NHA CPCT-A Terms and Definitions

Afebrile

Absence of fever

Anuria

Absence of urine formation Apnea - Cessation of breathing

Aspiration

The drawing of fluid and other substances into the lungs

Auscultation

Listening to sounds from the lungs, heart and other organs, often with the use of a stethoscope

Blood pressure

The tension exerted on the walls of the arteries by the contraction of the heart

Bradycardia

Slow heart rate

Bradypnea

Slow breathing

Diarrhea

The passage of fluid, unformed stool

Dyspnea

Difficult or labored breathing

Dysuria

Painful or difficult urination

Edema

Excessive fluid buildup in body cavities or tissue

Enuresis

Involuntary discharge of urine after the age at which bladder control should have been established

Hematuria

Blood in the urine

Hyper

Prefix meaning above, excessive, or beyond

Hypo

Prefix meaning below, under, beneath or deficient

Hypoxia

An oxygen deficiency in the tissues of the body

Inspection

Visual examination of the external surface of the body

Manipulation

To move or feel a part of the body with the hands

Melena

Black, tarry stool caused by digested blood in the GI tract

Nocturia

Excessive or frequent urination after going to bed

Orthopnea

Labored breathing that occurs while lying flat and improves when standing or sitting up

Ostomy

A surgically formed fistula connecting a portion of intestine or urinary tract to a site outside the body

Palpate

Examine by touch

Percussion

Tapping a body part (usually with a finger or a small hammer) to determine position, size, or density of underlying organ

Polyuria

Excessive production of urine

Position

The manner in which the body is arranged

Pyrexia

Elevated body temperature

Pyuria

Pus in the urine

Tachycardia

Rapid heart rate

Tachypnea

Rapid breathing

Abuse

Injurious, pathological, or malignant treatment of another person. Such abuse includes physical, mental, sexual, or financial factors.

Dehydration

The clinical consequences of a negative fluid balance. Marked by thirst, orthostatic hypotension, tachycardia, delirium, falls, hyperthermia, renal failure, and death.

Domestic violence

Mistreatment or injury in a domestic setting. This includes physical violence as well as psychological, emotional, and economic abuse.

Malnourishment

A condition resulting from either an inadequate or excessive exposure to nutrients. Common causes are inadequate calorie consumption and the inadequate intake of essential vitamins.

Neglect

Inattention to one's responsibilities (especially those related to a dependent person)

Pressure sore

Damage to the skin or underlying structures caused by tissue compression and inadequate perfusion. The most common sites of breakdown are bony prominences. If left untreated, the area can slough off all the skin, muscle, and tissue to the bone. This can result in gangrene.

Sharps container

A container used for medical articles that may cause a puncture or cuts to those handling them. This includes broken medical glassware, syringes, needles, scalpels, and disposable razors.

Automated external defibrillator (AED)

A device that identifies cardiac arrhythmias and stops them by applying an electric charge to a patient's heart, which interrupts the arrhythmia and gives the patient's heart a chance to reset to a normal rhythm

Cardiopulmonary resuscitation (CPR)

A manual procedure involving chest compressions and rescue breathing that provides air exchange and blood circulation to a person whose heart has stopped beating

Chain of command

A military term that refers to the formal hierarchy within an organization; it is a pathway of communication, responsibility, and authority; it is important that each person in an organization be aware of their place, whom they report to, and whom reports to them

Compressions

The act of pressing down on the sternum of a patient in a rhythmic and intentional manner to stimulate the heart to circulate, or pump, blood throughout the patient's body; these are done in response to a patient who has no pulse, and is usually accompanied by rescue breathing; also known as chest compressions

Electronic health records (EHRs)

Computer systems for the storage, manipulation, and retrieval of patient information; replaces the traditional paper-based medical record; EHR generally refers to a system-wide application, such as in a hospital or across a health system, whereas an electronic medical record (EMR) is a single provider electronic record usually seen in a physician's office or a small clinic setting

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Legislation that established the foundation for privacy protection of health information (HIPAA Privacy Rule) and set the standards for the transmission of electronic health information (HIPAA Security Rule) to ensure its confidential transmission

HITECH Act of 2009

Legislation that further delineates privacy and security issues around patients' protected health information and raises the penalties for any breach; it also changes the accountability to include individuals, not only organizations;in addition, it sets a goal for the transition to electronic records across all health care organizations and provides for an incentive, or financial program, to encourage quick adoption and use of electronic health record technology; the act is part of the American Reinvestment and Recovery Act of 2009 (ARRA)

Joint Commission (TJC)

An independent, nonprofit organization that accredits more than 19,000 health care facilities in the U.S.; accreditation is granted upon review of each facility's adherence to a set of standards around patient care, documentation, organization leadership, facilities, and more; although there are other accrediting agencies, accreditation by the Joint Commission remains the gold standard in hospital and health care accreditation; the Joint Commission was formally known as the Joint Commission on the Accreditation of Health Care Organizations (JCAHO).

Organizational chart

A graphical representation of the hierarchy, or chain of command in an organization, with names and titles in boxes that link to other boxes in vertical orientation to signif y reporting structure or in horizontal orientation when duties are shared or exist outside the command structure; also known as an org chart; the chief executive officer or president of a firm appears at the top of an org chart; large organizations have multiple organizational charts that break into departmental hierarchies to show the details across the organization

Therapeutic communication

A face-to-face communication process; the goal of therapeutic communication is to promote a patient's physical and emotional well-being; specific techniques help the health care professional gather information they need to identify illness, assess patient behavior, evaluate for modification when necessary, and provide patient education

Aseptic

A condition free from germs or infection

Biohazard

Anything that is potentially harmful to humans, other species, or the environment

Compromised host

A person who lacks resistance to infection, owing to a deficiency in any of their defenses

Environment

The surroundings, conditions, or influences that affect an organism or the cells within it

Exposure

Contact with an agent able to cause disease or injury, such as bacterium or other contagious microbes

Infection

A disease caused by microorganisms, especially those that release toxins or invade body tissues

Isolation

The physical separation of individuals with certain infections from others; used to prevent or limit the transmission of this infection

Nosocomial

Pertaining to or occurring in a health care setting (such as a nursing home or hospital)

Pathogen

A microorganism capable of producing a disease

Precaution

An action taken in advance to protect against danger or possible failure

Standard precautions

Guidelines recommended by the CDC used to reduce the risk of the spread of infections in hospitals of the spread of infection in hospitals

Sharps

A colloquial term for medical articles that may cause punctures or cuts to those handling them; includes broken medical glassware, syringes, needles, scalpel blades, suture needles, and disposable razors.

Transmission

Transfer of anything, including a disease or hereditary characteristic

Antecubital (AC) fossa

The area between the upper and lower arm, when the arm is palm up. It is the area most often used for venipuncture.

Bevel

The angled part of a venipunture needle

Blood culture

A blood specimen used to detect the presence of microorganisms in the blood

Capillary

The smallest type of blood vessel, located in the periphery of the body

Chain of custody

Documentation, handling, and transport of a specimen

Chlorhexidine

A disinfectant used to clean skin before venipuncture. It is used specifically when cleaning the skin prior to obtaining a blood culture.

CLIA

Clinical Laboratory Improvement Amendments. These are federal regulatory standards for laboratories that perform laboratory testing of human samples.

Cyanosis

Blue coloration of the skin caused by lack of oxygen or decreased circulation

Finger stick

method of obtaining blood samples when veins cannot or should not be used

Heel stick

Method of obtaining blood samples when veins cannot or should not be used

Hematoma

A localized collection of blood; the most common complication associated with venipuncture

Hemoconcentration

A concentrated blood sample caused by excessive pressure forcing fluids from the blood

Hemolysis

Destruction of red blood cells

Inversion

The process of turning blood tubes back and forth after they have been collected. Inversion is done to mix the blood sample with additives in the tubes.

Isopropyl alcohol

A disinfectant that is used to clean skin prior to a venipuncture

Lancet

A small sterile blade that is used to puncture the skin when performing a finger stick or a heel stick

Lateral

A medical term that refers to parts of the body away from the center

Medial

A medical term that refers to parts of the body that are at or near the center

Palpation

Touching or examining the body with the fingers

Peripheral smear

A specialized blood collection, used most often to check the white blood cell differential

Petechiae

Tiny hemorrhages that look like small red or purple spots on the skin.

Phlebitis

Inflammation of a blood vessel

Phlebotomy

The process of accessing a blood vessel to obtain a blood sample

Sclerosis

A narrowing and scarring of blood vessels

Stat

A medical term that means immediately or without delay

Sterile

Absence of microorganisms

Syncope

A sudden loss of consciousness, more often called fainting

Thrombus

A blood clot inside a blood vessel

Tortuous

Twisted

Tourniquet

A medical device wrapped around arm prior to performing a venipuncture

Vacutainer

A brand name of a piece of phlebotomy equipment; a plastic sleeve that holds a venipuncture needle and a blood collection tube

Venipuncture

The process of puncturing a blood vessel to obtain a blood sample

Winged infusion set

A piece of medical equipment that is used to perform venipucture; commonly called a Butterfly set.

Angina Pectoris

The sensation of pain or discomfort in the chest. Typically divided into "stable" and "unstable" episodes. Stable angina typically occurs with exercise and is relieved with rest or medication. Attacks usually last less than 20 minutes and occur with an expected pattern or frequency. Unstable angina is characterized by pain that occurs suddenly and without warning. Pain may last in excess of 20 minutes and may not be relieved with the usual measures. It represents a change in frequency and character from the patient's "usual" pain.

Aorta

The largest artery in the human body. The aorta carries oxygenated blood away from the heart.

Aortic valve (aortic semilunar)

The aortic semilunar valve prevents blood in the aorta from returning to the left ventricle during diastole

Apex

The lower pointed end of the heart Arrhythmia - An abnormal heart rhythm

Arteriosclerosis

A chronic disease characterized by thickening and hardening of the arteries

Artifact

Electrical or magnetic interference that alters the EKG tracing

Asystole

The absence of any electrical activity in the heart Atherosclerosis - Plaque buildup on the inner lining of blood vessels