California CNA key terms

Measurements of the body's basic functions: temperature, pulse, respirations, blood pressure, and often pain level or oxygen saturation. The CNA measures and records them and reports any value outside the resident's usual range.

A record of how much fluid a resident takes in by mouth, feeding tube, or IV and how much leaves the body as urine, vomit, or drainage. Careful measuring helps the care team spot dehydration or fluid overload.

Moving a joint through its normal directions of movement to keep muscles and joints flexible. Active ROM is done by the resident alone; passive ROM is done by the CNA when the resident cannot move the joint.

Damage to skin and underlying tissue caused by unrelieved pressure, usually over bony areas such as the sacrum, hips, or heels. Prevention includes turning and repositioning, keeping skin clean and dry, and good nutrition.

A semi-sitting position with the head of the bed raised about 45 to 60 degrees and the knees slightly bent. It makes breathing and eating easier and reduces pressure on the back.

Everyday self-care tasks such as bathing, dressing, grooming, eating, toileting, and moving from place to place. CNAs assist with ADLs while encouraging each resident to do as much as possible independently.

Cleaning the genital and anal area, always wiping from front to back, to remove urine, stool, and odor and to help prevent infection. It is given during bathing and after toileting or incontinence care.

A bath given in bed to a resident who cannot bathe independently. The CNA washes the whole body in a planned order, changes the water as needed, dries the skin well, and checks for redness or breaks.

Cleaning the mouth, teeth, gums, and dentures to remove food and plaque, keep the mouth comfortable, and prevent infection. Dependent residents need it at least twice daily and after meals.

The condition of skin that is intact and healthy. CNAs protect it by keeping skin clean, dry, and moisturized, avoiding friction and shearing, and reporting redness or open areas right away.

Freedoms protected by federal and state law, including dignity, privacy, choice, keeping personal possessions, having visitors, and being free from abuse. Staff must honor these rights and help residents exercise them.

A resident's voluntary agreement to care or treatment after being told its purpose, risks, benefits, and alternatives. Consent must be given freely, and the resident may withdraw it at any time.

A resident's legal right to say no to any treatment, medication, food, or care task, even when staff believe it is needed. The refusal is respected, documented, and reported to the nurse.

Deliberate acts that harm a resident, such as hitting, yelling or threatening, unwanted sexual contact, stealing money, or forcing care. Any suspected abuse must be stopped and reported immediately.

A legal duty of CNAs and other caregivers to report suspected abuse, neglect, or exploitation right away to the nurse in charge and to the proper outside agency. Failing to report can lead to penalties.

Any device or medication that limits a resident's freedom of movement and is not a usual part of treatment. Restraints need a doctor's order, must be the least restrictive option, and are used only to keep someone safe.

Steps taken to lower the chance of falling, such as keeping the call light within reach, wiping spills at once, using non-skid footwear, keeping the bed low, and answering requests quickly.

The device a resident uses to signal staff for help. CNAs keep it within reach, answer it promptly, and never leave a resident who cannot move safely without it nearby.

A fire response sequence: Rescue anyone in danger, Alarm (pull the alarm and call), Contain the fire by closing doors, then Evacuate or Extinguish if it is safe. It reminds staff of the order of actions during a fire.

Measures that keep a resident safe during a seizure: clear the area, lower the bed, loosen tight clothing, protect the head, and stay with the person. Never hold the person down or put anything in the mouth.

A factual written record of an unexpected event such as a fall, injury, or medication error, describing what happened and who was notified. It is used to improve safety and is not part of the resident's care record.

Basic infection-control practices used with every resident: hand hygiene, gloves, gowns, masks, and eye protection when splashing is likely, plus careful handling of sharps, linens, and body fluids.

Cleaning the hands with soap and water or an alcohol-based rub. It is the single most effective way to prevent the spread of infection and is done before and after every resident contact.

Gloves, gowns, masks, goggles, and face shields worn to protect the CNA from blood and body fluids and to stop germs from passing to residents. It is removed carefully and disposed of properly.

Extra precautions used for certain infections that spread by contact (touching), droplet (spray from coughing or sneezing), or airborne (tiny floating particles). They are used along with standard precautions and stop when the infection is no longer contagious.

The series of steps a germ needs in order to spread: a germ, a place to live, a way out, a way to travel, a way in, and a person who can get sick. Breaking any one link stops infection.

Difficulty swallowing. Signs include coughing or choking during meals, drooling, a wet or gurgling voice, or food staying in the mouth. CNAs report these signs and follow the prescribed safe-eating plan.

Breathing food, liquid, saliva, or vomit into the lungs instead of swallowing it. It can cause choking and pneumonia. Prevention includes sitting upright, offering small bites, and going slowly when feeding.

A doctor's order meaning nothing by mouth, so no food or fluids are given. The CNA keeps the resident's mouth comfortable with oral care and reports thirst or hunger to the nurse.

Drinks with a thickening product added so they move more slowly and are easier to swallow safely for a resident with dysphagia. The prescribed consistency must be followed exactly at every meal and snack.

Too little fluid in the body, causing thirst, dark urine, dry mouth, confusion, and weakness. CNAs offer fluids as allowed, track intake, and report these signs to the nurse promptly.

A lasting decline in memory and thinking that interferes with daily life, often caused by Alzheimer's disease. Residents may repeat questions, forget familiar people, or get lost. Calm, simple, consistent care helps.

A sudden change in attention and thinking, often with confusion, restlessness, or seeing things that are not there. Common causes are illness, new medication, pain, or dehydration. It is a medical emergency and must be reported at once.

A way of responding that accepts and acknowledges the feelings behind a confused person's words instead of correcting the facts. It lowers distress and helps the resident feel understood and safe.

Increased confusion, restlessness, or agitation that appears in the late afternoon or evening, common in dementia. Calm routines, less noise, good lighting, and limited late naps may reduce it.

Activities and exercises that help a resident regain or keep function lost through illness or disuse, such as walking, practicing dressing, or range of motion. It is done as ordered and builds independence.

Purposeful, respectful conversation that helps a resident express feelings and needs. It uses simple words, silence, and empathy, and avoids arguing, giving false reassurance, or changing the subject.

Giving full attention to a speaker, noticing body language and tone, and confirming understanding by nodding, asking brief questions, or repeating the message back in your own words.

A question that invites a full answer instead of a yes or no, often starting with 'tell me about' or 'how do you feel.' It helps the CNA learn more about a resident's concerns and preferences.

Basing care on each resident's preferences, routines, culture, and strengths rather than on staff convenience, and involving the resident in decisions about daily life and care.