This document defines important medical terminology used in communication, including prefixes, roots, and suffixes. It explains that medical terms are made up of word parts including roots, which provide the basic meaning, prefixes which come before the root, and suffixes which are added to the end. Examples of each part are provided, as well as how they are combined to form medical terms. The document also lists common medical prefixes, roots, and suffixes and their meanings to help understand terminology.

1. 3Communication Skills

2. CommunicationSkills
3
1. Define the important words in this chapter
active listening
a way of communicating that involves giving a person one’s full attention while he
is speaking and encouraging him to give information and clarify ideas.
adverse event
an unexpected event that causes serious injury or death; also called sentinel event.
barrier
a block or an obstacle.
body language
all of the conscious or unconscious messages a person’s body sends as she
communicates; facial expressions, gestures, and posture are examples.
care conference
a meeting to share and gather information about a resident in order to develop a
care plan.
2

3. CommunicationSkills
3
1. Define the important words in this chapter
care plan
a plan for each resident created by a registered nurse that outlines the tasks
that team members must perform to help the resident reach her goals of
care.
charting
the act of noting care and observations; documenting.
code
in health care, an emergent medical situation in which specially trained
responders provide the necessary care.
3

4. CommunicationSkills
3
1. Define the important words in this chapter
code status
formal documentation of the type and scope of care that should be provided
to a particular resident 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
nursing assistant, critical thinking means making careful observations and
promptly reporting all potential problems.
culture
a set of learned beliefs, values, traditions, and behaviors shared by a social or
ethnic group.
4

5. CommunicationSkills
3
1. Define the 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
called an occurrence, accident, accident/incident or event report.
medical chart
legal record of all medical care a patient, resident, or client receives.
5

6. CommunicationSkills
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1. Define the 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 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.
6

7. CommunicationSkills
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1. Define the 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 that comes before the root to help form a new term.
prioritize
to place things in order of importance.
7

8. CommunicationSkills
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1. Define the important words in this chapter
root
the main part of a word that contains its basic meaning or definition.
rounds
scheduled visits to each resident’s room to assess the resident’s condition and
needs and
to discuss the care plan with participating staff.
sentinel event
an unexpected event that causes serious injury or death; also called adverse
event.
subjective information
information collected from residents, their family members, and their
friends; information may not be true, but is what the person reported; also
called symptoms.
8

9. CommunicationSkills
3
1. Define the important words in this chapter
suffix
a word part added to the end of a root or a prefix to create a new word.
verbal communication
communication involving the use of spoken or written words or sounds; also
called oral communication.
vital signs
measurements—temperature, pulse, respirations, and blood pressure —that
monitor the functioning of the vital organs of the body.
9

10. CommunicationSkills
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2. Explain types of communication
Define the following terms:
verbal communication
communication involving the use of spoken or written words or sounds; also
called oral communication.
nonverbal communication
communication without using words, such as through gestures and facial
expressions.
10

11. CommunicationSkills
3
2. Explain types of communication
Define the following terms:
body language
all of the conscious or unconscious messages a person’s body sends as she
communicates; facial expressions, gestures, and posture are examples.
active listening
a way of communicating that involves giving a person one’s full attention
while he is speaking and encouraging him to give information and clarify
ideas.
11

12. CommunicationSkills
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2. Explain types of communication
REMEMBER:
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

13. CommunicationSkills
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Key Material 3-1: Communication Process
13

14. CommunicationSkills
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2. Explain types of communication
REMBEMBER:
How the voice sounds when someone speaks is as important as the words he uses.
14

15. CommunicationSkills
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2. Explain types of communication
Critical Thinking: Conversation Starter
How do you feel when a teacher or supervisor sounds irritated when answering a question you
have asked?
How might a resident feel when a nursing assistant sounds irritated when providing care?
15

16. CommunicationSkills
3
2. Explain types of communication
REMEMBER:
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

17. CommunicationSkills
3
Key Material 3-2: Body Language
17

18. CommunicationSkills
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2. Explain types of communication
Body language can be positive or negative.
Examples of positive nonverbal communication include the following:
• Smiling in a friendly manner
• Leaning forward to listen
• Nodding while a person is speaking
• With permission, putting your hand over a resident’s hand
18

19. CommunicationSkills
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2. Explain types of communication
Examples of negative nonverbal communication include the following:
• Rolling eyes
• Crossing arms in front of the body
• Tapping feet
• Pointing at someone while speaking
19

20. CommunicationSkills
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2. Explain types of communication
Critical Thinking: Conversation Starter
Can you think of other examples of either positive or negative nonverbal communication?
20

21. CommunicationSkills
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2. Explain types of communication
Remember these guidelines for proper communication:
• Use appropriate words.
• Be aware of your body language.
• Use a friendly and professional tone of voice.
• Wait for responses and let pauses happen.
• Practice active listening.
• Use mostly facts when communicating.
21

22. CommunicationSkills
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2. Explain types of communication
Critical Thinking: Conversation Starter
How might you use verbal or nonverbal communication to reach a specific goal?
22

23. CommunicationSkills
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3. Explain barriers to communication
Define the following term:
barrier
a block or an obstacle.
23

24. CommunicationSkills
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3. Explain barriers to communication
REMEMBER:
Nursing assistants often encounter various barriers to communication with residents.
It is important to be aware of these barriers and to know ways to avoid them.
24

25. CommunicationSkills
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Key Material: Barriers to Communication
25

26. CommunicationSkills
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3. Explain barriers to communication
Barriers to communication include the following:
• Resident does not hear, does not hear correctly, or does not understand.
• Resident is difficult to understand.
• NA, resident, or others use words that are not understood.
• NA uses slang or profanity.
• NA uses clichés.
26

27. CommunicationSkills
3
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

28. CommunicationSkills
3
3. Explain barriers to communication
Critical Thinking: Conversation Starter
Imagine a day – or a lifetime – without communication. How would that feel?
Can you think of a situation in which you wasted time and effort because of miscommunication?
Could it have been avoided?
Can you think of a situation in which effective communication resulted in a positive outcome?
28

29. CommunicationSkills
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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 or
ethnic group.
29

30. CommunicationSkills
3
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 regarding a person’s comfort level with touch.
30

31. CommunicationSkills
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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 asked
31

32. CommunicationSkills
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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
• Inappropriately touching or rubbing against a resident or staff member
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33. CommunicationSkills
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4. List ways that cultures impact communication
Critical Thinking: Conversation Starter
Can you think of other examples of acceptable and unacceptable touch?
33

34. CommunicationSkills
3
4. List ways that cultures impact communication
Critical Thinking: Conversation Starter
How does your culture influence your communication and use of touch?
Can you think of any other cultural considerations which could be useful when working with
residents from different cultures than your own?
34

35. CommunicationSkills
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5. Identify the people a nursing assistant communicates with in a facility
There are many different people a nursing assistant communicates with on the job. This is
another reason why understanding communication and communicating clearly are so
important.
Remember that a nursing assistant communicates with the following while on the job:
• Doctors, nurses, supervisors, and other staff members
• Other departments
• Residents
• Families and visitors
• The community
35

36. CommunicationSkills
3
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 contains its basic meaning or definition.
prefix
a word part that comes before the root to help form a new term.
suffix
a word part added to the end of a root or a prefix to create a new word.
36

37. CommunicationSkills
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6. Understand basic medical terminology and abbreviations
In order to communicate well with other members of the care team, nursing assistants need to
learn medical language. NAs use medical terms for specific conditions.
Medical terms are made up of these word parts:
• Roots
• Prefixes
• Suffixes
37

38. CommunicationSkills
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6. Understand basic medical terminology and abbreviations
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.
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39. CommunicationSkills
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6. Understand basic medical terminology and abbreviations
A suffix is found at the end of a 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.
39

40. CommunicationSkills
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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 40
Handout 3-1: Prefixes, Roots, and Suffixes

41. CommunicationSkills
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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
41
Handout 3-1: Prefixes, Roots, and Suffixes

42. CommunicationSkills
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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
42
Handout 3-1: Prefixes, Roots, and Suffixes

43. CommunicationSkills
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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 43
Handout 3-1: Prefixes, Roots, and Suffixes

44. CommunicationSkills
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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
44
Handout 3-1: Prefixes, Roots, and Suffixes

45. CommunicationSkills
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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
45
Handout 3-1: Prefixes, Roots, and Suffixes

46. CommunicationSkills
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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
46
Handout 3-1: Prefixes, Roots, and Suffixes

47. CommunicationSkills
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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/pnea: 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
47
Handout 3-1: Prefixes, Roots, and Suffixes

48. CommunicationSkills
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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
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Handout 3-1: Prefixes, Roots, and Suffixes

49. CommunicationSkills
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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
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Handout 3-1: Prefixes, Roots, and Suffixes

50. CommunicationSkills
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-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
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Handout 3-1: Prefixes, Roots, and Suffixes

51. CommunicationSkills
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-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
51
Handout 3-1: Prefixes, Roots, and Suffixes

52. CommunicationSkills
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6. Understand basic medical terminology and abbreviations
REMEMBER:
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.
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53. CommunicationSkills
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a before
AAROM active-assistive range of motion
abd abdomen
ABR absolute bedrest
ac, a.c. before meals
AD Alzheimer’s disease
ADC AIDS dementia complex
ad lib as desired
adm. admission
ADLs activities of daily living
AED automated external defibrillator
AHA American Heart Association
AIDS acquired immune deficiency
syndrome
AIIR airborne infection isolation room
AKA above-knee amputation, also
known as
53
Handout 3-2: Abbreviations
am, AM morning
AMA against medical advice, American Medical
Association
amb ambulate, ambulatory
AMD age-related macular
degeneration
amt. amount
ANS autonomic nervous system
ant. anterior
a.p./AP apical pulse
approx. approximately
AROM active range of motion
ASAP as soon as possible
assist assistance
as tol as tolerated
A, T, D admission, transfer, and discharge
ax axillary
BID,
b.i.d. two times a day

54. CommunicationSkills
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BKA below-knee amputation
bld blood
BLS basic life support
BM bowel movement
BP, B/P blood pressure
BPH benign prostatic hypertrophy
BPM beats per minute
BR bedrest
BRP bathroom privileges
BSC bedside commode
BSE breast self examination
C centigrade, Celsius
c with
Ca/CA calcium, cancer, carcinoma
CAD coronary artery disease
cal calorie
cath. catheter
CBC complete blood count
CBI continuous bladder irrigation
54
Handout 3-2: Abbreviations CBR complete bedrest
CCMS clean-catch midstream
CDC Centers for Disease Control and
Prevention
CDE certified diabetes educator
C. diff clostridium difficile
CEP competency evaluation (testing) programs
CEU continuing education unit
CHD coronary heart disease
CHF congestive heart failure
chol cholesterol
ck check
cl liq clear liquid
cm centimeter
CMS Centers for Medicare and Medicaid
Services
CNA certified nursing assistant
CNP certified nurse practitioner

55. CommunicationSkills
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CNS central nervous system
c/o complains of, in care of
CO2 carbon dioxide
COLD chronic obstructive lung
disease
COPD chronic obstructive pulmonary
disease
CP cerebral palsy
CPM continuous passive motion
CPR cardiopulmonary resuscitation
CRF chronic renal failure
C.S. Central Supply
CSF cerebrospinal fluid
CVA cerebrovascular accident,
stroke
CVP central venous pressure
CVS cardiovascular system
CXR chest x-ray
DAT diet as tolerated
DJD degenerative joint disease
55
Handout 3-2: Abbreviations
DKA diabetic ketoacidosis
DM diabetes mellitus
DNR do not resuscitate
DO doctor of osteopathy
DOA dead on arrival
DOB date of birth
DON director of nursing
Dr. doctor
DRG diagnostic related group
drsg dressing
DVT deep vein thrombosis
Dx/dx diagnosis
ECG/EKG electrocardiogram
ED emergency department
EENT eye, ear, nose and throat
e.g. for example
EMS emergency medical services
ER emergency room
ESRD end-stage renal disease

56. CommunicationSkills
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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
F/U, f/u follow-up
FUO fever of unknown origin
FWB full weight-bearing
fx fracture
FYI for your information
GAD generalized anxiety disorder
gal gallon 56
Handout 3-2: Abbreviations
GB gallbladder
GERD gastroesophageal reflux disease
geri chair geriatric 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
H20 water
H202 hydrogen peroxide
H/A headache
HAART highly active anti-retroviral therapy
H&P history and physical
HAV hepatitis A virus
HBV hepatitis B virus

57. CommunicationSkills
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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
HMO health maintenance organization
HOB head of bed
HOH hard of hearing
HPV human papillomavirus
HS/hs hours of sleep
ht height
HTN hypertension
H.U.C. Health Unit Coordinator
Hx history
57
Handout 3-2: Abbreviations
hyper above normal, too fast, rapid
hypo low, less than normal
I&D incision and drainage
I&O intake and output
IBD irritable bowel disease
IBS irritable bowel syndrome
ICU intensive care unit
ID identification
i.e. that is
IICU intermediate intensive care unit
IM intramuscular
in inch
inc incontinent
inf inferior
IQ intelligence quotient
Irr/irrig irrigation
isol isolation
I.V., IV intravenous
K potassium

58. CommunicationSkills
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kg kilogram
KS Kaposi’s sarcoma
l, L liter
L, lt left
lab laboratory
lb pound
LBP low back pain
LE lower extremity
lg large
liq liquid
LLE left lower extremity
LLQ left lower quadrant
LOC level of consciousness, level
of care
Low-cal low-calorie
Low-fat/ low-fat, low-calorie
Low-cal
Low-Na low-sodium
LPN Licensed Practical Nurse 58
Handout 3-2: Abbreviations
LTC long-term care
LTCF long-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
mg milligram
MI myocardial infarction
min minute
mL milliliter
mm millimeter
mm Hg millimeters of mercury
MO microorganism
mod moderate

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MRI magnetic resonance imaging
MRSA methicillin-resistant
staphylococcus aureus
MS multiple sclerosis
MSDs musculoskeletal disorders
MSDS material safety data sheet
MSW medical social worker
MUFA monounsaturated fat
MVA motor vehicle accident
Na sodium
N/A not applicable
NA nursing assistant
NaCl sodium chloride
NAS no added salt
NATCEP Nurse Aide Training and
Competency Evaluation
Program
N/C no complaints, no call 59
Handout 3-2: Abbreviations NCS no concentrated sweets
neg negative
NF nursing facility
NG, ng nasogastric
NIBP non-invasive blood pressure
monitoring
NKA no known allergies
NKDA no known drug allergies
no number
noc night
NPO nothing by mouth
NVD nausea, vomiting, and diarrhea
NWB non-weight-bearing
O2 oxygen
O&P ova and parasites
OB obstetrics
ob/gyn obstetrics and gynecology
OBRA Omnibus Budget Reconciliation Act
occ occasionally

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NF nursing facility
NG, ng nasogastric
NIBP non-invasive blood pressure
monitoring
NKA no known allergies
NKDA no known drug allergies
no number
noc night
NPO nothing by mouth
NVD nausea, vomiting, and diarrhea
NWB non-weight-bearing
O2 oxygen
O&P ova and parasites
OB obstetrics
ob/gyn obstetrics and gynecology
OBRA Omnibus Budget Reconciliation
Act
occ occasionally
60
Handout 3-2: Abbreviations p after
P.A. physician’s assistant
PAD peripheral artery disease
pc, p.c. after meals
PCA patient-controlled anesthesia
PDR Physician’s Desk Reference
PE pulmonary embolism
Peds/ pediatrics
peds
PEG percutaneous endoscopic
gastrostomy
peri care perineal care
per os by mouth
PET positron emission tomography
pH parts hydrogen
PH past history
PHI protected health
information
phy. ex. physical exam

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PID pelvic inflammatory disease
PM/pm afternoon
PMH past medical history
PNS peripheral nervous system
PO (per os) by mouth
pos. positive
post op after surgery
PPD purified protein derivative (test for
tuberculosis)
PPE personal protective equipment
pre op before surgery
prep preparation
p.r.n./ when necessary
prn
prog. progress
PROM passive range of motion
Pt/pt patient
pt. pint
PT physical therapist, physical therapy
PTH parathyroid hormone
PTSD post-traumatic stress disorder 61
Handout 3-2: Abbreviations PUFA polyunsaturated fat
PVD peripheral vascular disease
PWB partial weight-bearing
q every
q2h, every two hours, every three
q3h, hours, every four hours
q4h
QA quality assurance
qam every morning
Q&A questions and answers
qd every day
qh, qhr every hour
qhs every night at bedtime
q.o.d. every other day
qt.quart
quad quadrant, quadriplegic
R respirations, rectal
R, rt. right

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RA rheumatoid arthritis
RBC red blood cell
RDT registered dietician
reg. regular
rehab rehabilitation
REM rapid eye movement
req. requisition
res. resident
resp. respiration
RF restrict fluids
RLE right lower extremity
RLQ right lower quadrant
RN registered nurse
RNA restorative nursing assistant
R/O rule out
ROM range of motion
RR respiratory rate
RT respiratory therapy/therapist 62
Handout 3-2: Abbreviations
RUE right upper extremity
RUQ right upper quadrant
Rx prescription, treatment
s without
S&A sugar and acetone
S&S, signs and symptoms
S/S
s.c. subcutaneously
SCA sudden cardiac arrest
SCDs sequential compression devices
SIDS sudden infant death syndrome
sl sublingually
SLE systemic lupus erythematosis
SLP speech-language pathologist
sm. small
SNAFU situation normal, all fouled up (slang)
SNF skilled nursing facility
SNS somatic nervous system

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SOB shortness of breath
SP Standard Precautions
S.P.D. Supply, Processing and
Distribution
spec. Specimen
ss one-half
SSE soapsuds enema
ST. standard, speech therapy
staph staphylococcus
STAT/stat immediately
Std prec Standard Precautions
STDs sexually-transmitted diseases
STIs sexually-transmitted infections
strep streptococcus
supp. suppository
surg. Surgery
T., temp temperature
TB tuberculosis 63
Handout 3-2: Abbreviations
tbsp. tablespoon
T,C, DB turn, cough, and deep breathe
THR total hip replacement
TIA transient ischemic attack
t.i.d., tid three times a day
TKR total knee replacement
TLC tender loving care
TPN total parenteral nutrition
T.P.R. temperature, pulse, and
respiration
trach. tracheostomy
tsp. teaspoon
TWE tap water enema
Tx/tx traction, treatment
U/A, u/a urinalysis
UE upper extremity
UGI upper gastrointestinal
UNK,unk unknown

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URI upper respiratory infection
US ultrasound
USDA United States Department of
Agriculture
UTI urinary tract infection
vag. vaginal
VAP ventilator-acquired pneumonia
VD venereal disease
VRE vancomycin-resistant
enterococcus
VS, vs vital signs
W/A,WA while awake
WBC white blood cell/count
w/c wheelchair
WNL within normal limits
wt. weight
yr. year 64
Handout 3-2: Abbreviations

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6. Understand basic medical terminology and abbreviations
Critical Thinking: Conversation Starter
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?
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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 p.m. to military time, add 12 to the
regular time.
• To change from military time to regular time, subtract 12.
• Minutes and seconds do not change.
• Midnight may be written as 0000 or 2400; follow facility policy.
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Key Material 3-4: 24-hour Clock
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8. Describe a standard resident chart
Define the following terms:
medical chart
legal record of all medical care a patient, resident, or client receives.
charting
the act of noting care and observations; documenting.
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8. Describe a standard resident chart
REMEMBER:
A nursing assistant’s responsibility with a resident’s medical chart is to gather information and
report it to the nurse. NAs write down their observations and record the care they give. This is
called charting.
Some facilities allow nursing assistants to chart in a medical record. Others limit nursing
assistants’ charting to certain forms.
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8. Describe a standard resident chart
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.
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8. Describe a standard resident chart
Information found on a resident’s chart includes the following:
• 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
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8. Describe a standard resident chart
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
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8. Describe a standard resident chart
REMEMBER:
All information in a resident’s chart is confidential.
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9. Explain guidelines for documentation
REMEMBER:
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.
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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 when documenting by hand.
• Sign each note you make.
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9. Explain guidelines for documentation
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.
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10. Describe the use of computers in documentation
Some care require that computers be used 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 e-mail 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.
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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.
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11. Explain the Minimum Data Set (MDS)
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
• Must be reviewed every 3 months
• New MDS is completed when there is any major change in resident’s
condition
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11. Explain the Minimum Data Set (MDS)
REMEMBER:
Nursing assistants’ reports on changes in the condition of residents in their care are very
valuable. These reports may trigger needed assessments.
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12. Describe how to observe and report accurately
Define the following terms:
care plan
a plan for each resident created by a registered nurse that outlines the tasks
that team members must perform to help the resident reach her goals of
care.
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 their
friends; information may not be true, but is what the person reported; also
called symptoms.
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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, and blood pressure—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 careful observations and
promptly reporting all potential problems.
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12. Describe how to observe and report accurately
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.
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12. Describe how to observe and report accurately
Critical Thinking: Conversation Starter
What could happen if a nursing assistant reported incorrect or inaccurate information about a
resident?
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Key Material 3-6: Using Your Senses
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12. Describe how to observe and report accurately
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.
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12. Describe how to observe and report accurately
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.
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12. Describe how to observe and report accurately
REMEMBER:
Critical thinking for nursing assistants involves making careful observations, evaluating resident
information, and immediately reporting all potential problems.
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12. Describe how to observe and report accurately
Remember that these signs and symptoms should be reported right away:
• Falls
• Wheezing
• Difficulty breathing
• Chest pain and pressure
• Pain in calf of leg
• Blurred vision
• Slurred speech
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12. Describe how to observe and report accurately
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
• Severe headache
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Handout 3-4: 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.
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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.
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13. Explain the nursing process
The nursing process has five steps:
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
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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 a resident in order to
develop a care plan.
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14. Discuss the nursing assistant’s role in care planning and at care conferences
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, NAs should not be afraid to share their observations. If an NA is
unsure about what information to share, he should talk to the nurse before the meeting.
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14. Discuss the nursing assistant’s role in care planning and at care conferences
REMEMBER:
HIPAA privacy guidelines apply to care plans. Team members should not share a resident’s
information with anyone not directly involved with the resident’s care.
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15. Describe incident reporting and recording
Define the following terms:
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
called an occurrence, accident, accident/incident or event report.
sentinel event
an unexpected event that causes serious injury or death; also called adverse
event.
adverse event
an unexpected event that causes serious injury or death; also called sentinel
event.
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15. Describe incident reporting and recording
Incident reports are vital to the safety of the staff and residents.
The following are events in the facility that are considered incidents:
• An accident or problem during the course of care
• An error in care
• A fall or injury to a resident or staff member
• An accusation against staff members
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15. Describe incident reporting and recording
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.
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15. Describe incident reporting and recording
When completing an incident report, the NA should
• Include exactly what she saw
• State the time and the mental and physical condition of the person
• Describe the person’s reaction to the incident
• State the facts; the NA should not give her opinion
• Not include “Incident report filed” in the resident’s medical record
• Not make any photocopies of the incident report
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16. Explain proper telephone etiquette
REMEMBER:
When nursing assistants use the telephone during their shift, they are representing their facility
to the community. Following the rules for proper telephone etiquette is important.
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16. Explain proper telephone etiquette
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.”
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16. Explain proper telephone etiquette
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 personal phone calls and cell phone use.
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16. Explain proper telephone etiquette
Critical Thinking: Conversation Starter
What could happen if an NA gave out confidential information about residents or staff over the
phone?
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17. Describe the resident call system
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.
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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 an NA leaves the room.
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18. Describe the nursing assistant’s role in change-of-shift reports and rounds
Define the following term:
rounds
scheduled visits to each resident’s room to assess the resident’s condition and
needs and to discuss the care plan with participating staff.
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18. Describe the nursing assistant’s role in change-of-shift reports and rounds
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.
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18. Describe the nursing assistant’s role in change-of-shift reports and rounds
REMEMBER:
The nursing assistant’s role in end-of-shift reports is to report information gathered about
residents during the shift so that the staff members on the next shift can provide good care.
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19. List the information found on an assignment sheet
Define the following terms:
code status
formal documentation of the type and scope of care that should be provided
to a particular resident in the event of a cardiac arrest, other catastrophic
organ failure, or terminal illness.
code
in health care, an emergent medical situation in which specially trained
responders provide the necessary care.
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19. List the information found on an assignment sheet
An assignment sheet lists residents and all of the tasks that must be done for them.
The following information is typically found on an assignment sheet:
• Residents’ names and room numbers
• Medical diagnosis
• Code status
• Activity level
• Range of motion (ROM) exercises
• Bathing information
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19. List the information found on an assignment sheet
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
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20. Discuss how to organize work and manage time
Define the following term:
prioritize
to place things in order of importance.
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20. Discuss how to organize work and manage time
Remember these tips for organization and time management:
• Plan ahead.
• Prioritize.
• Make a schedule.
• Combine activities.
• Get help when needed.
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20. Discuss how to organize work and manage time
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.
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20. Discuss how to organize work and manage time
Critical Thinking: Conversation Starter
How strong are your organization and time management skills?
In what ways can you improve them?
Do you have any additional ideas for being more organized?
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