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.
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.
Q. Why is it so important for nursing assistants to have a good understanding of some of the most common medical terms and medical abbreviations?
A. When you work as a nursing assistant, you will need to have a good understanding of some of the most frequently used medical terms and abbreviations so that you can receive your CNA assignments and so that you can safely and effectively carry out your duties.
Explanations: Many of the instructions you receive in written format-including in a patient’s chart, will include medical terms and abbreviations. If you do not know these terms, you will not be able to care for your patient. You could make a mistake that would cause harm to the patient if you misread instructions.
Q. What are the abbreviations for Once Per day, twice per day and Three times per day?
A. Once Per day: QD, Twice Per day: BID, Three times per day: TID
Explanation: These abbreviations can tell you things such as how many times per day a patient receives certain medications. The abbreviations can also be used to let you know how many times each day certain other tasks or duties must be carried out. As a nursing assistant, you are not likely to be giving out medication unless you have been specially trained and certified. For instance, some states have a training option for CNA’s to become certified medication aids.
Q: What should a certified nursing assistant do if they have any questions about their assignment with one or more patients in any given day?
A. If a CNA has any questions about their assignment, they should contact their supervisor. They should not attempt to “guess” about the portion of their instructions that they do not understand.
Explanation: When working as a certified nursing assistant, it is possible that you will have a question about your assignment every now and then. You should simply ask questions if you are not sure about something. If you cannot read someone’s handwriting with instructions, just ask for further explanation. If you have a new duty that you have not yet performed, do not be afraid to talk to your supervisor for assistance.
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.