NURSING HEALTH HISTORY
Purpose
• To elicit information about all variables that may affect the client’s health status
• To obtain data that help the nurse understand and appreciate the client’s life experiences
• To initiate a non-judgmental, trusting interpersonal relationship with the client
BIOGRAOHIC DATA
• Name
• Address
• Age
• Sex
• Race
• Marital status
• Occupation
• Religion
• Health care financing
• User source of medicare
CHIEF COMPLAINT
• Reason for visit
• “What is troubling you?”
• Recorded in client’s words
HISTORY OF PRESENT ILLNESS
• Usual health status
• Chronologic story
• Relevant family history
• Disability assessment
PAST HISTORY
• Childhood illnesses
• Childhood immunizations
• Allergies
• Accident and injuries
• Hospitalization
• Medications
FAMILY Hx OF ILLNESS
• Ages of siblings, parents, etc.
• Current state of health
• If deceased, cause of death
REVIEW OF SYSTEMS
• Subjective data
• Checklist
LIFE-STYLE
• Personal habits
• Diet
• Sleep/rest patterns
• Activities of daily living
• Instrumental activities of daily living
• Recreation/hobbies
SOCIAL DATA
• Family relationships/friendships
• Ethnic affiliations
• Educational history
• Occupational history
• Economic status
• Home and neighborhood conditions
PSYCHOLOGIC DATA
• Major stressors
• Usual coping pattern
• Communication style
• Self-concept
• Mood
PATTERN OF HEALTH CARE
• Note all health care resources
ABBREVIATIONS
Page 343 and 795 Fundamentals of Nursing – Kozier 7th Edition
Chapter 16 ASSESSING
Page 256 Fundamentals of Nursing – Kozier 7th Edition
Nursing Process
- Is a systematic, rational method of planning and providing individualized nursing care for individuals, families, groups and communities.
- Originated by Hall(1995), Johnson(1959), Orlando (1961), Wiedenbach (1963)
Phases of Nursing Process
Assessing
- Collecting, organizing, validating and documenting client data – client’s personal perceptions
- Involves active participation by the client and nurse in obtaining subjective and objective data about the client’s health status
Subjective data, symptoms, covert data – client’s personal perception
Objective data – detectable by an observer
- Sources of data: primary and secondary
Primary – client
Secondary – family members or other support persons, client records (medical and laboratory), health care professionals, literature
- Data collection methods
Observing
Interviewing
Directive interview – structured
Nondirective interview – rapport building interview
o Types of Interview Questions
- Open-ended questions, neutral question
- Closed questions, leading questions
Examining
Diagnosing
- analyzing and synthesizing data
Planning
- determining how to prevent, reduce or resolve the identified client problems; how to support client strengths, and how to implement nursing interventions in an organized, individualized and goal directed manner
Implementing
- carrying out the planned interventions
Evaluating
- measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement
Characteristics of Nursing Process
- Cyclic, dynamic
- Client Centered
- Interpersonal and collaborative
- Universally applicable
- Focus on problem solving and decision making
Wednesday, February 27, 2008
Leopold's Maneuvers
Leopold's maneuvers
In obstetrics, Leopold's Maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus.
Overview and rationale
The maneuvers consist of four distinct actions, each helping to determine the position of the fetus. The maneuvers are important because they help determine the position and presentation of the fetus, which in conjunction with correct assessment of the shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or whether a Cesarean section is necessary.
The examiner's skill and practice in performing the maneuvers are the primary factor in whether the fetal lie is correctly ascertained, and so the maneuvers are not truly diagnostic. Actual position can only be determined by ultrasound performed by a competent technician or professional.
Performing the maneuvers
Leopold's Maneuvers are difficult to perform on obese women and women who have hydramnios. The palpation can sometimes be uncomfortable for the woman if care is not taken to ensure she is relaxed and adequately positioned. To aid in this, the health care provider (or other professional) should first ensure that the woman has recently emptied her bladder. If she has not, she may need to have a straight urinary catheter inserted to empty it if she is unable to micturate herself. The woman should lay on her back with her shoulders raised slightly on a pillow and her knees drawn up a little. Her abdomen should be uncovered, and most women appreciate it if the individual performing the maneuver warms their hands prior to palpation.
First maneuver
While facing the woman, palpate the woman's upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard, firm, round, and moves independently of the trunk while the buttocks feels softer, is symmetric, and has small bony processes; unlike the head, it moves with the trunk.
Second maneuver
After the upper abdomen has been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palms of his or her hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The fetal back, once determined, should connect with the form found in the upper abdomen and also a mass in the maternal inlet, lower abdomen.
Third maneuver - Pawlick's Grip
In the third maneuver the health care provider attempts to determine what fetal part is lying above the inlet, or lower abdomen. The individual performing the maneuver first grasps the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneauver. If the woman enters labor, this is the part which will most likely come first in a vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth.
Fourth maneuver
The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. The side where there is the resistance to the descent of the fingers toward the pubis is greatest is where the brow is located. If the head of the fetus is well flexed, it should be on the opposite side from the fetal back. If the fetal head is extended though, the occiput is instead felt and is located on the same side as the back .
Cautions
Leopold's maneuvers are intended to be performed by health care professionals, as they have received training and instruction in how to perform them. That said, as long as care is taken not to roughly or excessively disturb the fetus, there is no real reason it cannot be performed at home as an informational exercise. It is important to note that all findings are not truly diagnostic, and as such ultrasound is required to conclusively determine fetal lie.
In obstetrics, Leopold's Maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus.
Overview and rationale
The maneuvers consist of four distinct actions, each helping to determine the position of the fetus. The maneuvers are important because they help determine the position and presentation of the fetus, which in conjunction with correct assessment of the shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or whether a Cesarean section is necessary.
The examiner's skill and practice in performing the maneuvers are the primary factor in whether the fetal lie is correctly ascertained, and so the maneuvers are not truly diagnostic. Actual position can only be determined by ultrasound performed by a competent technician or professional.
Performing the maneuvers
Leopold's Maneuvers are difficult to perform on obese women and women who have hydramnios. The palpation can sometimes be uncomfortable for the woman if care is not taken to ensure she is relaxed and adequately positioned. To aid in this, the health care provider (or other professional) should first ensure that the woman has recently emptied her bladder. If she has not, she may need to have a straight urinary catheter inserted to empty it if she is unable to micturate herself. The woman should lay on her back with her shoulders raised slightly on a pillow and her knees drawn up a little. Her abdomen should be uncovered, and most women appreciate it if the individual performing the maneuver warms their hands prior to palpation.
First maneuver
While facing the woman, palpate the woman's upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard, firm, round, and moves independently of the trunk while the buttocks feels softer, is symmetric, and has small bony processes; unlike the head, it moves with the trunk.
Second maneuver
After the upper abdomen has been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palms of his or her hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The fetal back, once determined, should connect with the form found in the upper abdomen and also a mass in the maternal inlet, lower abdomen.
Third maneuver - Pawlick's Grip
In the third maneuver the health care provider attempts to determine what fetal part is lying above the inlet, or lower abdomen. The individual performing the maneuver first grasps the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneauver. If the woman enters labor, this is the part which will most likely come first in a vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth.
Fourth maneuver
The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. The side where there is the resistance to the descent of the fingers toward the pubis is greatest is where the brow is located. If the head of the fetus is well flexed, it should be on the opposite side from the fetal back. If the fetal head is extended though, the occiput is instead felt and is located on the same side as the back .
Cautions
Leopold's maneuvers are intended to be performed by health care professionals, as they have received training and instruction in how to perform them. That said, as long as care is taken not to roughly or excessively disturb the fetus, there is no real reason it cannot be performed at home as an informational exercise. It is important to note that all findings are not truly diagnostic, and as such ultrasound is required to conclusively determine fetal lie.
Friday, February 22, 2008
The Menstrual Cycle
The Menstrual Cycle
The "typical" menstrual cycle occurs regularly over 28 days. Most women have cycles with an interval that lasts from 21 to 35 days. Frequently cycles are unusually short or long during adolescence.
THE FIRST HALF OF THE MENSTRUAL CYCLE (Day 1 to About Day 14 in a 28-Day Cycle)
The Menstrual Phase
The first day of your menstrual period is considered Day 1 of your cycle. The menstrual phase includes your period. During this time, the endometrium (the built-up lining of the uterus) is shed, along with a little blood. Many of the problems that women experience with their menstrual cycle occur during this phase. For example, some women experience menstrual disorders such as dysmenorrhea (painful periods) or menorrhagia (unusually heavy periods).
The Follicular/Proliferate Phase
During the proliferate phase, the body produces a hormone called follicle-stimulating hormone (FSH). Follicle-stimulating hormone promotes the growth of a follicle (egg sac) within the ovary. An ovum (egg) matures in the follicle during the proliferative phase. FSH also stimulates the ovary to produce increasing amounts of estrogen. In turn, the estrogen causes endometrial tissue to build up (or proliferate), lining the interior of the uterus.
THE MIDPOINT OF THE MENSTRUAL CYCLE (About Day 14 in a 28-Day Cycle)
The mature ovum bursts from the follicle about midway (approximately 2 weeks before onset of next menstrual period) through the menstrual cycle. This process is known as ovulation. The ovum then travels from the ovary down the fallopian tube, and into the uterus.
The Luteal/Secretory Phase
Once the ovum has been released, the follicle becomes a sac known as the corpus luteum ("yellow body," because it contains yellowish, fatty matter). A hormone called luteinizing hormone (LH) causes the corpus luteum to grow and to secrete progesterone, another female hormone.
During the secretory phase, progesterone makes the endometrial lining stronger and spongy in texture. Progesterone also stimulates glands in the endometrium. These glands produce uterine fluid, and their purpose is to support embryonic development if fertilization has occurred at or around the time of ovulation. It is in this phase of the menstrual cycle that women who suffer from premenstrual syndrome (PMS) may begin to experience their symptoms. Generally symptoms are worse during the last seven to ten days of the cycle, ending at or soon after the start of the menstrual period. In a woman who hasn't become pregnant, the level of progesterone peaks about a week after ovulation and then begins to drop along with the estrogen level. The flow of blood to the endometrium decreases, and its upper portion is broken down and shed during menstruation. At the same time, the corpus luteum withers.
The dip in estrogen and progesterone at the end of the cycle help let the body know that it's time to start the cycle all over again. The menstrual cycle doesn't have to be a drag, it actually shows how complex your body is and a sign that it is functioning properly! Congratulations, you are a woman and being a woman is terrific!
The "typical" menstrual cycle occurs regularly over 28 days. Most women have cycles with an interval that lasts from 21 to 35 days. Frequently cycles are unusually short or long during adolescence.
THE FIRST HALF OF THE MENSTRUAL CYCLE (Day 1 to About Day 14 in a 28-Day Cycle)
The Menstrual Phase
The first day of your menstrual period is considered Day 1 of your cycle. The menstrual phase includes your period. During this time, the endometrium (the built-up lining of the uterus) is shed, along with a little blood. Many of the problems that women experience with their menstrual cycle occur during this phase. For example, some women experience menstrual disorders such as dysmenorrhea (painful periods) or menorrhagia (unusually heavy periods).
The Follicular/Proliferate Phase
During the proliferate phase, the body produces a hormone called follicle-stimulating hormone (FSH). Follicle-stimulating hormone promotes the growth of a follicle (egg sac) within the ovary. An ovum (egg) matures in the follicle during the proliferative phase. FSH also stimulates the ovary to produce increasing amounts of estrogen. In turn, the estrogen causes endometrial tissue to build up (or proliferate), lining the interior of the uterus.
THE MIDPOINT OF THE MENSTRUAL CYCLE (About Day 14 in a 28-Day Cycle)
The mature ovum bursts from the follicle about midway (approximately 2 weeks before onset of next menstrual period) through the menstrual cycle. This process is known as ovulation. The ovum then travels from the ovary down the fallopian tube, and into the uterus.
The Luteal/Secretory Phase
Once the ovum has been released, the follicle becomes a sac known as the corpus luteum ("yellow body," because it contains yellowish, fatty matter). A hormone called luteinizing hormone (LH) causes the corpus luteum to grow and to secrete progesterone, another female hormone.
During the secretory phase, progesterone makes the endometrial lining stronger and spongy in texture. Progesterone also stimulates glands in the endometrium. These glands produce uterine fluid, and their purpose is to support embryonic development if fertilization has occurred at or around the time of ovulation. It is in this phase of the menstrual cycle that women who suffer from premenstrual syndrome (PMS) may begin to experience their symptoms. Generally symptoms are worse during the last seven to ten days of the cycle, ending at or soon after the start of the menstrual period. In a woman who hasn't become pregnant, the level of progesterone peaks about a week after ovulation and then begins to drop along with the estrogen level. The flow of blood to the endometrium decreases, and its upper portion is broken down and shed during menstruation. At the same time, the corpus luteum withers.
The dip in estrogen and progesterone at the end of the cycle help let the body know that it's time to start the cycle all over again. The menstrual cycle doesn't have to be a drag, it actually shows how complex your body is and a sign that it is functioning properly! Congratulations, you are a woman and being a woman is terrific!
What You Need To Know About Menstruation
What You Need To Know About Menstruation
If you're a teenage girl you probably have started having a period. If you have not, you might be anxious about the subject or a bit concerned. This whole menstruation thing might seem a bit mysterious, it is to many young women. It's actually very complex, but interesting too.
Menstruation is the outward proof that a girl is becoming a woman. Having a period is your body's way of saying it’s functioning properly.
During puberty, hormones are released from the brain that stimulate the ovaries. The ovaries then produce estrogen and progesterone -- hormones that cause the eggs in the ovaries to mature so the woman can become pregnant when she chooses to. Here's how the process goes:
Every month, one egg leaves one of the ovaries on its way to the uterus via the fallopian tubes. Meanwhile, in preparation for the egg, the uterus starts to develop a thicker lining and it’s walls become cushiony (the endometrial lining). If the egg reaches the uterus and is fertilized by a sperm cell, it attaches to this cushiony wall.
Most of the time the egg just passes right through without fertilization. Since the uterus no longer needs the extra blood and tissue which made up the walls thick, it sheds them by way of the vagina. This cycle will happen nearly every month until the ovaries stop releasing eggs, usually several decades later. (Menopause).
Periods are different for every woman. Some girls start menstruation when they're 9 or 10; some in their late teens. The length of the cycle also varies. Some periods last longer than 28 days, some shorter. If you have just begun your menstruation, your body will need time to regulate itself to these changes. Your periods might be a bit erratic at first. You may have two cycles in one month and miss having one the next month. How long your period lasts also varies . Some girls have their periods for only 3 or 4 days, others as long as a week. The menstrual flow of blood can vary from woman to woman also.
Some girls may have body and or mood changes around the time of their period. Menstrual cramps are pretty common during the first few days of your period. These are most likely caused by prostagladins. Prostaglandins causes the muscles of the uterus to contract. These cramps tend to become less uncomfortable and sometimes even disappear completely as a girl gets older. Over-the-counter pain medication like ibuprofen or acetaminophen can often give relief; if not, a health care provider can help. If your cramps are very severe, see a gynecologist.
As your period approaches, you may experience premenstrual syndrome (PMS). You may find your emotions amplified during this time. Many women get depressed, irritated, angry, and others cry more than usual or get cravings for certain foods. PMS may be related to changes in hormones. Hormone levels rise and fall during a menstrual cycle, affecting the way a female feels both mentally and physically.
Emotions can become more intense than usual, and many women may feel bloated because of water retention. When your period begins, PMS usually goes away. You may also have acne flare-ups.
Periods are a complex part of puberty, but also your body's way of telling you it is functioning properly and you have taken good care of it. You can still exercise, swim and do everything you enjoy. If you have any questions about periods, ask a parent, health teacher, health care provider, or nurse. You can also ask friends or sisters who have already had their periods. In time you will see that periods are a normal and routine part of your life.
If you're a teenage girl you probably have started having a period. If you have not, you might be anxious about the subject or a bit concerned. This whole menstruation thing might seem a bit mysterious, it is to many young women. It's actually very complex, but interesting too.
Menstruation is the outward proof that a girl is becoming a woman. Having a period is your body's way of saying it’s functioning properly.
During puberty, hormones are released from the brain that stimulate the ovaries. The ovaries then produce estrogen and progesterone -- hormones that cause the eggs in the ovaries to mature so the woman can become pregnant when she chooses to. Here's how the process goes:
Every month, one egg leaves one of the ovaries on its way to the uterus via the fallopian tubes. Meanwhile, in preparation for the egg, the uterus starts to develop a thicker lining and it’s walls become cushiony (the endometrial lining). If the egg reaches the uterus and is fertilized by a sperm cell, it attaches to this cushiony wall.
Most of the time the egg just passes right through without fertilization. Since the uterus no longer needs the extra blood and tissue which made up the walls thick, it sheds them by way of the vagina. This cycle will happen nearly every month until the ovaries stop releasing eggs, usually several decades later. (Menopause).
Periods are different for every woman. Some girls start menstruation when they're 9 or 10; some in their late teens. The length of the cycle also varies. Some periods last longer than 28 days, some shorter. If you have just begun your menstruation, your body will need time to regulate itself to these changes. Your periods might be a bit erratic at first. You may have two cycles in one month and miss having one the next month. How long your period lasts also varies . Some girls have their periods for only 3 or 4 days, others as long as a week. The menstrual flow of blood can vary from woman to woman also.
Some girls may have body and or mood changes around the time of their period. Menstrual cramps are pretty common during the first few days of your period. These are most likely caused by prostagladins. Prostaglandins causes the muscles of the uterus to contract. These cramps tend to become less uncomfortable and sometimes even disappear completely as a girl gets older. Over-the-counter pain medication like ibuprofen or acetaminophen can often give relief; if not, a health care provider can help. If your cramps are very severe, see a gynecologist.
As your period approaches, you may experience premenstrual syndrome (PMS). You may find your emotions amplified during this time. Many women get depressed, irritated, angry, and others cry more than usual or get cravings for certain foods. PMS may be related to changes in hormones. Hormone levels rise and fall during a menstrual cycle, affecting the way a female feels both mentally and physically.
Emotions can become more intense than usual, and many women may feel bloated because of water retention. When your period begins, PMS usually goes away. You may also have acne flare-ups.
Periods are a complex part of puberty, but also your body's way of telling you it is functioning properly and you have taken good care of it. You can still exercise, swim and do everything you enjoy. If you have any questions about periods, ask a parent, health teacher, health care provider, or nurse. You can also ask friends or sisters who have already had their periods. In time you will see that periods are a normal and routine part of your life.
Sunday, February 17, 2008
Common Medical Abbreviations
AAA abdominal aortic aneurysm
A-a gradient alveolar to arterial gradient
AAD antibiotic-associated diarrhea
AAO alert, awake, and oriented
A&O alert & oriented
AAS acute abdominal series
ABD abdomen
ABG arterial blood gas
AC before eating
ACLS advanced cardiac life support
ACTH adrenocorticotropic hormone
ADH anti-diuretic hormone
ADR adverse drug reaction. | acute dystonic reaction
ad lib as much as needed
AED antiepileptic drug
AF atrial fibrillation or afebrile
AFB acid-fast bacilli
AFP alpha-fetoprotein
A /G albumin/globulin ratio
AI aortic insufficiency
AKA above the knee amputation
ALD alcoholic liver disease
ALL acute lymphocytic leukemia
amb ambulate
AML acute myelogenous leukemia
ANA antinuclear antibody
ANS autonomic nervous system
AOB alcohol on breath
AODM adult onset diabetes mellitus
AP anteroposterior or abdominal - perineal
ARDS acute respiratory distress syndrome
ARF acute renal failure
AS aortic stenosis
ASAP as soon as possible
ASCVD atherosclerotic cardiovascular disease
ASD atrial septal defect
ASHD atherosclerotic heart disease
AV atrioventricular
A-V arteriovenous
A-VO2 arteriovenous oxygen
BBB bundle branch block
BCAA branched chain amino acids
BE barium enema
BEE basal energy expenditure
bid twice a day
BKA below the knee amputation
BM bone marrow or bowel movement
BMR basal metabolic rate
BOM bilateral otitis media
BP blood pressure
BPH benign prostatic hypertrophy
BPM beats per minute
BRBPR bright red blood per rectum
BRP bathroom priviledges
BS bowel or breath sounds
BUN blood urea nitrogen
BW body weight
BX biopsy
C with
C&S culture and sensitivity
CA cancer
Ca calcium
CAA crystalline amino acids
CABG coronary artery bypass graft
CAD coronary artery disease
CAT computerized axial tomography
CBC complete blood count
CBG capillary blood gas
CC chief complaint
CCU clean catch urine or cardiac care unit
CCV critical closing volume
CF cystic fibrosis
CGL chronic granulocytic leukemia
CHF congestive heart failure
CHO carbohydrate
CI cardiac index
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN cranial nerves
CNS central nervous system
CO cardiac output
C/O complaining of
COLD chronic obstructive lung disease
COPD chronic obstructive pulmonary disease
CP chest pain or cerebral palsy
CPAP continuous positive airway pressure
CPK creatine phosphokinase
CPR cardiopulmonary resuscitation
CRCL creatinine clearance
CRF chronic renal failure
CRP C-reactive protein
CSF cerebrospinal fluid
CT computerized tomography
CVA cerebrovascular accident or costovertebral angle
CVAT CVA tenderness
CVP central venous pressure
CXR chest X-ray
DAT diet as tolerated
DAW dispense as written
DC discontinue or discharge
D&C dilation and curettage
DDx differential diagnosis
D5W 5% dextrose in water
DI diabetes insipidus
DIC disseminated intravascular coagulopathy
DIP distal interphalangeal joint
DJD degenerative joint disease
DKA diabetic ketoacidosis
dL deciliter
DM diabetes mellitus
DNR do not resuscitate
DOA dead on arrival
DOE dyspnea on exertion
DPL diagnostic peritoneal lavage
DPT diphtheria, pertussis, tetanus
DTR deep tendon reflexes
DVT deep venous thrombosis
DX diagnosis
EAA essential amino acids
EBL estimated blood loss
ECG electrocardiogram
ECT electroconvulsive therapy
EFAD essential fatty acid deficiency
EMG Electromyogram
EMV eyes, motor, verbal response (Glasgow coma scale)
ENT ears, nose, and throat
EOM extraocular muscles
ESR erythrocyte sedimentation rate
ET endotracheal
ETT endotracheal tube
ERCP endoscopic retrograde cholangio -pancreatography
ETOH ethanol
EUA examination under anesthesia
FBS fasting blood sugar
FEV forced expiratory volume
FFP fresh frozen plasma
FRC functional residual capacity
FTT failure to thrive
FU follow-up
FUO fever of unknown origin
FVC forced vital capacity
Fx fracture
GC gonorrhea
GETT general by endotracheal tube
GFR glomerular filtration rate
GI gastrointestinal
gr grain; 1 grain = 65mg. Therefore Vgr = 325mg
GSW gun shot wound
gt or gtt drops
GTT glucose tolerance test
GU genitourinary
GXT graded exercise tolerance (Stress test)
HA headache
HAA hepatitis B surface antigen
HAV hepatitis A virus
HBP high blood pressure
HCG human chorionic gonadotropin
HCT hematocrit
HDL high density lipoprotein
HEENT head, eyes, ears, nose, throat
Hgb hemoglobin
H/H henderson- hasselbach equation or hemoglobin/ hematocrit
HIV human immunodeficiency virus
HLA histocompatibility locus antigen
HJR hepatojugular reflex
HO history of
HOB head of bed
HPF high power field
HPI history of present illness
HR heart rate
HS at bedtime
HSM hepatosplenomegaly
HTLV-III human lymphotropic virus, type III (AIDS agent, HIV)
HSV herpes simplex virus
HTN hypertension
Hx history
I&D incision and drainage
I&O intake and output
ICS intercostal space
ICU intensive care unit
ID infectious disease or identification
IDDM insulin dependent diabetes mellitus
IG immunoglobulin
IHSS idiopathic hypertropic subaortic stenosis
IM intramuscular
IMV intermittent mandatory ventilation
INF intravenous nutritional fluid
IPPB intermittent positive pressure breathing
IRBBB incomplete right bundle branch block
IRDM insulin resistant diabetes mellitus
IT interthecal
ITP idiopathic thrombocytopenic purpura
IV intravenous
IVC intravenous cholangiogram | inferior vena cava
IVP intravenous pyelogram
JODM juvenile onset diabetes mellitus
JVD jugular venous distention
KOR keep open rate
KUB kidneys, ureters, bladder
KVO keep vein open
L left
LAD left axis deviation or left anterior descending
LAE left atrial enlargement
LAHB left anterior hemiblock
LAP left atrial pressure or leukocyte alkaline phosphatase
LBBB left bundle branch block
LDH lactate dehydrogenase
LE lupus erythematosus
LIH left inguinal hernia
LLL left lower lobe
LMP last menstrual period
LNMP last normal menstrual period
LOC loss of consciousness or level of consciousness
LP lumbar puncture
LPN licensed practical nurse
LUL left upper lobe
LUQ Left Upper Quadrant
LV left ventricle
LVEDP left ventricular end diastolic pressure
LVH left ventricular hypertrophy
MAO monoamine oxidase
MAP mean arterial pressure
MAST medical antishock trousers
MBT maternal blood type
MCH mean cell hemoglobin
MCHC mean cell hemoglobin concentration
MCV mean cell volume
MI myocardial infarction or mitral insufficiency
mL milliliter
MLE midline episiotomy
MMEF maximal mid expiratory flow
mmol millimole
MMR measles, mumps, rubella
MRI magnetic resonance imaging
MRSA methicillin resistant staph aureus
MS multiple sclerosis or mitral stenosis, or morphine sulfate
MSSA methicillin-sensitive staph aureus
MVA motor vehicle accident
MVI multivitamin injection
MVV maximum voluntary ventilation
NAD no active disease
NAS no added salt
NCV nerve conduction velocity
NED no evidence of recurrent disease
ng nanogram
NG nasogastric
NIDDM non-insulin dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergies
NMR nuclear magnetic resonance
NPO nothing by mouth
NRM no regular medications
NSAID non-steroidal anti- inflammatory drugs
NSR normal sinus rhythm
NT nasotracheal
OB obstetrics
OCG oral cholecystogram
OD overdose or right eye
OM otitis media
OOB out of bed
OPV oral polio vaccine
OR operating room
OS left eye
OU both eyes
P para
PA posteroanterior
PAC premature atrial contraction
PAO2 alveolar oxygen
PaO2 peripheral arterial oxygen content
PAP pulmonary artery pressure
PAT paroxysymal atrial tachycardia
P&PD percussion and postural drainage
PC after eating
PCWP pulmonary capillary wedge pressure
PDA patent ductus arteriosus
PDR physicians desk reference
PE pulmonary embolus, or physical exam or pleural effusion
PEEP positive end expiratory pressure
PFT pulmonary function tests
pg picogram
PI pulmonic insufficiency disease
PKU phenylketonuria
PMH previous medical history
PMI point of maximal impulse
PMN polymorphonuclear leukocyte (neutrophil)
PND paroxysmal nocturnal dyspnea
PO by mouth
POD post-op day
PP postprandial or pulsus paradoxus
PPD purified protein derivative
PR by rectum
PRBC packed red blood cells
PRN as needed
PS pulmonic stenosis
PT prothrombin time, or physical therapy
Pt patient
PTCA percutaneous transluminal coronary angioplasty
PTH parathyroid hormone
PTHC percutanous transhepatic cholangiogram
PTT partial thromboplastin time
PUD peptic ulcer disease
PVC premature ventricular contraction
PVD peripheral vascular disease
q every (e.g. q6h = every 6 hours)
qd every day
qh every hour
q4h, q6h.... every 4 hours, every 6 hours etc.
qid four times a day
QNS quantity not sufficient
qod every other day
Qs/Qt shunt fraction
Qt total cardiac output
R right
RA rheumatoid arthritis or right atrium
RAD right atrial axis deviation
RAE right atrial enlargement
RAP right atrial pressure
RBBB right bundle branch block
RBC red blood cell
RBP retinol-binding protein
RDA recommended daily allowance
RDW red cell distribution width
RIA radioimmunoassay
RIH right inguinal hernia
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
RNA ribonucleic acid
R/O rule out
ROM range of motion
ROS review of systems
RPG retrograde pyelogram
RRR regular rate and rhythm
RT respiratory or radiation therapy
RTA renal tubular acidosis
RTC return to clinic
RU resin uptake
RUG retrograde urethogram
RUL right upper lobe
RUQ right upper quadrant
RV residual volume
RVH right ventricular hyperthrophy
Rx treatment
s without | ss = one-half
SA sinoatrial
SAA synthetic amino acid
S&E sugar and acetone
SBE subacute bacterial endocarditis
SBFT small bowel follow through
SBS short bowel syndrome
SCr serum creatinine
SEM systolic ejection murmur
SG Swan-Ganz
SGA small for gestational age
SGGT serum gamma- glutamyl transpeptidase
SGOT serum glutamic- oxaloacetic transaminase
SGPT serum glutamic- pyruvic transaminase
SIADH syndrome of inappropriate antidiuretic hormone
sig write on label
SIMV synchronous intermittent mandatory ventilation
sl sublingual
SLE systemic lupus erythematous
SMO slips made out
SOAP subjective, Objective, Assessment, Plan
SOB shortness of breath
SQ subcutaneous
STAT immediately
SVD spontaneous vaginal delivery
Sx symptoms
T&C type and cross
TAH total abdominal hysterectomy
T&H type and hold
TB tuberculosis
TBG total binding globulin
Td tetanus-diphtheria toxoid
TIA transient ischemic attack
TIBC total iron binding capacity
tid three times a day
TIG tetanus immune globulin
TKO to keep open
TLC total lung capacity
TMJ temporo mandibular joint
TNTC too numerous to count
TO telephone order
TOPV trivalent oral polio vaccine
TPN total parenteral nutrition
TSH thyroid stimulating hormone
TT thrombin time
TTP thrombotic thrombocytopenic purpura
TU tuberculin units
TUR transurethral resection
TURBT TUR bladder tumors
TURP transurethral resection of prostate
TV tidal volume
TVH total vaginal hysterectomy
tw twice a week
Tx treatment, transplant
UA urinalysis
UAC uric acid | umbilical artery catheter
UAO upper airway obstruction
UBD universal blood donor
UC ulcerative colitis | umbilical cord
ud as directed
UFH unfractionated heparin
UGI upper gastrointestinal
URI upper respiratory infection
URQ upper right quadrant
US ultrasound
UTI urinary tract infection
UUN urinary urea nitrogen
UVA ultraviolet A light
VAD venous access device
VC vital capacity
VCT venous clotting time
VCUG voiding cysourethrogram
VDRL Venereal Disease Research Laboratory (test for syphilis)
VMA vanillymadelic acid
VO verbal or voice order
V/Q ventilation - perfusion
VRE vancomycin-resistant enterococcus
VSS vital signs stable
VT ventricular tachycardia
VV varicose veins
VW vessel wall
VWD von Willebrand's disease
VZV varicella zoster virus
WB whole blood
WBC white blood cell or count
WBR whole body radiation
WD well developed
WF white female
WIA wounded in action
WID widow, widower
WM white male
WN well nourished
WNL within normal limits
WO written order | weeks old | wide open.
WOP without pain
W.P. whirlpool
WPW Wolff-Parkinson-White
W-T-D wet to dry
W/U workup
X2d times 2 days.
XI Eleven
XII Twelve
XL extended release. | extra large.
XM Crossmatch
XMM Xeromammography
XOM extraocular movements
XRT X-ray therapy (radiation therapy)
XS Excessive
XULN times upper limit of normal
YF yellow fever
YLC youngest living child
yo years old
YOB year of birth
yr year
ytd year to date
ZDV zidovudine
ZE Zollinger-Ellison
Z-ESR zeta erythrocyte sedimentation rate
Zn zinc
ZnO zinc oxide
ZSB zero stools since birth
A-a gradient alveolar to arterial gradient
AAD antibiotic-associated diarrhea
AAO alert, awake, and oriented
A&O alert & oriented
AAS acute abdominal series
ABD abdomen
ABG arterial blood gas
AC before eating
ACLS advanced cardiac life support
ACTH adrenocorticotropic hormone
ADH anti-diuretic hormone
ADR adverse drug reaction. | acute dystonic reaction
ad lib as much as needed
AED antiepileptic drug
AF atrial fibrillation or afebrile
AFB acid-fast bacilli
AFP alpha-fetoprotein
A /G albumin/globulin ratio
AI aortic insufficiency
AKA above the knee amputation
ALD alcoholic liver disease
ALL acute lymphocytic leukemia
amb ambulate
AML acute myelogenous leukemia
ANA antinuclear antibody
ANS autonomic nervous system
AOB alcohol on breath
AODM adult onset diabetes mellitus
AP anteroposterior or abdominal - perineal
ARDS acute respiratory distress syndrome
ARF acute renal failure
AS aortic stenosis
ASAP as soon as possible
ASCVD atherosclerotic cardiovascular disease
ASD atrial septal defect
ASHD atherosclerotic heart disease
AV atrioventricular
A-V arteriovenous
A-VO2 arteriovenous oxygen
BBB bundle branch block
BCAA branched chain amino acids
BE barium enema
BEE basal energy expenditure
bid twice a day
BKA below the knee amputation
BM bone marrow or bowel movement
BMR basal metabolic rate
BOM bilateral otitis media
BP blood pressure
BPH benign prostatic hypertrophy
BPM beats per minute
BRBPR bright red blood per rectum
BRP bathroom priviledges
BS bowel or breath sounds
BUN blood urea nitrogen
BW body weight
BX biopsy
C with
C&S culture and sensitivity
CA cancer
Ca calcium
CAA crystalline amino acids
CABG coronary artery bypass graft
CAD coronary artery disease
CAT computerized axial tomography
CBC complete blood count
CBG capillary blood gas
CC chief complaint
CCU clean catch urine or cardiac care unit
CCV critical closing volume
CF cystic fibrosis
CGL chronic granulocytic leukemia
CHF congestive heart failure
CHO carbohydrate
CI cardiac index
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN cranial nerves
CNS central nervous system
CO cardiac output
C/O complaining of
COLD chronic obstructive lung disease
COPD chronic obstructive pulmonary disease
CP chest pain or cerebral palsy
CPAP continuous positive airway pressure
CPK creatine phosphokinase
CPR cardiopulmonary resuscitation
CRCL creatinine clearance
CRF chronic renal failure
CRP C-reactive protein
CSF cerebrospinal fluid
CT computerized tomography
CVA cerebrovascular accident or costovertebral angle
CVAT CVA tenderness
CVP central venous pressure
CXR chest X-ray
DAT diet as tolerated
DAW dispense as written
DC discontinue or discharge
D&C dilation and curettage
DDx differential diagnosis
D5W 5% dextrose in water
DI diabetes insipidus
DIC disseminated intravascular coagulopathy
DIP distal interphalangeal joint
DJD degenerative joint disease
DKA diabetic ketoacidosis
dL deciliter
DM diabetes mellitus
DNR do not resuscitate
DOA dead on arrival
DOE dyspnea on exertion
DPL diagnostic peritoneal lavage
DPT diphtheria, pertussis, tetanus
DTR deep tendon reflexes
DVT deep venous thrombosis
DX diagnosis
EAA essential amino acids
EBL estimated blood loss
ECG electrocardiogram
ECT electroconvulsive therapy
EFAD essential fatty acid deficiency
EMG Electromyogram
EMV eyes, motor, verbal response (Glasgow coma scale)
ENT ears, nose, and throat
EOM extraocular muscles
ESR erythrocyte sedimentation rate
ET endotracheal
ETT endotracheal tube
ERCP endoscopic retrograde cholangio -pancreatography
ETOH ethanol
EUA examination under anesthesia
FBS fasting blood sugar
FEV forced expiratory volume
FFP fresh frozen plasma
FRC functional residual capacity
FTT failure to thrive
FU follow-up
FUO fever of unknown origin
FVC forced vital capacity
Fx fracture
GC gonorrhea
GETT general by endotracheal tube
GFR glomerular filtration rate
GI gastrointestinal
gr grain; 1 grain = 65mg. Therefore Vgr = 325mg
GSW gun shot wound
gt or gtt drops
GTT glucose tolerance test
GU genitourinary
GXT graded exercise tolerance (Stress test)
HA headache
HAA hepatitis B surface antigen
HAV hepatitis A virus
HBP high blood pressure
HCG human chorionic gonadotropin
HCT hematocrit
HDL high density lipoprotein
HEENT head, eyes, ears, nose, throat
Hgb hemoglobin
H/H henderson- hasselbach equation or hemoglobin/ hematocrit
HIV human immunodeficiency virus
HLA histocompatibility locus antigen
HJR hepatojugular reflex
HO history of
HOB head of bed
HPF high power field
HPI history of present illness
HR heart rate
HS at bedtime
HSM hepatosplenomegaly
HTLV-III human lymphotropic virus, type III (AIDS agent, HIV)
HSV herpes simplex virus
HTN hypertension
Hx history
I&D incision and drainage
I&O intake and output
ICS intercostal space
ICU intensive care unit
ID infectious disease or identification
IDDM insulin dependent diabetes mellitus
IG immunoglobulin
IHSS idiopathic hypertropic subaortic stenosis
IM intramuscular
IMV intermittent mandatory ventilation
INF intravenous nutritional fluid
IPPB intermittent positive pressure breathing
IRBBB incomplete right bundle branch block
IRDM insulin resistant diabetes mellitus
IT interthecal
ITP idiopathic thrombocytopenic purpura
IV intravenous
IVC intravenous cholangiogram | inferior vena cava
IVP intravenous pyelogram
JODM juvenile onset diabetes mellitus
JVD jugular venous distention
KOR keep open rate
KUB kidneys, ureters, bladder
KVO keep vein open
L left
LAD left axis deviation or left anterior descending
LAE left atrial enlargement
LAHB left anterior hemiblock
LAP left atrial pressure or leukocyte alkaline phosphatase
LBBB left bundle branch block
LDH lactate dehydrogenase
LE lupus erythematosus
LIH left inguinal hernia
LLL left lower lobe
LMP last menstrual period
LNMP last normal menstrual period
LOC loss of consciousness or level of consciousness
LP lumbar puncture
LPN licensed practical nurse
LUL left upper lobe
LUQ Left Upper Quadrant
LV left ventricle
LVEDP left ventricular end diastolic pressure
LVH left ventricular hypertrophy
MAO monoamine oxidase
MAP mean arterial pressure
MAST medical antishock trousers
MBT maternal blood type
MCH mean cell hemoglobin
MCHC mean cell hemoglobin concentration
MCV mean cell volume
MI myocardial infarction or mitral insufficiency
mL milliliter
MLE midline episiotomy
MMEF maximal mid expiratory flow
mmol millimole
MMR measles, mumps, rubella
MRI magnetic resonance imaging
MRSA methicillin resistant staph aureus
MS multiple sclerosis or mitral stenosis, or morphine sulfate
MSSA methicillin-sensitive staph aureus
MVA motor vehicle accident
MVI multivitamin injection
MVV maximum voluntary ventilation
NAD no active disease
NAS no added salt
NCV nerve conduction velocity
NED no evidence of recurrent disease
ng nanogram
NG nasogastric
NIDDM non-insulin dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergies
NMR nuclear magnetic resonance
NPO nothing by mouth
NRM no regular medications
NSAID non-steroidal anti- inflammatory drugs
NSR normal sinus rhythm
NT nasotracheal
OB obstetrics
OCG oral cholecystogram
OD overdose or right eye
OM otitis media
OOB out of bed
OPV oral polio vaccine
OR operating room
OS left eye
OU both eyes
P para
PA posteroanterior
PAC premature atrial contraction
PAO2 alveolar oxygen
PaO2 peripheral arterial oxygen content
PAP pulmonary artery pressure
PAT paroxysymal atrial tachycardia
P&PD percussion and postural drainage
PC after eating
PCWP pulmonary capillary wedge pressure
PDA patent ductus arteriosus
PDR physicians desk reference
PE pulmonary embolus, or physical exam or pleural effusion
PEEP positive end expiratory pressure
PFT pulmonary function tests
pg picogram
PI pulmonic insufficiency disease
PKU phenylketonuria
PMH previous medical history
PMI point of maximal impulse
PMN polymorphonuclear leukocyte (neutrophil)
PND paroxysmal nocturnal dyspnea
PO by mouth
POD post-op day
PP postprandial or pulsus paradoxus
PPD purified protein derivative
PR by rectum
PRBC packed red blood cells
PRN as needed
PS pulmonic stenosis
PT prothrombin time, or physical therapy
Pt patient
PTCA percutaneous transluminal coronary angioplasty
PTH parathyroid hormone
PTHC percutanous transhepatic cholangiogram
PTT partial thromboplastin time
PUD peptic ulcer disease
PVC premature ventricular contraction
PVD peripheral vascular disease
q every (e.g. q6h = every 6 hours)
qd every day
qh every hour
q4h, q6h.... every 4 hours, every 6 hours etc.
qid four times a day
QNS quantity not sufficient
qod every other day
Qs/Qt shunt fraction
Qt total cardiac output
R right
RA rheumatoid arthritis or right atrium
RAD right atrial axis deviation
RAE right atrial enlargement
RAP right atrial pressure
RBBB right bundle branch block
RBC red blood cell
RBP retinol-binding protein
RDA recommended daily allowance
RDW red cell distribution width
RIA radioimmunoassay
RIH right inguinal hernia
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
RNA ribonucleic acid
R/O rule out
ROM range of motion
ROS review of systems
RPG retrograde pyelogram
RRR regular rate and rhythm
RT respiratory or radiation therapy
RTA renal tubular acidosis
RTC return to clinic
RU resin uptake
RUG retrograde urethogram
RUL right upper lobe
RUQ right upper quadrant
RV residual volume
RVH right ventricular hyperthrophy
Rx treatment
s without | ss = one-half
SA sinoatrial
SAA synthetic amino acid
S&E sugar and acetone
SBE subacute bacterial endocarditis
SBFT small bowel follow through
SBS short bowel syndrome
SCr serum creatinine
SEM systolic ejection murmur
SG Swan-Ganz
SGA small for gestational age
SGGT serum gamma- glutamyl transpeptidase
SGOT serum glutamic- oxaloacetic transaminase
SGPT serum glutamic- pyruvic transaminase
SIADH syndrome of inappropriate antidiuretic hormone
sig write on label
SIMV synchronous intermittent mandatory ventilation
sl sublingual
SLE systemic lupus erythematous
SMO slips made out
SOAP subjective, Objective, Assessment, Plan
SOB shortness of breath
SQ subcutaneous
STAT immediately
SVD spontaneous vaginal delivery
Sx symptoms
T&C type and cross
TAH total abdominal hysterectomy
T&H type and hold
TB tuberculosis
TBG total binding globulin
Td tetanus-diphtheria toxoid
TIA transient ischemic attack
TIBC total iron binding capacity
tid three times a day
TIG tetanus immune globulin
TKO to keep open
TLC total lung capacity
TMJ temporo mandibular joint
TNTC too numerous to count
TO telephone order
TOPV trivalent oral polio vaccine
TPN total parenteral nutrition
TSH thyroid stimulating hormone
TT thrombin time
TTP thrombotic thrombocytopenic purpura
TU tuberculin units
TUR transurethral resection
TURBT TUR bladder tumors
TURP transurethral resection of prostate
TV tidal volume
TVH total vaginal hysterectomy
tw twice a week
Tx treatment, transplant
UA urinalysis
UAC uric acid | umbilical artery catheter
UAO upper airway obstruction
UBD universal blood donor
UC ulcerative colitis | umbilical cord
ud as directed
UFH unfractionated heparin
UGI upper gastrointestinal
URI upper respiratory infection
URQ upper right quadrant
US ultrasound
UTI urinary tract infection
UUN urinary urea nitrogen
UVA ultraviolet A light
VAD venous access device
VC vital capacity
VCT venous clotting time
VCUG voiding cysourethrogram
VDRL Venereal Disease Research Laboratory (test for syphilis)
VMA vanillymadelic acid
VO verbal or voice order
V/Q ventilation - perfusion
VRE vancomycin-resistant enterococcus
VSS vital signs stable
VT ventricular tachycardia
VV varicose veins
VW vessel wall
VWD von Willebrand's disease
VZV varicella zoster virus
WB whole blood
WBC white blood cell or count
WBR whole body radiation
WD well developed
WF white female
WIA wounded in action
WID widow, widower
WM white male
WN well nourished
WNL within normal limits
WO written order | weeks old | wide open.
WOP without pain
W.P. whirlpool
WPW Wolff-Parkinson-White
W-T-D wet to dry
W/U workup
X2d times 2 days.
XI Eleven
XII Twelve
XL extended release. | extra large.
XM Crossmatch
XMM Xeromammography
XOM extraocular movements
XRT X-ray therapy (radiation therapy)
XS Excessive
XULN times upper limit of normal
YF yellow fever
YLC youngest living child
yo years old
YOB year of birth
yr year
ytd year to date
ZDV zidovudine
ZE Zollinger-Ellison
Z-ESR zeta erythrocyte sedimentation rate
Zn zinc
ZnO zinc oxide
ZSB zero stools since birth
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