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terminology

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