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3 Communication Skills 1. Define important words in this chapter active listening a way of communicating that involves giving a person your full attention.

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Presentation on theme: "3 Communication Skills 1. Define important words in this chapter active listening a way of communicating that involves giving a person your full attention."— Presentation transcript:

1 3 Communication 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. barrier a 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 conference a meeting to share and gather information about residents in order to develop a care plan.

2 3 Communication Skills 1. Define important words in this chapter 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. charting the act of noting care and observations; documenting. code in health care, an emergent medical situation in which specially-trained responders provide resuscitative measures to a person.

3 3 Communication Skills 1. Define important words in this chapter 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 thinking the 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. culture a set of learned beliefs, values, traditions, and behaviors shared by a social, ethnic, or age group.

4 3 Communication Skills 1. Define important words in this chapter 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 report or event report. medical chart written legal record of all medical care a patient, resident, or client receives.

5 3 Communication Skills 1. Define important words in this chapter 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.

6 3 Communication Skills 1. Define important words in this chapter 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.

7 3 Communication Skills 1. Define important words in this chapter 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 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.

8 3 Communication Skills 1. Define important words in this chapter 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.

9 3 Communication Skills 2. Explain types of communication Define the following terms: verbal communication communication involving the use of spoken or written words or sounds. nonverbal communication communication without using words, such as making gestures and facial expressions.

10 3 Communication Skills 2. Explain types of communication 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.

11 3 Communication Skills 2. Explain types of 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.”

12 3 Communication Skills Transparency 3-1: Communication Process

13 3 Communication Skills 2. Explain types of communication 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.

14 3 Communication Skills 2. Explain types of communication 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.

15 3 Communication Skills 2. Explain types of communication 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.

16 3 Communication Skills Transparency 3-2: Body Language

17 3 Communication Skills 2. Explain types of communication Think about this question: What signals are the two people on Transparency 3-2 sending to each other through their body language?

18 3 Communication Skills 2. Explain types of communication 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

19 3 Communication Skills 2. Explain types of communication Examples of negative nonverbal communication: Rolling your eyes Crossing your arms in front of you Tapping your foot Pointing at someone while speaking

20 3 Communication Skills 2. Explain types of communication Think about this question: Can you think of other examples of either positive or negative nonverbal communication?

21 3 Communication Skills 2. Explain types of 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.

22 3 Communication Skills 3. Explain barriers to communication Define the following term: barrier a block or an obstacle.

23 3 Communication Skills 3. Explain barriers to communication 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.

24 3 Communication Skills Transparency 3-3: Barriers to Communication

25 3 Communication Skills 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. 3. Explain barriers to communication

26 3 Communication Skills 3. Explain barriers to communication 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.

27 3 Communication Skills 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.

28 3 Communication Skills 4. List ways that cultures impact communication 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.

29 3 Communication Skills 4. List ways that cultures impact communication 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

30 3 Communication Skills 4. List ways that cultures impact communication 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

31 3 Communication Skills 4. List ways that cultures impact communication Think about this question: Can you think of other examples of acceptable and unacceptable touch?

32 3 Communication Skills 4. List ways that cultures impact communication 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?

33 3 Communication Skills 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

34 3 Communication Skills 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.

35 3 Communication Skills 6. Understand basic medical terminology and abbreviations 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

36 3 Communication Skills 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. 6. Understand basic medical terminology and abbreviations

37 3 Communication Skills Handout 3-1: Prefixes a, an: without, not, lack of analgesic = without pain ante: before, in front of antepartum = before delivery bi: two, twice, double bifocal = two lenses brady: slow bradycardia = slow pulse, heartbeat contra: against contraceptive = prevents pregnancy dis: apart, free from disinfected = free from microorganisms dys: bad, painful dysuria = painful urination endo: inner endoscope = instrument for examining the inside of an organ epi: on, upon, over epidermis = outer layer of skin erythro: red erythrocyte = red blood cell

38 3 Communication Skills 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, under hypotension = 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

39 3 Communication Skills 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, beneath subcutaneous = beneath the skin supra: above, over suprapelvic = located above the pelvis tachy: swift, fast, rapid tachycardia = rapid heartbeat

40 3 Communication Skills Handout 3-2: Roots abdomin (o): abdomen abdominal = 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): joint arthrotomy = cut into a joint brachi (o): arm brachial = pertaining to the arm bronchi, bronch (o): bronchus bronchopneumonia = 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

41 3 Communication Skills 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

42 3 Communication Skills Handout 3-2: Roots (cont’d.) 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

43 3 Communication Skills Handout 3-2: Roots (cont’d.) 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 brain meningitis = 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

44 3 Communication Skills Handout 3-2: Roots (cont’d.) 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

45 3 Communication Skills Handout 3-2: Roots (cont’d.) 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

46 3 Communication Skills 6. Understand basic medical terminology and abbreviations 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.

47 3 Communication Skills 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

48 3 Communication Skills 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

49 3 Communication Skills Handout 3-3: Suffixes (cont’d.) -scopy: examination using a scope colonoscopy = 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

50 3 Communication Skills 6. Understand basic medical terminology and abbreviations 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.

51 3 Communication Skills Handout 3-4: Abbreviations abefore AAROMactive-assistive range of motion abdabdomen ABRabsolute bedrest ac, a.c.before meals ADAlzheimer’s disease ADCAIDS dementia complex ad libas desired adm.admission ADLsactivities of daily living AEDautomated external defribrillator AHAAmerican Heart Association AIDSacquired immune deficiency syndrome AIIRairborne infection isolation room AKAabove-knee amputation, also known as am, AMmorning AMAagainst medical advice, American Medical Association ambambulate, ambulatory AMDage-related macular degeneration amt.amount ant.anterior ANSautonomic nervous system a.p./APapical pulse approx.approximately AROMactive range of motion ASAPas soon as possible assistassistance as tolas tolerated A, T, Dadmission, transfer, and discharge axaxillary BID, b.i.d.two times a day

52 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) BKAbelow-knee amputation bldblood BLSbasic life support BMbowel movement BP, B/Pblood pressure BPHbenign prostatic hypertrophy BPMbeats per minute BRbedrest BRPbathroom privileges BSCbedside commode BSEbreast self examination Ccentigrade, Celsius cwith Ca/CAcalcium, cancer, carcinoma CADcoronary artery disease calcalorie cath.catheter CBCcomplete blood count CBIcontinuous bladder irrigation CBRcomplete bedrest CCMSclean-catch midstream CDCCenters for Disease Control and Prevention CDEcertified diabetes educator C-diffclostridium difficile CEPcompetency evaluation (testing) programs CEUcontinuing education unit CHDcoronary heart disease CHFcongestive heart failure cholcholesterol ckcheck cl liqclear liquid cmcentimeter CMSCenters for Medicare and Medicaid Services CNAcertified nursing assistant CNPcertified nurse practitioner

53 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) CNScentral nervous system c/ocomplains of, in care of CO 2 carbon dioxide COLDchronic obstructive lung disease COPDchronic obstructive pulmonary disease CP cerebral palsy CPMcontinuous passive motion CPRcardiopulmonary resuscitation CRF chronic renal failure CSF cerebrospinal fluid C.S. Central Supply CVA cerebrovascular accident, stroke CVP central venous pressure CVS cardiovascular system CXR chest x-ray DAT diet as tolerated DKA diabetic ketoacidosis DJD degenerative joint disease DM diabetes mellitus DNR do not resuscitate DO doctor of osteopathy DOA dead on arrival DOB date of birth DONdirector of nursing Dr. doctor DRG diagnostic related group drsg dressing DVT deep vein thrombosis Dx/dx diagnosis ECG/EKG electrocardiogram ED emergency department EENTeye, ear, nose and throat e.g. for example EMS emergency medical services ER emergency room ESRD end-stage renal disease

54 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) et al. and other things ETOH alcohol exam examination F Fahrenheit, female FBS fasting blood sugar FDA Food and Drug Administration Fe iron FF force fluids FH family history fld fluid FS fingerstick FSBS fingerstick blood sugar ft foot FUO fever of unknown origin FWB full weight-bearing FYI for your information F/U, f/u follow-up fx fracture GAD generalized anxiety disorder gal gallon GB gallbladder GERD gastroesophageal reflux disease geri chairgeriatric 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 H 2 0 water H hydrogen peroxide HAART highly active anti-retroviral therapy H/A headache HAV hepatitis A virus HBV hepatitis B virus

55 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) HCV hepatitis C virus HDV hepatitis D virus HEV hepatitis E virus Hg mercury HHA home health aide Hi-cal high calorie HIPAA Health Insurance Portability and Accountability Act HIV human immunodeficiency virus H&P history and physical HOB head of bed HOH hard of hearing HMO health maintenance organization HPV human papillomavirus 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 IBD irritable bowel disease IBS irritable bowel syndrome ICCU intermediate intensive care unit ICU intensive care unit ID identification I&D incision and drainage i.e.that is IM intramuscular In inch inc incontinent inf inferior I&O intake and output IQ intelligence quotient Irr/irrig irrigation I.V., IV intravenous isol isolation K+ potassium

56 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) kg kilogram KS Kaposi’s sarcoma l liter L left lab laboratory lb pound LBP low back pain LE lower extremity LLE left lower extremity lg large liq liquid LLQ left lower quadrant LOC level of consciousness, level of care Low-cal low calorie Low Fatlow fat Low callow calorie Low Na low sodium LPN Licensed Practical Nurse ltleft LTC long-term care LTCFlong-term care facility LUQ left upper quadrant LVN Licensed Vocational Nurse M.D. medical doctor MD muscular dystrophy MDROs multidrug-resistant organisms MDR-TB multidrug resistant tuberculosis MDS minimum data set meds medications med-surg medical-surgical mg milligram MI myocardial infarction min minute mLmilliliter mmmillimeter mm Hgmillimeters of mercury MOmicroorganism modmoderate

57 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) MRImagnetic resonance imaging MRSAmethicillin-resistant staphylococcus aureus MSmultiple sclerosis MSDsmusculoskeletal disorders MSDSmaterial safety data sheet MSWmedical social worker MUFAmonounsaturated fat MVAmotor vehicle accident Nasodium N/Anot applicable NAnursing assistant NaClsodium chloride NASno added salt NATCEPNurse Aide Training and Competency Evaluation Program N/C no complaints, no call NCSno concentrated sweets negnegative NFnursing facility NG, ngnasogastric NIBPnon-invasive blood pressure monitoring nonumber NKAno known allergies NKDAno known drug allergies nocnight NPOnothing by mouth NVDnausea, vomiting, and diarrhea NWBnon-weight-bearing O 2 oxygen OBobstetrics ob/gynobstetrics and gynecology OBRAOmnibus Budget Reconciliation Act OCDobsessive-compulsive disorder OGorogastric

58 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) OOBout of bed occoccasionally OCDobsessive compulsive disorder ODoverdose O.D.right eye O&Pova and parasites OPDoutpatient department O.R.operating room ord.orderly, ordered ORIFopen reduction, internal fixation orthoorthopedics osmouth O.S.left eye OSHAOccupational Safety and Health Administration OToccupational therapist, occupational therapy OTCover-the-counter (medication) O.U.both eyes oz.ounce Pafter P.A.physician’s assistant PADperipheral artery disease pc, p.c.after meals PCApatient-controlled anesthesia PDRPhysician’s Desk Reference PE pulmonary embolism Pedspediatrics PEGpercutaneous endoscopic gastrostomy per osby mouth PETpositron emission tomography peri careperineal care pHparts hydrogen PHpast history PHIprotected health information phy. ex.physical exam

59 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) PIDpelvic inflammatory disease PM/pmafternoon PMHpast medical history PNSperipheral nervous system PO(per os) by mouth post opafter surgery PPDpurified protein derivative (test for tuberculosis) PPEpersonal protective equipment pos.positive pre opbefore surgery preppreparation prn when necessary prog.progress PROMpassive range of motion Pt/ptpatient pt.pint P.T.physical therapist, physical therapy PTHparathyroid hormone PTSDpost-traumatic stress disorder PUFApolyunsaturated fat PVDperipheral vascular disease PWBpartial weight-bearing qevery Q&Aquestions and answers QAquality assurance qamevery morning qdevery day qh, qhrevery hour qhsevery night at bedtime Q2h every two hours Q3hevery three hours q4h every four hours q.o.d.every other day qt.quart quadquadrant, quadriplegic Rrespirations, rectal R, rt.right

60 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) RArheumatoid arthritis RBCred blood cell RDTregistered dietician reg.regular rehabrehabilitation REMrapid eye movement req.requisition res.resident resp.respiration RFrestrict fluids RLEright lower extremity RLQright lower quadrant RNregistered nurse RNArestorative nursing assistant R/Orule out ROMrange of motion RRrespiratory rate R/rt.right RTrespiratory therapy/therapist RUEright upper extremity RUQright upper quadrant Rxprescription, treatment s without S&Asugar and acetone s.c.subcutaneously SCAsudden cardiac arrest SCDssequential compression devices SIDSsudden infant death syndrome slsublingually SLEsystemic lupus erythematosis SLPspeech-language pathologist sm.small SNAFUsituation normal, all fouled up (slang) SNFskilled nursing facility spec.specimen SOBshortness of breath

61 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) SNSsomatic nervous system SPStandard Precautions S.P.D.Supply, Processing and Distribution Ssone-half S&S, S/Ssigns and symptoms SSEsoapsuds enema ST.standard, speech therapy staphstaphylococcus STAT/statimmediately Std precStandard Precautions STDssexually-transmitted diseases STIssexually-transmitted infections strepstreptococcus supp.suppository surg.Surgery T., temptemperature TBtuberculosis tbsp.tablespoon T,C, DBturn, cough, and deep breathe THRtotal hip replacement TIAtransient ischemic attack t.i.d., tidthree times a day UTIurinary tract infection vag.vaginal VAPventilator-acquired pneumonia VDvenereal disease VREvancomycin-resistant enterococcus VS, vsvital signs W/A,WAwhile awake WBCwhite blood cell/count w/cwheelchair WNLwithin normal limits wt.weight yr.year

62 3 Communication Skills Handout 3-4: Abbreviations (cont’d.) TKRtotal knee replacement TLCtender loving care TPNtotal parenteral nutrition T.P.R.temperature, pulse, and respiration trach.tracheostomy tsp.teaspoon TWEtap water enema Tx, txtraction, treatment U/A, u/aurinalysis UEupper extremity UGIupper gastrointestinal unkunknown URIupper respiratory infection USultrasound USDAUnited States Department of Agriculture

63 3 Communication Skills 6. Understand basic medical terminology and abbreviations 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?

64 3 Communication Skills 7. 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.

65 3 Communication Skills Transparency 3-4: 24-hour Clock

66 3 Communication Skills 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. charting the act of noting care and observations; documenting.

67 3 Communication Skills 8. Describe a standard resident chart 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.

68 3 Communication Skills 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. 8. Describe a standard resident chart

69 3 Communication Skills 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 8. Describe a standard resident chart

70 3 Communication Skills 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 8. Describe a standard resident chart

71 3 Communication Skills REMEMBER: All information in a resident’s chart is confidential. 8. Describe a standard resident chart

72 3 Communication Skills 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.

73 3 Communication Skills 9. Explain guidelines for documentation 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.

74 3 Communication Skills 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. 9. Explain guidelines for documentation

75 3 Communication Skills 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 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.

76 3 Communication Skills 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.

77 3 Communication Skills 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 11. Explain the Minimum Data Set (MDS)

78 3 Communication Skills 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 11. Explain the Minimum Data Set (MDS)

79 3 Communication Skills 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. 11. Explain the Minimum Data Set (MDS)

80 3 Communication Skills 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 information factual 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.

81 3 Communication Skills 12. Describe how to observe and report accurately 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 thinking the 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.

82 3 Communication Skills 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. 12. Describe how to observe and report accurately

83 3 Communication Skills Think about this question: What would happen if a nursing assistant reported incorrect or inaccurate information about a resident? 12. Describe how to observe and report accurately

84 3 Communication Skills Transparency 3-5: Using Your Senses

85 3 Communication Skills 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.” 12. Describe how to observe and report accurately

86 3 Communication Skills 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. 12. Describe how to observe and report accurately

87 3 Communication Skills REMEMBER: Critical thinking for nursing assistants involves making good observations to get help for potential problems. 12. Describe how to observe and report accurately

88 3 Communication Skills 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 12. Describe how to observe and report accurately

89 3 Communication Skills 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 12. Describe how to observe and report accurately

90 3 Communication Skills 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.

91 3 Communication Skills 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.

92 3 Communication Skills The nursing process has five steps: Assessment Diagnosis Planning Implementation Evaluation 13. Explain the nursing process

93 3 Communication Skills 14. Discuss the nursing assistant’s role in care planning and at care conferences Define the following term: care conference a meeting to share and gather information about residents in order to develop a care plan.

94 3 Communication Skills 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

95 3 Communication Skills 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

96 3 Communication Skills 15. Describe incident reporting and recording Define the following terms: incident an accident, problem, or unexpected event during the course of care. sentinel event an 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.

97 3 Communication Skills 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 15. Describe incident reporting and recording

98 3 Communication Skills 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. 15. Describe incident reporting and recording

99 3 Communication Skills 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. 15. Describe incident reporting and recording

100 3 Communication Skills 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. 15. Describe incident reporting and recording

101 3 Communication Skills 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.

102 3 Communication Skills 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.” 16. Explain proper telephone etiquette

103 3 Communication Skills 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. 16. Explain proper telephone etiquette

104 3 Communication Skills Think about this question: What could happen if you gave out confidential information about residents or staff over the phone? 16. Explain proper telephone etiquette

105 3 Communication Skills 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

106 3 Communication Skills 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.

107 3 Communication Skills 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.

108 3 Communication Skills 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. 18. Describe the nursing assistant’s role in change-of-shift reports and “rounds”

109 3 Communication Skills 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. 18. Describe the nursing assistant’s role in change-of-shift reports and “rounds”

110 3 Communication Skills 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.” code in health care, an emergent medical situation in which specially-trained responders provide resuscitative measures to a person.

111 3 Communication Skills 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 19. List the information found on an assignment sheet

112 3 Communication Skills 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 19. List the information found on an assignment sheet

113 3 Communication Skills 20. Discuss how to organize your work and manage time Define the following term: prioritize to place things in order of importance.

114 3 Communication Skills 20. Discuss how to organize your work and manage time 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.

115 3 Communication Skills 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. 20. Discuss how to organize your work and manage time

116 3 Communication Skills Think about these questions: How strong are your organization and time management skills? In what ways can you improve them? 20. Discuss how to organize your work and manage time

117 3 Communication Skills 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

118 3 Communication Skills 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

119 3 Communication Skills 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.)

120 3 Communication Skills 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.)

121 3 Communication Skills 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.)

122 3 Communication Skills 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.)

123 3 Communication Skills 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.)

124 3 Communication Skills 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.)

125 3 Communication Skills 17. When using the computer at work, a nursing assistant should: (A) Access personal 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.)

126 3 Communication Skills 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.)

127 3 Communication Skills 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.)

128 3 Communication Skills 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.)

129 3 Communication Skills 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.)

130 3 Communication Skills 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.)

131 3 Communication Skills 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.)

132 3 Communication Skills 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.)

133 3 Communication Skills 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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