Chapter 3 PCT

Active Listening

A way of communicating that involves giving a person one’s full attention and encouraging them to give information and clarify ideas.

Barrier

A block or an obstacle

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 Conference

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

Charting

The act of noting care and observations; documenting

Code

In health care, and emergent 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 NA, critical thinking means making careful observations and promptly reporting all potential problems.

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

Medical Chart

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

Minimum Data Sheet (MDS)

A detailed from with guidelines for assessing residents in long-term care facilities

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

Rounds

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

Sentinel Event

An unexpected occurence involving death or serious physical or psychological injury.

Subjective Information

Information collected from residents, their family members, and their friends; information may or may not be true, but is what the person reported; also called symptoms.

Verbal Communcation

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.