clinicals vocab

acute care

the care of people with a short illness

alzheimer’s disease

a brain disease of later life that comes with changes in the brain tissue with gradual loss of memory and mental illness

ADL

activities of daily life

advance directive

identifies the resident’s wishes during an emergency regarding lifesaving efforts

airborne precautions

actions taken to minimize the transmission of infectious agents that remain infectious when suspended in the air

ambulation

the ability to walk from place to place independently

AMA

against medical advice

anuria

presence of urine or a very small amount of urine (under 100cc) in a 24 hour period

aphasia

absence of speaking

apical pulse

number of heartbeats when using a stethoscope

aspiration

person takes food, liquid, or an object into the airway

assisted living

a place for people who require a certain amount of suvervised assistance in meeting basic needs, but less than a skilled facility

atrophy

a wasting, weakening, or decrease in size of muscle due to disease, injury, or lack of use

AX

temperature taken at the axilla

bed pad

protective waterproof covering used for incontinence

bedpan

piece of equipment used to collect urine and feces

b.i.d

twice a day

biohazard containers

dispose of equipment and supplies contaminated with infectious wastes

biohazardous waste

items that are contaminated with blood, bodily fluids, feces, or any other bodily substances that could be harmful

bloodborne pathogens

microorganisms that are present in human blood ans can casue disease

bony prominences

elbows, shoulder blades, tailbone, hip bones, ankles, heels

BP

the force of the blood against the artery walls as the heart beat

brachial pulse

pulse in the upper arm

care plans

written plans developed by the nurse that outline the steps taken by the staff to reach the goals or outcomes set

cc/ml

cubic centimeter

chart

written record of all care received within a facility

charting

the act of making notes of care and observation

chemical restraint

a medication that reduces a person’s ability to move freely

Cheyne Stokes Respiration

a person will have periods of apnea lasting at least 10 seconds along with alternating periods of deep and slow breathing

closed bed

bed completely made with bedspread in place; for a resident who will be out of bed all day

code

when a group of specially trained staff is called to provide advanced life support to a resident in arrest

colostomy

opening into the colon

commode

chair containing a bedpan or bucket used to collect urine and feces

contact precautions

measures that are intended to prevent the transmission of infectious agents that are spread by direct or indirect contact with a resident

contractures

abnormal shortening of a muscle resulting in the disability of a limb; permanent shortening of the muscle

CVA

ceasing of bloodflow to the brain is stopped either by breakage or blockage of a vessel (stroke)

cyanosis

blue tinge to skin due to lack of oxygen

cystitis

inflammation of the bladder

DAT

diet as tolerated

dangling

position with the resident sitting on the side of the bed with legs over the side

delegation

the assignment of any responsibility to another person to carry out specific task (giving someone a task)

dementia

loss of mental abilities such as thinking, remembering, reasoning, and communicating; decline in a person’s mental ability that is severe enough to interfere with his/her daily life

dementia with lewy bodies

3rd most common type of dementia that shows the clumps of the protein alpha-synuclein that develop in the cortex

diaphoretic

heavy sweating or perspiration

discharge

when a patient leaves a facility

disoriented

not aware of person, place, or time

draw sheet

half-sheet used for lifting and moving residents

droplet precautions

actions designed to reduce or prevent the transmission of pathogens spread through close respiratory secretions

dysphagia

difficulty swallowing

dyspnea

difficulty breathing

dysuria

painful urination

edema

swelling of body tissues due to accumulation of fluids

elder abuse

7 types: psychological/verbal, physical, neglect, sexual, domestic, involuntary seclusion, financial, exploitation

emesis

vomiting

encephalitis

inflammation of the brain

endoscope

instrument for examining the inside of the organ

enema

introduction of fluid into the colon through the rectum to cleanse the colon of feces

etiology

factors involved in causing a disease

expiration

when air is removed from the lungs during breathing

fecal impaction

inability to pass stool because it has formed into a large mass, toward the lower part of the colon

foley catheter

flexible tube that is passed through the urethra and into the bladder to drain urine

fowler’s

head of the bed is usually elevated to a 45-75 defree angle, knees may be slightly bent

gait

manner of walking

gait belt

transfer belt used to assist with walking

geriatric chair

a special chair with an attached lap table

glycosuria

glucose in the urine

graduate

measuring container with markings for ounces and cubic centimeters used for measuring body fluids

“hat”

specimen pan, usually plastic, used to collect and measure urine and stool from the toilet

HIPAA

health insurance portability and accountability act of 1996, law which protects the privacy of individual identifiable health information

hematuria

blood in the urine

hemiplegia

paralysis on one side of the body

hemoccult

test performed to check for occult blood in the stool

hemorrhage

excessive flow of blood, severe bleeding

holisitc health

care involving the entire person, including their physical, emotional, spiritual, and social needs

hypertension

high blood pressure

hypotension

low blood pressure

I & O

intake and output

incident report

a report completed whenever an accident or injury occurs to a resident staff, or visitor that documents the incident along with the response to the incident

VRE

Vanomycin Resistant Enterococcus; an infectious disease caused by a bacteria resistant to the drug Vancomycin

vital signs

signs of life; pulse rate, respiratory rate, body temperature, blood pressure

vertigo

dizziness, room seems to be spinning

vein

vessel that carries carbon dioxide rich blood towards the heart

vascular dementia

multi-infarct; most common type of dementia (shows up in the brain)

urinary retention

when urine is retained in the body

urinal

plastic container used to collect urine from males

urgency

the need to urinate or have a bowel movement right away

urethritis

inflammation of the urethra

trendelenburg

position with the resident in the back with the HOB down and FOB up

Transmission Based Precautions (Isolation Precautions)

steps taken to prevent the spread of infection by identifiying potentially infectious and using precautions

transfer

moving a resident from one location to another

tracheostomy

opening into the trachea to open an airway

TPR

temperature/pulse/respiration

TIA

transient ischemic attack (little stroke) warning sign of a CVA

thrombus

blood clot

temperature

the amount of heat in the body

tachypnea

fast breathing

tachycardia

rapid heartbeat, over 100 bpm

tact

the ability to do or say things without upsetting other people

systemic

pertaining to the whole body

syncope

fainting, loss of consciousness