Term | Definition |
Occupied Bed | Making bed with pt in it. |
Unoccupied Bed | Making bed without pt in it. |
Bed Cradle | Metal frame placed between bottom and top sheets to hold blankets off pt's feet. |
Foot Board | Padded board placed at the end of the bed to keep feet aligned in a ninety degree position. |
Pressure Relief Mattress | Mattress used to decrease potential for pressure sores/ulcers. |
Closed Bed | Bed with top blanket or cover pulled over the pillow. Bed is "made". |
Open Bed | Covers are fan-folded to end of bed so pt can get into it easier. Used more often in hospitals. |
Surgical Bed | Covers are fan-folded to the side away from the door. |
Mitered Corner | Method of folding & tucking bottom edge of sheets/blankets to secure them onto bed. |
Over bed Table | Table which is able to go over the bed or chair and may be raised or lowered. |
Call Light | Method of allowing pt to signal that assistance is required, usually by pushing a call light. |
Absorbent Pads | Pads placed on bed over the bottom sheet to absorb liquids, such as urine. May also be used as a draw sheet. |
Admission Process | Procedure for welcoming a new pt and completing documentation according to your job description. |
Discharge Process | Procedure for assisting to pack up pt's belongings prior to leaving. |
Transferring Patient | Procedure for assisting to be taken home or to another healthcare facility. |
Admission Inventory | Listing all items pt brings with them during their admission to the facility. |
AMA | Pt leaves medical facility without Doctors permission or "against medical advice". |
Medical Record | Legal document or pt chart containing health information and actions of healthcare staff. |
Care Plan/Plan of Care | Contains goals for the pt and steps on how to achieve those goals. Defines care to be provided. |
Kardex | Condensed or mini-care plan. Details day to day care and pt's ability to perform ADL's. |
ADL | Activity of Daily Living.
Things one does each day to care for self, such as brushing teeth, using cup, dressing, etc. |
Comprehensive Assessment | Document which contains all information needed about pt, including medical/surgical history, next of kin, funeral desired, etc. |
Care Conference | Meeting with all persons caring for pt including family. Purpose is to review and revise care plan. |
Aphasia | Inability to understand communication. Expressive is the inability to speak. Receptive is inability to talk. |
Charge Nurse | RN or LPN supervising the rest of the staff. This is a person all problems are reported to. |
Report | Giving information about your pt's to the oncoming shift of care givers. |
Cueing | Assisting a pt to complete an ADL by refocusing. |
Subjective | Information that only the pt can tell you from his/her point of view.
example: pain |
Objective | Information gathered by yourself using one of your five senses. |
Verbal Communication | Words, sounds (either spoken or written) used to send a message. |
Non-Verbal Communication | Information given through body language, gestures, facial expressions & tone of voice. |
Confidentiality | Keeping information about the pt to yourself. |
Culture | System of beliefs, values, tradition & behaviors a pt learned from people they grow up with. |
Charting Mistake | Error in charting. Correct by drawing a line through item and initial. Do NOT white-out. |
Graphic Sheet | Table used for documenting information, such as vital signs or intake/output. |
MAR | Record of medications given by nurse. |
Telephone Etiquette | Anwsering the phone with a smile & pleasant voice by the third ring. Identify yourself by name & title. |