Medical Notes

Tachy-

Tachy-

Fast

Brady-

Slow

Objective-

Whatever you can prove

Subjective-

What the patient tells you

Bilateral-

Both sides

Ipsilateral-

Same side

Unilateral-

One side

Apnea-

To stop breathing

Pnea-

Something having to do with breathing

Dyspnea-

Having difficulty to breathe

Dys-

Usually it means difficult

Eupnea-

Normal Breathing

Tachypnea--

Fast Breathing

Bradypnea-

Slow Breathing

PRN-

Always needed

Diaphoretic-

Sweaty/Extremely Sweaty

Holistic-

Taking care of the whole patient

Cardia-

Related to heart

Tachycardia-

Fast heart beating

Bradycardia-

Slow heart beating

Hospice-

Expecting this person to die in the next six months or less/ The person may choose to do hospice care at hospital or at home/ Can be any age

Chronic-

Experiencing pain all of the time

Acute-

Pain that is short lived/opposite of chronic/don't know why it happened

C-

With

ADL-

(Activities of Daily Living) Activities that are necessary for daily care of oneself. It includes using the toilet, grooming, dressing, and feeding oneself.

Ambulate-

Walk

CNA-

Certified nursing assistant

PCT-

Patient Care Technician

EKG-

Sticky things put on chest

MA-

Medical Assistant

RX-

Prescriptions

LPN-

Licensed Practical Nurse

RN-

Registered Nurse

DON-

Director of Nursing

Trendelenburg position-

This position looks like the patient is almost turned completely upside down, the head is a lot lower than the feet. You'd put a patient in trendelenburg to get the blood to the brain as quickly as possible. (Blood pressure has dropped extremely low)

Sim's Position-

This position is someone laying on their left side, their legs are straight, your right leg is bent (enema or rectal exam)

Prone-

This position is patient is laying on their stomach

Supine-

This position is patient is laying on their back

Fowler's (Semi) -

Forty five degrees

Fowler's (High) -

Ninety degrees

P-

Offer

S-

Without

A-

Before

Q-

Every

QD-

Every day

BID-

Twice a day

TID-

Three times a day

QOD-

Every other day

QID-

Four times a day

PO-

By mouth

NPO-

Nothing by mouth

STAT-

Immediately

DNR-

Do not resuscitate

DNI-

Do not intubate

Hypo-

Low

Hyper-

High

Normal temperature range-

97.6-99.6

Normal Pulse Range-

60-100 bpm

Respiration-

Counting how many times the person chest rises and falls

Normal Respiration Range-

12-20 bpm

(Blood Pressure) Top Number-

Systolic Number

(Blood Pressure) Bottom Number-

Diastolic Number

Normal Range for Systolic Number-

100-140

Normal Range for Diastolic Number-

60-90

Pain Range-

1 to 10

Oral-

Mouth Temperature

Ear-

Tympanic Temperature

Armpit-

Axillary Temperature

Butt-

Rectal Temperature

Wrist Pulse-

Radial Pulse

If your patient is confused or disoriented-

Never take an oral temperature

Radial Pulse-

Side of the thumb (Most common spot to take a pulse)

Juggular-

Carotid (Located in the neck)

Apical-

At the base of the heart (Need a stethoscope/Most accurate pulse/Needs a full minute)

Popliteal Pulse-

Behind the knee

Pedal Pulse-

Found at the top of the foot

Mastectomy-

Surgical removal of a breast (Blood pressure can not be taken on the side of the Mastectomy)

Hypertension-

High blood pressure

Hypotension-

Low blood pressure

Pre-hypertension

Exhibiting signs of hypertension

Orthostatic hypotension

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

Glucose normal range-

70 to 120

Pulse Oximetry-

Measuring the amount of oxygen in your blood

hx-

History

tx-

Treatment

dx-

Diagnosis

fx-

Fracture

OOD-

Out of bed

ROM-

Range of motion

AMA-

Against medical advice

d/c-

Discontinued or discharge

DOA-

Dead on arrival

a/c-

Give the patient a snack before meals

h/s-

Before bedtime or hour of sleep

w/c-

wheelchair

Ausculate-

To listen

Palpate-

To touch or feel

Gait-

To walk/balanced

Syncope-

To faint

Emesis-

Vomit