solve problems; for the nursing assistant, critical thinking means making good observations and promptly reporting all potential problems.


REMEMBER:Nursing assistants spend more time with residents than any other care team members do. Because they spend the most time with residents, they are in the best position to observe changes in residents.

The care plan that nurses create for residents is based on information observed and reported by nursing assistants and other staff members.



Think about this question:What would happen if a nursing assistant reported incorrect or inaccurate information about a resident?



Transparency 3-5: Using Your Senses


Nursing assistants will report signs and symptoms that they observe. This information will be either objective or subjective.

Objective information is information based on what you see, hear, touch, or smell; it is collected using four of the five senses: sight, hearing, smell, and touch. It is also called “signs.”

Subjective information is information collected from something that residents or their families reported to you, and it may or may not be accurate. It is 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.



REMEMBER: Critical thinking for nursing assistants involves making good observations to get help for potential problems.



Remember that these signs and symptoms should be reported right away:

• Wheezing • Difficulty breathing• Chest pain and pressure• Pain in calf of leg• Blurred vision• Slurred speech



Signs and symptoms that should be reported right away (cont'd.):• 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• Headache• Falls



Handout 3-5: Scientific Method

The scientific method is a process used to determine the best solution to solve certain problems. In order to do this, a problem must be identified. Once the problem is discovered, a hypothesis must be created. A hypothesis is a possible explanation for a problem or observation. After the hypothesis is created, it is tested through investigation and experiments. After performing tests, a conclusion is usually reached. In order to determine solutions using the scientific method, facts, not opinions or emotions, must be used.

Problem:Resident Mrs. S says that it hurts when she urinates. Hypothesis: She has a UTI. Conclusion:The urine was tested, and bacteria was found in the urine. The resident has started taking antibiotics, and she states: “I feel much better

now.” The resident is resting comfortably.


13. Explain the nursing process

Define the following term: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.


The nursing process has five steps:• Assessment• Diagnosis• Planning• Implementation• Evaluation

13. Explain the nursing process

3Communication Skills14. Discuss the nursing assistant’s role in care planning and at care conferencesDefine the following term:care conference

a meeting to share and gather information about residents in order to develop a care plan.


REMEMBER:• Nursing assistants have an important role in care planning.

Care plans are prepared from the observations of staff caring for the resident.

• At care planning meetings, do not be afraid to share your observations. If you are unsure about what information to share, talk to the nurse before the meeting.

14. Discuss the nursing assistant’s role in care planning and at care conferences


Care plans may be written at a special care conference. The care conference is a meeting to share and gather information.

This is done in order to develop care plans for residents. Care team members may attend. Each team member may share important information used to create or add to the care plan.

14. Discuss the nursing assistant’s role in care planning and at care conferences


15. Describe incident reporting and recording

Define the following terms:incident

an accident, problem, or unexpected event during the course of care.

sentinel eventan unexpected occurrence involving death or serious physical or psychological injury.

incident report a report documenting an incident and the response to the incident; also known as an occurrence report or event report.


Incident reports are vital to the safety of the staff and residents. An incident is an accident, problem, or unexpected event during the course of care.

Events in the facility that are considered incidents:• An accident or problem during the course of care• An error in care, such as feeding the resident from the wrong

meal tray• A fall or injury to a resident or staff member• An accusation against staff members



A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury.

An example of a sentinel event is a resident falling out of bed and breaking a hip or a medication error that results in a resident’s death.



REMEMBER:An incident report must be filled out if a nursing assistant is injured on the job in any way, even if it seems minor.



Remember these guidelines for incident reporting:• Include exactly what you saw. • State the time and the condition of the resident or visitor.• Describe the person’s reaction to the incident. • State the facts. • Do not give your opinion.



16. Explain proper telephone etiquette

REMEMBER:When you use the telephone during your shift, you are representing your facility to the community. You must follow rules for proper telephone etiquette.


Remember these 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.”



Remember these rules for general 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 cell phone use.



Think about this question:What could happen if you gave out confidential information about residents or staff over the phone?



Residents signal staff that they need them by using the call system.

Other terms for this system are “signal light,” or “call light.”

This system allows residents to call for help when needed.

17. Describe the resident call system


17. Describe the resident call system

REMEMBER:• The call light is the residents’ lifeline and must always be

answered immediately. Ignoring a call light is abuse.

• A call light must always be left within the resident’s reach before leaving the room.


18. Describe the nursing assistant’s role in change-of-shift reports and “rounds”

Define the following term:rounds

physical movement of staff from room to room to discuss each resident and his or her care plan.


Remember these guidelines for start-of-shift reports:• Arrive on time.• Listen for your assignment and for information about all

residents in your area.• Listen carefully to information from the prior shift.• Ask any questions you have about your residents.



REMEMBER:Your role in end-of-shift reports is to report information gathered about residents during your shift so that the staff members on the next shift can provide good care.



19. List the information found on an assignment sheet

Define the following terms: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 failure, or terminal illness; terms and acronyms are used to identify the care desired by the person, such as “DNR” (do not resuscitate) and “no code.”

codein health care, an emergent medical situation in which specially-trained responders provide resuscitative measures to a person.


An assignment sheet lists residents and all of the tasks that you must do for them.

Information typically found on an assignment sheet:• Residents’ names and room numbers• Medical diagnosis • Code status• Activity level• Range of motion (ROM) exercises• Bathing information



Information typically found on an assignment sheet (cont'd.):• Diet orders• Fluid orders• Bowel and bladder information• How often to measure vital signs• Treatments to be performed• Tests and procedures to be performed



20. Discuss how to organize your work and manage time

Define the following term:prioritize

to place things in order of importance.



Remember these tips for organization and time management:• Plan ahead.• Identify the most important tasks and get those done first.• Make a schedule.• Combine activities.• Get help when needed.


REMEMBER:Do not be afraid to ask for help. If you cannot complete an assignment for any reason, notify the nurse. Nursing assistants who are not afraid to ask for help provide the best care to their residents.



Think about these questions:• How strong are your organization and time management

skills?• In what ways can you improve them?



Exam

Multiple Choice. Choose the correct answer.1. Which of the following is an example of nonverbal communication?(A) Writing a note in a resident’s chart(B) Giving an oral report to a supervisor(C) Smiling at a new resident(D) Speaking in an encouraging tone of voice to a resident who is moving slowly

2. Which of the following is an example of positive nonverbal communication by a nursing assistant?(A) Leaning forward to listen as a resident talks about her day(B) Rolling her eyes as the supervisor gives an assignment(C) Tapping her foot while waiting for a resident to get ready for his bath(D) Shaking her head when a resident has been incontinent


Exam (cont’d.)

3. To communicate well with a resident, a nursing assistant should:(A) Finish his sentences for him if he is taking a long time to say something(B) State her opinions as though they were facts (C) Be aware of her body language(D) Fill any pauses in conversation to prevent awkwardness

4. If a resident is difficult to understand, a nursing assistant should:(A) Pretend to understand the resident even when she doesn’t(B) Restate what she is saying in her own words to find out if she has understood(C) Avoid communicating with the resident(D) Use clichés to make it easier for the resident to understand what is being said


5. Why is it important to consider a resident’s cultural background when communicating with him or her?(A) It is not important to consider cultural background.(B) Because the resident will certainly want to tell stories about his or her culture.(C) Because you might know somebody with the same background and you can tell the resident about that person.(D) Because cultural background helps determine how people communicate and can help you communicate better with the resident.

6. If a resident’s native language is different from the nursing assistant’s, the nursing assistant should:(A) Use an interpreter to translate the message(B) Ignore the resident unless she speaks in the nursing assistant’s language(C) Communicate with coworkers in nursing assistant’s native language in front of the resident(D) Ask the resident only yes/no questions

Exam (cont’d.)


7. Each time a nursing assistant greets a resident, he should:(A) Assume that the resident knows who he is(B) Explain the procedure to be performed(C) Reassure the resident that she won’t have to do anything during the procedure(D) Avoid telling the resident about the procedure if he thinks it will upset her

8. One way to have a good relationship with a resident’s family and friends is to:(A) Avoid talking to the resident when he has visitors(B) Let the family take care of the resident’s needs themselves(C) Tell the resident’s friends stories about the resident that will make them laugh(D) Respond immediately when the resident calls for help

Exam (cont’d.)


9. The main part of a word that gives it meaning is the:(A) Prefix(B) Root(C) Suffix(D) Abbreviation

10. When is it appropriate to use medical terminology?(A) When communicating with the care team(B) When communicating with residents(C) When communicating with residents’ families(D) When communicating with visitors

Exam (cont’d.)


11. In regular time, 1330 hours would be:(A) 1:30 a.m.(B) 1:30 p.m.(C) 11:30 a.m.(D) 11:30 p.m.

12. In military time, 7:45 p.m. would be:(A) 0745 hours(B) 1975 hours(C) 1945 hours(D) 0775 hours

Exam (cont’d.)


13. A nursing assistant’s responsibility with the resident’s medical chart is to:(A) Keep the chart in case it is needed later(B) Make changes to the care plan(C) Gather information and write down observations and care(D) Suggest the best treatment for the resident

14. A nursing assistant can share information about residents with:(A) Anyone she chooses(B) The resident’s family and friends(C) Other members of the care team(D) No one

Exam (cont’d.)


15. Accurate documentation is important because:(A) The medical chart includes information about the menus offered at the facility each day(B) Documentation provides an up-to-date record of residents’ status and care(C) Family members will want to view medical charts(D) Nursing assistants put their diagnoses in medical charts

16. When should documentation be recorded?(A) Immediately after care is given(B) At the end of the shift(C) Whenever there is time(D) Before the care is given

Exam (cont’d.)


17. When using the computer at work, a nursing assistant should:(A) Access personal e-mail accounts(B) Log off the computer when she is finished using it(C) Look for websites she has a personal interest in(D) Share her password with the rest of the care team

18. Why must a nursing assistant be concerned about privacy if documentation is done on a computer?(A) It is common for computer hackers to target LTC facilities.(B) Because the federal government is monitoring all computers in LTC facilities to ensure that HIPAA is followed.(C) Because residents will probably try to sneak a look at other residents’ information.(D) Because the information is confidential and someone who is not part of the care team might see the screen.

Exam (cont’d.)


19. Which of the following is true of the MDS? (A) MDS stands for Multiple Diagnosis System.(B) Every time an MDS is completed for a resident, an investigation by the state is done. (C) Not all residents will have an MDS.(D) A nursing assistant’s report may trigger a needed assessment for a resident.

20. Which of the following statements contains objective information?(A) Mr. Castillo seems a little grouchy today.(B) Mr. Castillo says that he has a stomachache.(C) Mr. Castillo’s blood pressure is 115/68.(D) Mr. Castillo doesn’t get along with the nurses very well.

Exam (cont’d.)


21. Which of the following statements gives subjective information?(A) Mrs. Parker says she is feeling dizzy.(B) Mrs. Parker has a temperature of 101°F.(C) Mrs. Parker had a visit from her son today.(D) Mrs. Parker didn’t eat any of her dinner today.

22. Which of the following senses is not used in making observations?(A) Sight(B) Touch(C) Smell(D) Taste

Exam (cont’d.)


23. Choose the resident condition that the NA should report immediately to the nurse.(A) Family fighting(B) Chest pain(C) Watching too much TV(D) Acting lonely

24. The correct order of the steps in the nursing process is:(A) Diagnosis, planning, evaluation, implementation, assessment(B) Assessment, diagnosis, planning, implementation, evaluation(C) Evaluation, implementation, assessment, planning, diagnosis(D) Planning, assessment, implementation, evaluation, diagnosis

Exam (cont’d.)


25. What is the nursing assistant’s role in care planning?(A) The nursing assistant will write the care plan.(B) The nursing assistant will share observations that may affect the care plan.(C) The nursing assistant makes changes to the care plan.(D) The nursing assistant has no role in care planning.

26. If a nursing assistant is not sure what information to share at the care conference, she should:(A) Talk to the nurse before the meeting(B) Not attend the meeting(C) Attend the meeting, but not say anything(D) Ask the other team members at the meeting what they need to know

Exam (cont’d.)


27. Which of the following would be considered an incident?(A) Mrs. Storey eats half of her dinner.(B) Mrs. Desmond’s family thanks a nursing assistant for taking such good care of her.(C) Mr. Noble wants to go for a walk after his bath.(D) Ms. Martin slips and falls in the bathroom but seems uninjured.

28. A sentinel event is:(A) Any event requiring an incident report(B) An occurrence involving death or serious injury(C) A normal event that occurs in the course of the day(D) A complaint by a resident or family member

Exam (cont’d.)


29. Under what conditions should a nursing assistant fill out an incident report if he is injured on the job?(A) Only if the injury is serious(B) Only if the nursing assistant feels the facility is at fault(C) Only if another employee was involved(D) Any time he is injured on the job

30. Which of the following is the best example of using proper telephone etiquette at work?(A) “Yes, Mr. Garcia is a resident here; he was admitted for dementia.”(B) “Good afternoon, Hartman Skilled Care Facility, Brenda Johnson speaking.”(C) “We’re very busy here today. Can you call back some other time?”(D) “No, I’m sorry, I can’t take a message. That is not part of my duties.”

Exam (cont’d.)


31. If a nursing assistant sees a call light for a resident that is not assigned to her, she should:(A) Answer the call light(B) Tell the nursing assistant assigned to that resident to answer it(C) Tell the supervisor(D) Ignore it 32. Rounds are:(A) The group of residents assigned to each nursing assistant(B) The list of tasks that must be done on each shift(C) A method of reporting in which staff move from room to room(D) Meetings during which the care plan is written

Exam (cont’d.)


33. What does a resident’s code status indicate?(A) The type of diet a resident has and how much food should be offered at each meal(B) The type care that should be provided in the event of a cardiac arrest or other catastrophic failure(C) The type and amount of medication that a resident must take each day(D) The type of personal care tasks that must be completed each day for a resident

34. What is the first thing a nursing assistant should do after getting a work assignment?(A) Set up residents for mealtime(B) Write down anything important on the assignment sheet(C) Check to see if any of his assigned residents requires immediate help or care(D) Take vital signs on all residents

Exam (cont’d.)

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1. Define important words in this chapter

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