Nursing Matters

Nursing Terminology Therapeutic Communication Clinical Nursing Practice Special Considerations

Clinical

nursing abbreviation Clinical Terms Terms used in Medical Records

Patient-Nurse

Interaction Health care team-Nurse Interaction Nurse-Nurse Interaction Families/Related Person-Nurse Interaction
Applying

nursing procedures Dealing with telephone order Hand Over

Grieving Dealing

with Children Dealing with Elder Patients Dealing with psychiatric patients

Nursing Terminology
Alfrina Hany

AIMS
Nursing students are able to Recognise the clinical terms (disease,laboratory findings, diagnostic studies, treatments, pharmacologies) Identify the nursing terminologies that are common used in clinical settings Understand terms used in medical records

Understanding Terminology
Same comprehension Used worldwide

Do You Understand??
1. Mr.K, 50-year-old man complains of pain in his right lower extremity. Diagnosed c MI. the physicians orders codeins 60 mg IV and aspirin grains XPO every four hours. Lab findings: ESR 10mm/h; Hct 42%; CK 150 U/ml. plan: CXR, ECG

Do You Understand??
2. Mrs.N, age 24, hospitalised in the GYN clinics. CC off-white vaginal discharge and anemia. Mucous membrane pale, anemia, CBC result : Hb 6,5 mg/dL, Hct 110 . Plan: transfusion, IV line D/W 5%, USG

Do You Understand??
3. Ms. R, 15 years old, CC : anorexia, body image disturbance: fat. Tx: supervising TPN. Plan NG tube. Body temperature 101.3 F (38.5 C), water PO 200 cc, paracetamol PRN

Do You Understand??
4. Mrs. B, age 56, CKD stage 5, unconscious, plan RT, GFR 5%, NPO, diet Na, K, IV line RL

CLINICAL TERMS
ADH antidiruetic hormone (vasopressin) AED automated external defibrilator AF or Atrial fibrillation AIDS acquired immunodeficiency syndrome AIDS-KS acquired immunodeficiency syndrome with Kaposi's sarcoma ARDS adult respiratory distress syndrome ABG arterial blood gas ABO systems of classifying blood groups ACS acute coronary syndrome

CLINICAL TERMS
ASD atrial septal defect ALT alkaline phospatase (SGPT) AST aspartate aminotransferase (SGOT) AV atrial ventricular AIDS-KS acquired immunodeficiency syndrome with Kaposi's sarcoma ARDS adult respiratory distress syndrome AKA above knee amputation ALL acute lympocytic leukemia AMI acute myocardial infarct

CLINICAL TERMS
BCG bacille calmette guerin BKA below knee amputation BLS basic life support BMR basal metabolic rate BP blood pressure BPH benign prostatic hypertrophy BUN blood, urea, nitrogen

CLINICAL TERMS
Ca calcium CA cancer CABG coronary artery bypass graft CAD coronary artery disease CKD chronic kidney disease CAPD continuous ambulatory peritoneal dialysis CBC complete blood count CCU coronary care unit, critical care unit CK creatinine kinase COPD chronic obstructive pulmonary disease CP cerebral palsy CPK creatinine phospokinase CSF cerebrospinal fluid

CLINICAL TERMS
CT computerised tomography CTS carpal tunnel syndrome CVC central venous catheter CVP central venous pressure CXR chest x ray CBC complete blood count CVA cerebrovascular accident

CLINICAL TERMS
DIC disseminated intravascular coagulation DIFF differential blood count D&C dilation and curettage DKA diabetic ketoacidosis DNA deoxyribonucleic acid DM diabetes mellitus DPT diphteria, pertussis, tetanus Dr. doctor DVT deep vein thrombosis

CLINICAL TERMS
ECG or EKG electrocardiography ECT electroconvulsive therapy ED emergency department EEG electroencephalogram EMG electromyography ESR erythtocyte sedimentation rate ENT ear nose throats ETT endotracheal tube ESRD end stage renal disease ESKD end stage kidney disease

CLINICAL TERMS
FBD fibrocystic breast disease FBS fasting blood sugar

CLINICAL TERMS
GI gastrointestinal GB gall bladder GFR glomerular filtration rate GH growth hormone GCS glasgow coma scale GU genitourinary GYN gynecology

CLINICAL TERMS
Hb or Hgb hemoglobin HCO3- bicarbonate Hct hematocrit HD hemodialysis HDL high density lipo proteins Hg mercury HHNC hypergycemia hyperosmolar nonketotic coma HLA human leucocyte antigen HR heart rate HSV herpes simplex virus HTN hypertension H2O water

CLINICAL TERMS
ICF intracellular fluid ICP increased intracranial pressure ICS intercostal space ICU intensive care unit IDDM insulin dependent diabetes mellitus IVP intravenous pyelogram IUD intra uterine device IOP intraocular pressure

CLINICAL TERMS
K potassium KUB kidney, ureter, bladder

CLINICAL TERMS
LAD left anterior descending artery LB large bowel LDL low density lipoprotein LE lupus erythematosus LFTs liver function tests LIJ left internal jugular LLQ left lower quadrant LMP last menstrual period LP lumbar puncture LSC left subclavian LUQ left upper quadrant

CLINICAL TERMS
MD Medical Doctor MAP mean arterial pressure MI myocardial infarction MRI magnetic resonance imaging

CLINICAL TERMS
NACL sodium chloride NED no evidence of disease NICU neonatal intensive care unit NIDDM noninsulin dependent diabetes mellitus NKDA non-ketotic diabetic acidosis NKMA no known medcation allergies NPD nightly peritoneal dialysis NSAID nonsteroidal antiinflammatory drug

CLINICAL TERMS
OD right eye OGTT oral glucose tolerance test ORIF open reduction internal fixation OS left eye OU both eyes

CLINICAL TERMS
PID pelvic inflammatory disease PMI point of maximal impulse PNH paroxysmal nocturnal hemoglobinuria PET positron emission tomography PFT pulmonary function test PG prostaglandin PRBC packed red blood cells PS pyloric stenosis PSA prostate specific antigen PT prothrombin time PTT partial thromboplastin time PUD peptic ulcer disease PVD peripheral vascular disease PX pneumothorax

CLINICAL TERMS
ICF intracellular fluid ICP increased intracranial pressure ICS intercostal space ICU intensive care unit DNA deoxyribonucleic acid IDDM insulin dependent diabetes mellitus IVP intravenous pyelogram IUD intra uterine device IOP intraocular pressure

CLINICAL TERMS
ICF intracellular fluid ICP increased intracranial pressure ICS intercostal space ICU intensive care unit DNA deoxyribonucleic acid IDDM insulin dependent diabetes mellitus IVP intravenous pyelogram IUD intra uterine device IOP intraocular pressure

NURSING ABBREVIATIONS
ABC airway, breathing, circulation abd. Abdomen ADL activies of daily living ADRs adverse drug reactions A&E accident and emergency a.c. before meals (Lat. ante cenam) a.p. before dinner A/O alert and oriented AAROM active assisted range of motion ABP arterial blood pressure

NURSING ABBREVIATIONS
Acc accident Accom accommodation amt. amount AP anteroposterior A&P anterior and posterior aq. Water

NURSING ABBREVIATIONS
bpm beats per minute BSA body surface area BVM bag valve mask BMI body mass index

NURSING ABBREVIATIONS
c with caps capsules CC chief complaint cc cubic centimeter C celcius cm centimeter CO carbon monoxide, cardiac output CO2 carbon dioxide cont continuous CNS central nerves system

NURSING ABBREVIATIONS
CPAP continuous positive airway
pressure

CPR cardiopulmonary resuscitation cu cubic

NURSING ABBREVIATIONS
dil. dilute dL deciliter (100ml) DOA death on arrival DOE dyspnea on exertion Dx diagnosis D/W dextrose in water DNR do not resuscitate

NURSING ABBREVIATIONS
F fahrenheit FFP fresh frozen plasma fl. fluid 4x4 piece of gauze 4 by 4 used for
dressings

ft foot, feet FUO fever of undeternined origin FVD fluid volume deficits FVE fluid volume excess

NURSING ABBREVIATIONS
g gram gr grainl gtts drops

NURSING ABBREVIATIONS
h or hrs hour or hours hs at bed time, hour of sleep Hx history Hz hertz

NURSING ABBREVIATIONS
IM intramuscular I&O intake & output IV lntravenous

NURSING ABBREVIATIONS
KVO keep vein open

NURSING ABBREVIATIONS
LPN Licensed Practical Nurse

NURSING ABBREVIATIONS
MAR medication administration record

NURSING ABBREVIATIONS
NPO nothing by mouth NV nausea & vomiting NYD not yet diagnosed NKA no known allergies

NURSING ABBREVIATIONS
PC after meals PCA patient controlled analgesia,
posterior communicating artery

PCN penicillin, primary care nurse PCV packed cell volume

PERL pupils equal, react to light

PERRLA pupils equal, round, react to

light, accommodation

NURSING ABBREVIATIONS
PH past history PI present illness PO by mouth

Documentation

Be

- factual - non-judgmental - accurate - unemotional - detailed notes esp. complication arose - timely in recording

Example of Bad handwriting

RESOURCES
http://www.rtstudents.com/rnstudents/l.htm Kaplan NCLEX Smeltzer & Bare, Medical Surgical Kozier, techniques in nursing