Every individual you will take care of will be unique, and each will have his or her own set of needs. A resident with heart or kidney problems might be restricted as to how much water he or she is to drink, and you would not put a carafe full of water at that resident’s bedside. You will need to measure the fluids some residents take in and lose. For others fluids might not be a problem, but they might need extra skin care. Paying close attention to change of shift report and to assignments given throughout the day will ensure that you complete all assignments competently.
If you are unsure about a procedure you have not done before, or you do not understand what you have been told, or if you are dealing with a new kind of equipment, ask your supervisor. There are no stupid questions; only stupid mistakes.
Healthcare professions are very big on abbreviations, because you must accomplish a great deal in a restricted amount of time. At first the abbreviations can seem confusing, because you are learning a new language. Once you have learned this new professional language, you will find that it saves you time. Here are some abbreviations which you will find useful:
A—Before. (Written with horizontal line over the letter).
ADA—American Dietetic Association. You might see this on a resident’s tray. It usually refers to the diet recommended for diabetics, the ADA diet.
BID—Twice per day.
BP or B/P—Blood pressure. It is measured along with temperature, pulse and respirations, which are collectively referred to as vital signs.
C—With. (Written with horizontal line over the top).
CA—Cancer. This covers a wide range of diseases, which must be specified as to type and anatomic region.
CABG—Coronary artery bypass graft, pronounced “cabbage”. The resident with CABG has had veins from his or her legs placed into the heart.
CXR—Chest xray.
DC—Discontinue. When an order is no longer needed it is DC’d, as a wheelchair that is DC’d when the patient graduates to a walker.
I’s and O’s—Intakes and Outputs. This means that you will measure and record all the fluids the resident drinks and all the urine he or she produces. It is used for residents with fluid imbalances, such as those with kidney or heart problems.
IV—Intravenous infusion. A resident who needs fluids and medications added directly to his or her bloodstream, or if the doctor thinks intravenous drugs might be needed in an emergency, tubes will be placed with a needle into a vein.
LVN—Licensed Vocational Nurse. LVN’s often serve as team leaders, handle medications and insert catheters. Some LVN’s take care of IV’s.
MI—Myocardial infarction. The resident with an MI has had a heart attack.
NPO—Nothing by mouth. If your resident is going to have certain blood tests or xray procedures in the morning, he or she might have to be NPO after dinner or NPO after midnight.
P—After. (Written with horizontal line over the top).
PE—Pulmonary embolus. The resident with a PE has a blood clot in his or her lung.
QD—Once per day. Warning: can easily be confused with QID in written records.
QID—Four times per day. Warning: can easily be confused with QD in written records.
RN—Registered Nurse. In nursing homes, usually the charge nurse or Director of Nurses is an RN. RN’s often handle medications and IV’s and insert catheters.
SNF—Skilled nursing facility. It can also be called a nursing home, rehabilitation hospital, or long-term care facility.
TID—Three times per day.
TPR—Temperature, pulse and respirations. Along with blood pressure, referred to as vital signs.
This is a collaborative effort and is thus a work in progress. This chapter and others in this study guide are constantly being changed and improved/added to.
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