CLINICAL TERMINOLOGY

VITAL SIGNS

Vitals (spoken) and VS (written).

Temperature, pulse, respiration and blood pressure. Some may include peripheral oxygen saturation (SpO2) and pain intensity.

Example: the patient's vitals are temp 99, pulse 87, respiratory rate 16, and bp 167 over 110.
Written: 99-87-16-167/110.

TPR (temperature, pulse and respiration).

TEMPERATURE

It's measured in the mouth, ear, axilla and rectum.

Normal body temperature- 37 Celsius or 98,6 Fahrenheit.
Fever (noun) and febrile (adjective).
Hypothermia- below 95 F or 35 C.
Hyperthermia- 100-101 F or 37,5-38,3 C. Less common (drugs with side effects, prolonged exposure to external heat and inability to dissipate it.
Fainting, pulse and breathing rate are elevated.
Fever- common, often caused by infection rescuing in internal reactions including increased core body temperature.

PULSE

Pulse points- carotid, apical (stethoscope at the apex of the heart), radial, femoral or pedal pulse.
Palpate or feel one carotid pulse at time. Place your fingers lightly on the neck to the side of the windpipe or trachea. Dont apply pressure to both
carotid arteries at the same time. This may decrease blood flow to the brain.
Thready - pulse is very soft, barely perceptible to palpation.
Bounding-pulses rises forcefully in the artery and can be clearly felt on palpation.

RESPIRATORY RATE

Number of times the patient breathes in and out over one minute.
Respirations (verbal) and rr (respiratory rate). RPM (respiration per minute).
Dyspnea - patient feels that they are unable to breath well or breath in enough air or oxygen. SOB - short of breath - frequently used instead of
dyspnea.
Apnea - temporary stopping or cessation of breathing.

PULSE OXIMETRY

Measure of oxygen saturation in the arterial blood. Reported as saturation or peripheral oxygen or SpO2.
It uses a small portable non-invasive device placed on the patient's fingertip or earlobe. Pulse ox.
Arterial oxygen saturation (SpO2/saturation/sat) - measure of the oxygen saturation in arterial blood by pulse oxygen and seen on the screen of
the pulse oxygen machine or on a monitor.
Healthy person - SpO2 94-99%.

BLOOD PRESSURE

Blood pressure cuff - sphygmomanometer. BP cuff (digital/aneroid).

Systolic - measure of the pressure blood flow against the arterial walls as the left ventricle contracts.
Diastolic - heart is at rest between contractions.
Example: 120/84 (systolic and diastolic bp).
Hypertension - hypertensive - hypertensive crisis or emergency is sustained bp above 180/120.
Hypotension - below 90/60.
Orthostatic hypotension (patient has hypertension) - lowering of bp when the patient moves from recumbent (lying down) position to standing
(erect) position. This is also termed postural hypotension. The patient complains of dizziness when getting out of the bed.
VS cart or vitals cart (equipment) - BP, pulse, temperature and SpO2.
HEALTH CARE PROVIDER TITLES

RN - Registered Nurse. Plans, organizes and provides direct patient care.

Supervising nurse - head nurse, charge nurse , clinical/unit coordinator.
CCRN - Clinical Coordinator Registered Nurse - or Clinical Case Manager. Coordinates patient care activities including patient
education / discharge and supervises RNs and team members delivering direct patient care.
CRNP - Certified Registered Nurse Practitioner - Nurse with a master's or doctoral level education and advanced assessment medical
diagnostic skills.
CNS - Clinical Nurse Specialist - nurse with a master's degree that often combines clinical supervision/consultation, teaching and
administrative rules.
CNL - Clinical Nurse Leader - RN at master's level provides administrative and educational leadership.
NA or CNA - Nursing Assistant or Certified Nursing Assistant - A technician with high school education and in-hospital training. May
earn certification with additional courses.
HUC - Unit secretary or Health Unit Coordinator - A person with high school or vocational school training who performs essential
non-medical clerical tasks such as scheduling ad ordering supplies.
SLP - Speech and Language Pathologist - Treats swallowing and communication dysfunction.
MD - Medical Doctor.
PA - Physician Assistant - A professional with 2-6 years of education after HS with advanced skills for assessment and medical
diagnostics. Generally employed by a physician. Seen most often on a surgical unit.

HOSPITAL ASSOCIATED LOCATION

Emergency Room (ER) or Emergency Department (ED) - Site in the hospital where patients receive emergency care.

Operating Room (OR) - Where surgery is performed.

Intensive Care Unit (ICU) - Where patients who are critically ill receive highly technical, life saving care.

Coronary Care Unit (CCU) - Unit specializing in care of patients with acute coronary problems.

Long Term Care (LTC) - Facility that provides extended nursing care.

Post Anesthesia Care Unit (PACU) - A unit where patients recover from anesthesia.

Long Term Acute Care Hospital (LTACH) - Special care hospital or unit for patients who are chronically acutely ill.

HEALTH CARE PRACTITIONER NOTATION

EMR
Eletronical Medical Records. A system of electronic clinical documentation within an institution or health care system U.S. regulations support
the implementation of EMR systems in all health care facilities by 2014. EMR systems are password protected and help to maintain
confidentiality of medical information.

eMAR
The electronic medication administration system enables electronic communication of physician's orders to the pharmacy for filling prescriptions.
Medications are then stored in electronically controlled medications administration machines. The nurses can recheck the physician's order, check
the medication administration record, and electronically record the dose of medication he/she is administering. A patient's EMR and eMAR can
be accessed with password throughout the hospital.

Medication cart (Med cart)

A work station on wheels that can be moved from room to room. The med cart contains a computer, the patient's medications and supplies.
NURSING ASSESSMENT NOTATION

Musculoskeletal activity

Range of motion (ROM) - As we bath the patient, the RN showed me how to move each other of his major joints through range of motion. ROM
to upper and lower extremities.
Active Range of Motion (AROM) - Range the patient can perform. AROM right knee limited by pain to 50% of normal.
Activities of Daily Living (ADLs) - A pair of nursing assessment is noting what ADL'S patient is able to perform independently. Independent in
all ADLs except applying socks and shoes.

Neurological (neuro) system

Pupils equal, round, react to light and accommodation (PERRLA) - Neurological evaluation of optic nerve function. Moving right extremities
PERRLA.
Level of Consciousness (LOC) - Degree of level of awareness of self and surroundings. LOC decreasing.

Exercise
Transcribe the following sentences into abbreviated clinical notation. Then check your answer.
The patient complained of a sharp headache and pain and swelling of his right ankle after falling down flight of 10 steps. On examination, his
level of consciousness was normal, his pupils were equal, and round and reactive to light. He was oriented times 3, and range of motion in his
ankle was limited by pain.

c/o headache, pain and swelling rt. ankle. LOC WNL, PERRLA, A & O x3, ROM limited by pain.

Heart and Lungs

Normal Sinus Rhythm (NSR) - Normal pacing of the heart from the sinoatrial. No C/O chest pain. NSR P84 R22.
Breathe Sounds (BS) - Sounds of breath heard with a stethoscope. BS=Crackles at left base.
Short of breath (SOB) - Feeling that one cannot breathe fully or comfortably. Less C/O SOB.
Paroxysmal nocturnal dyspnea - PND - Becoming short of breath after lying recumbent. Pt reports awakening with PND and must open a window
to get air.

Exercise

No c/o chest pain. NSR. R 22.

No complaints of chest pain. Normal sinus rhythm. Respirations 22.

Gastrointestinal system

Abdomen (ABD) - Usually seen in writing only except when saying "ABD dressing". Abd palpation negative for pain.
Nausea and vomiting (N/V) - BS active 12 hours. S/P colectomy. No c/o N/V.
Bowel Movement (BM) - Evacuation of feces from the lower intestine. No BM X3 da. Requesting laxative.
Bowel sounds (BS) - BS active 12 hrs. S/P colectomy.
Gastrointestinal (GI) - Stomach, small and large intestines. GI workup reveals tumors near the junction of the small and large intestine.
S/P ("status post") means that the client has had the procedure or event in the past.

Genitourinary system

Genitourinary (GU) - Will do GU work up for cause of hematuria.

Intake and output (I and O) .

Exercise

Pt c/o ABD pain. ABD tender to palpation. No BM 3 days. BS WNL.

"Patient complained of abdominal pain. The abdomen is tender to palpation. No bowel movement for 3 days. Bowel sounds within normal
limits."
HISTORY AND PHYSICAL EXAMINATION

History and physical - H and P

History of present illness - HPI
Chief complain - CC
History - HX
History of - H/O
Past medical history - PMH
Review of systems - ROS
Pt - patient
Sx - symptoms
Dx - diagnosis
AMB - ambulate

Example

H & P,
Betty Smith C.R.N.P.
CC Pain left lower leg
HPI The pt was well until 24 hrs ago when he noticed pain and swelling in the posterior left lower leg. Reports long plane travel (over 12 hours)
prior to onset of pain. Pts sx of pain increase with AMB. No hx of prior episodes of calf pain. No H/O blood clotting problems. No hx of prior
phlebitis. Dx probable phlebitis of left calf.

CASE STUDIES

THE SURGICAL PATIENT

Personal Protective Equipment

Part of standard or universal precautions; specialized clothing or equipment such as gloves, mask, eye protection , and gowns for protection
against infectious material.
Abbreviation: PPE

Abdominal Dressing
Another large thick more absorbent sterile gauze and cotton dressing or pad is most often used on the abdomen. The size varies, usually 6 inches
x 8 inches.
Abbreviation: ABD dressing or ABD

Negative Pressure Wound Therapy

A mild suction device that employs negative pressure or suction to remove fluid from the wound and improve healing.
Abbreviation: Wound VAC

Nasogastric tube
A flexible plastic tube that enters the body at one nostril and extends to the stomach. Used for providing nourishment or medication. Also used for
removing stomach contents by suction.
Abbreviation: NG tube

Sequential Compression Device

A machine used on the legs of immobilized patients to prevent pooling of venous blood in the lower extremities, or to increase venous blood flow
from the legs to the heart
Abbreviation: SCD
THE COMATOSE PATIENT

MVA - Motor vehicle accident

Percutaneous Endoscopic Gastrostomy tube

The Peg tube is visible on the upper left abdomen. Food and medications are injected or drained into the stomach through the feeding tube.
While the PEG tube is most common, other tubes provide direct access to the gasto-intestinal tract.
See G-tube, J-tube, and G-J tube
Abbreviation: PEG tube

Tracheostomy
Opening through the skin of the throat into the trachea or windpipe. A tracheostomy tube is placed in the opening. Air passes through the tube into
the lungs. The O2 mask used over the tracheostomy is called a trach mask.
Abbreviation: trach

Catheter
A hollow cylinder that allows for liquid to pass through. Commonly used to drain fluid, such as urine out of the body.
Abbreviation: cath

Foley Catheter
An indwelling urinary catheter held in the bladder by a small balloon inflated after insertion. The catheter is small (fitting into the urethra) and
then is connected to a larger tubing that leads to a transparent plastic bag for collection of urine.
Abbreviation: foley

MEDICAL PATIENT

Nasal Cannula
Mr. Cope receives low flow oxygen by nasal cannula or NC. Two types of nasal cannula are in use: the standard nasal cannula and the reservoir
nasal cannula. The standard NC is a plastic tubing with short prongs that fit into the nostrils and delivers 22-44% O2. The reservoir nasal cannula
stores exhaled oxygen and increases the percentage delivered to 100%. The type will be specified on physicians' orders; these NC are not
interchangeable.
Abbreviation: NC (written only)

Your nursing note reads:

Date: 00/00/0000
10:30AM: O2 by NC 2 L/min rr 34
10:40AM: Pt more comfortable 10 min after starting O2 NC. RR 32.
Note: Mr. Cope uses an NC with a reservoir

Antiembolic stocking or hose

An elastic stocking or hose used to control swelling and reduce the risk of developing deep vein thrombosis or blood clots in the legs. Rarely used
formal name is thrombo-embolism deterrent stocking or hose.
Abbreviation: TED hose or TED stockings

Nursing Notes:
transferred to chair. C/O little dizziness on standing.
3 position BP/ p = lying 110/70, 88; sitting 100/70, 96; standing 100/70, 100.
Rested 14 min then amb. 10-12steps.
Transient SOB on amb.
A & O x3, Refused lunch. States that he is ready to die.
A and O - alert and oriented.

EMERGENCY

Code Blue
The most common term used in U.S. hospitals for a medical emergency is code blue. Many hospitals will use a different term, such as Code C.
Other emergency situations requiring a public announcement (such as fire, need for security, etc.) will have terms unique to that hospital.
Be sure to learn what terms are used for emergencies in your work or learning site as soon as you start your clinical experience.

Cardiopulmonary Resuscitation
Cardiopulmonary resuscitation is an emergency lifesaving procedure with the goal of restoring breathing function and circulation of blood when a
fatal arrhythmia or cardiac arrest has occurred.
Abbreviation: CPR

Read the following question and choose the response option that best completes the sentence.
The nurse glanced at the monitor and said, Call a code. He is in ventricular fibrillation.
The term code means that this is a medical emergence.
Stat
Stat is a term derived from the Latin, statim, meaning immediately.
Stat = now, immediately, right away

Crash Cart
A set of trays and drawers on wheels, often red in color. The cart holds equipment and medications for emergency use.

Defibrillator
Equipment that provides electrical therapy that interrupts a fatal arrhythmia, allowing the heart to reestablish an effective rhythm. Defibrillation is
the noun and defibrillate is the verb.

Automated external defibrillator

A portable electronic device that automatically diagnoses a life threatening heart rhythm (such as ventricular tachycardia or fibrillation) and can
then treat the arrhythmia by defibrillation.
Abbreviation = AED

IMPORTANT
A fully automatic AED is found in all ambulances, federal buildings and many public places throughout the United States. Training for use
requires about 2 hours. Modern hospital units now use an AED that has the automatic features plus a manual override so that the health care
provider can defibrillate as needed.
The old defibrillator with paddles is rarely seen in modern U.S. hospitals; the electric current is delivered using gel containing pads in contact
with the skin.

Endotracheal Intubation
Insertion of a plastic tube into the trachea in order to provide an open airway
intubate = common term used verbally meaning to insert an endotracheal tube
Endo tube = common abbreviation for endotracheal tube

Bag Valve Mask

A facemask provides a seal over the nose and mouth, the bag or balloon is collapsed by squeezing with the hand and oxygen or room air is
pressed into the lungs. The BVM can also be attached to an adaptor for an endotracheal tube. Although the abbreviation, BVM is becoming more
common, you are most likely to hear the term Ambu bag, a proprietary name for the BVM. Squeezing the bag to force air into the lungs is
called bagging.
There are a variety of different BVM products, however, the proprietary name, Ambu bag is commonly used in clinical conversation.

TIMING OF MEDICATION

Q-every.
H, hr, hrs.
BID-two times a day.
TID-three times a day.
QID-four times a day.
AC-before meals.
PC-after meals.
PRN-whenever necessary, as needed.
Hs-bedtime or hour of sleep.

Route of Administration
The route of administration refers to how patients receive medications. We will examine abbreviations related to three routes: by mouth, injection,
or intravenously. The first, two terms below refer to administration by mouth; the last one refers to administration by injection.
Abbreviation Definition

PO By mouth

NPO Nothing by mouth

IM Intra-muscular: Injection into the muscle

Sub-Q or SQ Subcutaneous injection - Injection into the subcutaneous tissues

PCA Patient controlled analgesia - An electronically controlled infusion pump provides pain
medication at preset times and allows the patient to push a button and (within limits of
the prescribed dosage) self-administer medication for pain.

IV Intravenous - infusion of liquid substances into a

vein using either a hollow needle or plastic tubing.
IV Needle Hollow needle used for IV administration (puncture
the skin)

IV Pole Metal pole having hooked ends used for hanging IV

solution bags.

IV bag Disposable container of IV solution, usually one

liter.

D5W or D5 in water 5% Dextrose in water - Common solution used

for IV infusion. Contains dextrose and water.

NSS Normal saline solution commonly used for

infusion or rinsing IV lines.

D5NS IV solution containing dextrose in a normal saline

solution (0.9%) or dextrose in half normal saline
solution (0.45%).

IVP Intravenous push - when medication is injected

into the IV tubing or line. Medications
administered directly into an intravenous line may
be given slowly over a specific amount of time or
they may be given at one time. Drugs or fluid given
at one time rapidly is called an IV bolus.
Medication is injected from a syringe directly into a
port on the IV tubing or directly into a vein.

PVC Peripheral Venous Catheter - small plastic catheter placed in the vein (usually of the arm or hand) used to administer fluids and
withdraw blood. Also called IV catheter (abbreviation: IVC).

Hep lock Heparin Lock or Saline Lock - A catheter much like the PVC is inserted in a vein and connected to a short plastic tube. This tube
-or- has a port with a site for injection of drugs. The tube can then be flushed with saline so that all of the medication is placed in the
Saline lock bloodstream. At one time these short catheters with tubing and a port were used solely for heparin administration; the abbreviated
term "hep lock" continues in common use even though the set up now has a broader use.
 IVPB Intravenous piggy back - Using a previous IV solution administration set up, a container of medication is placed higher than the
basic IV infusion (piggy-backed) and gravity causes the dose of medication to be infused instead of larger container of fluid
hanging below the piggyback. (IV push)

IV Pump A device that controls the flow of IV solution into the patient (used with a PVC). The IV infusion pump can be calibrated or set to
deliver a specific amount of fluid over a specific amount of time. An alarm sounds if the flow is interrupted.

NEUROLOGICAL SYSTEM

Cerebral vascular accident

Impaired brain function resulting from decrease of blood flow to the brain. Also known as a stroke.
Abbreviation: CVA

Transient Ischemic Attack

A temporary reduction in the blood supply and adequate oxygen to brain cells.
Abbreviation: TIA

The difference between a TIA and a CVA, is that with a TIA there is no permanent loss of body movement or
sensory function.

Traumatic brain injury

Occurs when an external force injures the brain. Common causes are falls, vehicular accidents, and violence.
Abbreviation: TBI

Amyotrophic Lateral Sclerosis

A progressive and fatal degenerative disease of the nerves that control voluntary muscle function.
Abbreviation: ALS
Multiple Sclerosis
A degenerative disease affecting a covering of neurons of the brain and
spinal cord causing diffuse deficits including balance problems, increased tone or tightness of muscles, tremor and visual disturbances.
Abbreviation: MS

MUSCULOSKELETAL SYSTEM

Osteoarthritis
Degenerative change in the cartilage and bone of the joints often causing pain and disability more prevalent with aging.
Abbreviation: OA
oste - = bone arthr = joint - itis = inflammation
Also called: Degenerative Joint Disease
Abbreviation: DJD

Rheumatoid Arthritis
A chronic systemic autoimmune disease that causes inflammation of connective tissue, primarily affecting the joints of the wrists, hands,
feet, and cervical spine.
Joints of the wrists and hands acutely inflamed bilaterally. Red and warm to touch.
Abbreviation: RA

CARDIOVASCULAR SYSTEM
Myocardial Infarction
A destruction of heart muscle cells resulting from an interruption of blood supply to the heart muscle.
Abbreviation: MI

Coronary Artery Disease

A narrowing or blockage of the arteries that provide oxygen and nutrients to the cells of the heart.
Abbreviation: CAD

Coronary Artery Bypass Graft

A surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore blood flow to the
heart tissue.
Abbreviation: CABG

Congestive Heart Failure

Occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the body needs. Fatigue, dyspnea on
exertion, and swelling in both legs.
Abbreviation: CHF

Deep vein thrombosis

A blood clot in a major vein that usually develops in the legs and/or pelvis.
We need to consider AROM (active range of motion) exercises and SCDs (sequential compression device) to help prevent DVT.
Abbreviation: DVT

Abdominal aortic aneurysm

An abnormal dilation of the abdominal aorta, often asymptomatic. May require repair to prevent or treat rupture.
Abbreviation: AAA or triple A

Atrial Fibrillation
A common cardiac arrhythmia produced by rapid unsynchronized movement of the atria and consequent irregular pulse. Often
asymptomatic. Known to increase risk of CVA or stroke.
Abbreviation: A-fib -or- (less commonly AF)

Ventricular Fibrillation
Abnormal fatal arrhythmia usually caused by lack of oxygen to heart muscle. The ventricles quiver rather than contract, cardiac
output stops, and unless circulation is restored, the person dies.
Abbreviation: V-fib -or- (less commonly) VF
RESPIRATORY SYSTEM

Cystic Fibrosis