Test 1 Vocab- CNA Course

OBRA

The Omnibus Budget Reconciliation Act, enacted in 1987, sets standards for quality care in nursing homes and emphasizes the rights of residents. Sets scope of practicefor Certified Nursing Assistants (CNAs) and requires ongoing education and training.

NATCP

The Nurse Aide Training and Competency Evaluation Program, which establishes training requirements and testing for nursing assistants in long-term care facilities.

Ombudsman

An advocate for residents in long-term care facilities, ensuring their rights are protected and addressing complaints.

Misappropriation

The deliberate misplacement, exploitation, or improper use of a person’s belonging or money without the person’s consent

Neglect

The failure to provide necessary care of services, resulting in physical, mental, or emotional harm to a resident.

Protected Health Information (PHI)

information that can be used to identify a person and relates to the patient’s condition, including any health care the person has had, and payment for that health care

AxO#

How alert an oriented the patient is.

AxO4- fully mentally/cognitively there. Can answer four neuro check questions

AxO3- Answers ¾ neuro check questions

AxO2- Concerning

AxO1-Concerning

Dysphagia

Difficulty in swallowing food or liquids, often causing a risk of aspiration.

DNI

Do not intubate, a medical order that tells medical professionals not to place a breathing tube

Abuse

purposeful or willful mistreatment that causes physical, mental, emotional, finical harm or injury

Advance Directives

legal documents that allow people to decide what kind of medical care they wish to have in the event that they are unable to make those decisions themselves.

Etiquette

the code of proper behavior and courtesy in a certain setting

Battery

the intentional touching of a person without their consent

Assault

Threat to harm a person, resulting the person feeling fearful that he will be harmed.

Electronic health records (EHR)

the electronic form of a resident’s personal and health data that is used to manage and coordinate a resident’s health

Defamation

any untrue statement that harms a person’s reputation and/or damages the persons ability to make a living

Durable power of attorney for health care

a legal document that appoints someone to make the medical decisions for a person in the event he becomes unable to do so

PRN

“pro re nata” means as needed. Medications, staffing members

q#hr

Per blank hours. “Per two hours”

ROM

Range of motion

ADLS

Activities of daily living

NPO

Nothing per orally

I&O

Intake and output

What is the conversion of

a.c abbreviation

Before meals

TID abbreviation

Three times a day

BID

Twice a day

Adverse event

an unexpected event that causes serious injury or death; also called sentinel event

body language

all of the conscious or unconscious messages a persons body sends as they communicate. Examples include facial expressions, gestures, and posture.

Care plan

a plan for each resident created by a registered nurse that outlines the tasks that the team members must perform to help the resident reach their goal.

code

a medical situation

Code Status

formal documentation of the type and scope of care that should be provided to a resident in the event of cardiac or respiratory arrest, catastrophic organ failure or terminal illness.

edema

swelling in body tissues caused by excess fluid

incident report

a report documenting an incident and the response to the incident

medical chart

legal record of care

Minimum Data Set (MDS)

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

nonverbal communication

communication without using words such as facial expressions and body language

nursing process

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.

Objective information

factual information collected using the senses of sight, hearing, smell and touch

Orientation

a person’s awareness of person, place and time

rounds

scheduled visits to each residents room to assess the residents condition and needs and to discuss the care plan with participating staff

The four P’s

Pain, Potty, Possessions, Position

Sentinel event

an unexpected even that causes serious injury or death; also called an adverse event

Subjective information

information collected from residents or family members that may not be true, but is what the person reported

Vital signs

measurements temperature, blood pressure, oxygen saturation, respiratory rate, heart/pulse rate, pain

airway

the natural passageway for air to enter into the lungs

anxiety

Unease or worry often about a situation

artificial airway

any tube inserted into the respiratory tract for the purpose of maintaining an airway and facilitating ventilation

coma

state of deep unconscious for a prolong period of time

combative

violent or hostile

defense mechanism

unconscious behaviors used to release tension and/or help a person cope with stress

disorientation

confusion about person, place or time; may be permanent or temporary

dyspnea

difficulty breathing

impairment

a partial or complete loss of function or ability

tracheostomy

a surgically created opening through the neck into the trachea