Hospital and Associated Clinical Units

The Hospital and Associated Clinical Units
http://www.clinicalterminology.org/
home.php
The abbreviations for hospital-associated locations are usually the first letters of the term
denoting the location. Each letter is pronounced separately.
Hospital Locations
Study the following general hospital locations:
1) Emergency Room: Site in the hospital where patients receive emergency care.
Abbreviation= ER
Listen to how it would be heard on a clinical unit.

Loaded: 0%
Progress: 0%
Time Left 0:02

2) Emergency Department: Site in the hospital where patients receive emergency care.
Abbreviation= ED

Loaded: 0%
Progress: 0%
Time Left 0:02

3. Operating Room: Where surgery is performed.
Abbreviation= OR

Loaded: 0%
Progress: 0%
Time Left 0:02
Specialized Hospital Units

Study the following specific hospital units:
1) Intensive Care Unit: Where patients who are critically ill receive highly technical, lifesaving
care.
Abbreviation=ICU
Loaded: 0%
Progress: 0%
Time Left 0:03

2) Coronary Care Unit: Unit specializing in care of patients with acute coronary problems.
Abbreviation=CCU

Loaded: 0%
Progress: 0%
Time Left 0:02

3) Post Anesthesia Care Unit: A unit where patients recover from anesthesia.
Note: This location is abbreviated when written using first letters. It is pronounced using the
first syllable and the last letter.
Abbreviation (written) = PACU
Abbreviation (spokenl) = “Pac U”

Loaded: 0%
Progress: 0%
Time Left 0:02
Other Care Facilities

Study the following alternative care facilities:
1) Long Term Care: Facility that provides extended nursing care.
Abbreviation=LTC

Loaded: 0%
Progress: 0%
Time Left 0:02

2) Long Term Acute Care Hospital: Special care hospital or unit for patients who are
chronically acutely ill.
Note: This location is abbreviated using first letters. However, it is pronounced using the first
letter and a syllable within the word that lends itself to verbal usage.
Abbreviation (written) = LTACH
Abbreviation (spoken) = "L Tack"

Loaded: 0%
Progress: 0%
Time Left 0:02
Abbreviations and Terms Related to

Electronic Medical Records
U.S. regulations support the implementation of Electronic Medical Records systems in all
health care facilities and physicians' offices. Electronic Medical Records are password-
protected with the aim of protecting confidentiality of medical information.
Electronic Medical Record (EMR) is a system of electronic clinical documentation within an

institution or health care system. It is a digital version of a patient's paper "chart" for an
institution or health care system.
Abbreviation: EMR

Loaded: 0%
Progress: 0%
Time Left 0:12

Example
View an example of the vital signs portion of an EMR. Based on your prior knowledge, try to
answer the following questions:
 What is the heart's BPM?

 What is the RPM?
 How is the SpO2?
 Do you recognize the word apical?
 Note the difference in BP over 4 hours. Write down your description. Is this
normal?
 Are this patient's vitals normal?
Electronic Health Record or EHR is a term sometimes used interchangeably with EMR.
Definitions are evolving and vary. The new practitioner is most likely to use the EMR, a digital
form of what was previously the patient’s chart. The EHR is a collection of records from
sources (labs, providers from different health systems, etc.) and reflects the broader scope of
the patient’s health. The EMR can be accessed by health care providers in the hospital (For
example, a radiology technician needs to know when a patient had his last dose of a
medication.) or by those outside of the hospital such as emergency medical services or
community practitioners.
Administering Medications
1) Electronic Medication Administration Record
Using technology and bar coding, the Electronic Medication Administration Record or eMAR
facilitates the prescribing of medications, dispensing by the pharmacy, and administration by
the nurse. The pharmacy electronically receives the physician’s order, and the drug is
prepared and barcoded. The nurse administering the medication checks for barcode match
with the patient’s ID bracelet as well as eliciting the patient’s name. Using the eMar helps to
ensure that the right medication is given to the right patient. The medication, time and
administrator’s identification are automatically recorded in the EHR.
Abbreviation: eMAR

Loaded: 0%
Progress: 0%
Time Left 0:07
Example
View an example of an eMAR. You may notice information about medication dosing and
timing, as well as abbreviations for the names of specific medications.
2) Medication Cart
Patient medications are typically maintained and transported on a work station that can be
moved from room to room.
A Medication Cart is a portable work station containing a computer, patient medications,

and supplies.
Abbreviation: Med cart

Loaded: 0%
Progress: 0%
Time Left 0:15
Abbreviations and Terms related to the

History and Physical Examination
An important part of an EMR is the history and physical examination, which is usually
performed by a physician, nurse practitioner, or a physician’s assistant. Understanding the
abbreviations used in a patient’s history and physical examination will help you to read the
examination report and understand conversations about it.
Abbreviations in the History and Physical Exam

Study the following list of written abbreviations:
 History and physical: H & P

 History of present illness: HPI
 Chief complaint: CC
 History: HX
 History of____: H/O
 Past medical history: PMH
 Review of systems: ROS
1.
Вопрос 1
A physician asks that you read the first paragraphs of a patient’s history and physical to him over the
phone. You have the notes from the N.P. This physician is not accustomed to using abbreviations so
you “translate” the note using only full medical words.
Instructions: In the box below type your report to the doctor using full words instead of
abbreviations.
Hello Dr. Hall, I will read the History and physical notes provided to me by Betty Smith our
C.R.N.P.
Chief complaint: Pain left lower leg
History of present illness: 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 hrs) prior to onset of pain. Pts sx of
pain increase with AMB. No history of prior episodes of calf pain. No history of blood clotting
problems. No history of prior phlebitis. Dx possible DVT
Вопрос 2
Instructions: Now reinforce your learning by completing the exercise below. Transcribe the
sentences from the History and physical replacing the abbreviations with the full words.
Chief complaint: Pain left lower leg History of present illness: The pt was well until 24 hrs ago when
he noticed pain and swelling in the posterior left lower leg.
Patient Health Care Practitioner Notation

As you have learned, nursing notes contain many abbreviations that are used in both speech
and writing. They follow the first letters rule and must be memorized.
Abbreviations Related to the Patient’s Status or Care

Study the following list of abbreviations:
1) Do Not Resuscitate
Abbreviation= DNR

Loaded: 0%
Progress: 0%
Time Left 0:10
Example
Pt confirmed DNR order.
2) Do Not Intubate
Abbreviation= DNI

Loaded: 0%
Progress: 0%
Time Left 0:10
Example
Discussed DNI with pt.
3) Comfort Measures Only
Abbreviation= CMO

Loaded: 0%
Progress: 0%
Time Left 0:10
Example
You will hear "The family agreed with a CMO order." You will read: Family agreed with CMO.
4) Against Medical Advice
Abbreviation= AMA

Loaded: 0%
Progress: 0%
Time Left 0:09
Example
You will hear, "The patient left the hospital AMA." You will read: Pt left hospital AMA.
5) Discontinue
Abbreviation= D/C

Loaded: 0%
Progress: 0%
Time Left 0:05
Example
You will hear "DC the antibiotic." You will read: DC antibiotic.
6) Complains of
Abbreviation= C/O
You will hear “The patient complains of leg pain when ambulating”
You will see: Pt c/o leg pain c amb.
The two abbreviations below are derived from Latin and will require memorization.
Written Forms
1) with = c̄
Example
You will hear "Out of bed with assistance." You will read: OOB c̄ assistance
2) without = s̄ , w/o
Examples
 You will hear "Ambulating without pain." You will read: Amb s pain.
 You will hear "Ambulating without pain." You will read: Amb w/o pain.
The three abbreviations below use a first letter and then an X substituting for the remainder
of the word.
1) treatment = tx
Example
You will hear "Lotion treatment for pruritus applied." You will read: Lotion tx for pruritus
applied
2) symptoms = sx
Example
You will hear "The patients only symptom is fatigue." You will read: The pts only sx is fatigue.
3) diagnosis = dx
Example
You will hear "The diagnosis is probably appendicitis." You will read: Dx probably
appendicitis.
Frequently used Latin term

1) As desired = Ad lib

Loaded: 0%
Progress: 0%
Time Left 0:05
Example
You will hear "The patient ambulates to the bathroom as desired." Or “The patient ambulates
to the bathroom ad lib.” You will read: Pt amb to BR ad lib.
Abbreviations and Terms Related to Clinical Assessment

Notation
Clinical Assessment Notation
This reading presents common abbreviations used to describe the assessment of patients’
physical or mental status. Most of them are used in writing. They are organized according to
systems of the body.
Musculoskeletal System
Study the following abbreviations related to musculoskeletal activity:
1) Range of Motion
Abbreviation= ROM
Examples
 You will hear "As we bathed the patient, the RN showed me how to move each of
his major joints through range of motion."
 You will read: ROM to upper and lower extremities.
2) Active Range of Motion
Abbreviation= AROM
Examples
 You will hear "Active range of motion is restricted by pain.

 You will read: AROM right knee limited by pain to 50% of normal.
3) Activities of Daily Living
Abbreviation= ADLs

Loaded: 0%
Progress: 0%
Time Left 0:02
Examples
 You will hear "A part of nursing or the OT's assessment is noting what ADL’s the
patient is able to perform independently.
 You will read: Independent in all ADLs except applying socks and shoes.
Neurological System
Study the following abbreviations related to the neurological system:
1) Pupils Equal, Round, React to Light and Accommodation
Abbreviation=PERRLA
Examples
 You will hear "Neuro evaluation of optic nerve function showed pupils equal,
round and reactive to light and accommodation." You will read: PERRLA
2) Loss of Consciousness
Abbreviation=LOC

Loaded: 0%
Progress: 0%
Time Left 0:02
Examples
 You will hear "The patient says he lost consciousness for 30 minutes."
 You will read: Claims LOC 30 minutes.
3) Level of Consciousness
Abbreviation=LOC

Loaded: 0%
Progress: 0%
Time Left 0:02
Examples
 You will hear "Her level of consciousness is improving." You will read: LOC
improving.
4) Alert and Oriented to Time, Place and Person
Abbreviation=A&O x3

Loaded: 0%
Progress: 0%
Time Left 0:03
Examples
 You will hear "The patient is alert and oriented to time, place and person" or "The
patient is alert and oriented to all three spheres." You will read: A&O x3.
Cardiopulmonary System (Heart and Lungs)

Study the following abbreviations related to the cardiopulmonary system:
1) Normal Sinus Rhythm
Abbreviation=NSR
Examples
 You will hear "He's in NSR." You will read: No C/O chest pain. NSR P84 R22.
2) Breath Sounds
Abbreviation=BS
Examples
 You will hear "As I listen to his breath sounds, I am hearing crackles at the left
base." You will read: BS=Crackles at left base.
3) Short of Breath or Feeling that one cannot breathe fully or comfortably
Abbreviation=SOB

Loaded: 0%
Progress: 0%
Time Left 0:03
Examples
 You will hear "He has less complaints of shortness of breath." You will read: Less
C/O SOB.
4) Paroxysmal Nocturnal Dyspnea or Becoming short of breath after lying recumbent.
Abbreviation=PND

Loaded: 0%
Progress: 0%
Time Left 0:02
Examples
 You will hear "The patient reports awakening with PND and getting out of bed to
open a window." You will read: Pt c episode PND. Got OOB to open window.
Gastrointestinal System
Study the following abbreviations related to the gastrointestinal system:
1) Abdomen
Abbreviation=ABD
Examples
 You will hear "He has had severe abdominal pain for 2 hours."
 You will read: Abd palpation reveals peri-umbilical pain and rigidity.
 An exception: ABD is spoken when referring to the dressing or wound covering.
You will hear "Please bring me four ABD dressings."
2) Nausea and Vomiting
Abbreviation=N/V
Example
 You will hear "Bowel sounds are active."

 You will read: BS active 12 hrs. S/P colectomy. No c/o N/V.
3) Bowel Movement or Evacuation of feces from the lower intestine.
Abbreviation=BM

Loaded: 0%
Progress: 0%
Time Left 0:02
Examples
 You will hear "He has not had a BM in three days." You will read: No BM X3 da.
4) Bowel Sounds or sounds heard when listening (usually with a stethoscope) to noises in the
abdomen.
Abbreviation=BS

Loaded: 0%
Progress: 0%
Time Left 0:02
Example
 You will hear, "Bowel sounds are active 12 hours following the colectomy." You
will read BS active 12 hrs. S/P colectomy.
5) Gastrointestinal or about the esophagus, stomach, small and large intestines.
Abbreviation=GI

Loaded: 0%
Progress: 0%
Time Left 0:02

Examples
 You will hear "The GI workup reveals a tumor near the junction of the small and
large intestine.
 You will read: GI work up –tumor junction sm and lg intestine.
Genitourinary System
Study the following abbreviations related to the genitourinary system:
1) Genitourinary
Abbreviation=GU

Loaded: 0%
Progress: 0%
Time Left 0:02
Example
 You will hear "I will do a GU work up to find origin of the hematuria. You will read:
will do GU work up for hematuria.
2) Intake and Output
Abbreviation=I & O

Loaded: 0%
Progress: 0%
Time Left 0:02
Example
· You will hear "Record the i and o." You will read: i & o q 8 hrs.
The Surgical Patient: Mrs. Gerto

The Surgical Patient: Mrs. Gerto
It is time to learn clinical terminology using vicarious clinical experience.
If you have had little or no experience working on a U.S. clinical unit, and you have not taken
the “Video Tour”, do so now.
If your learning experience has been interrupted, or if English is a new language for you, it will
be beneficial to listen to the audio description of the patient Mrs. Gerto again. This time listen
carefully to Dx.
As you proceed through the case, follow the prompts to answer important questions about
your patient's care.
Now it is Time to Meet Mrs. Gerto

Loaded: 0%
Progress: 0%
Time Left 0:34

You stop briefly at the door to your patient’s Room. Mrs. Gerto appears to be sleeping.
You return to the nursing station to use the EMR and learn more about Mrs. Gerto.
The C.C.R.N. helps you to locate Mrs. Gerto’s EMR.

Loaded: 0%
Progress: 0%
Time Left 0:24
Equipment to Protect You and the Patient from Infection

Personal Protective Equipment: Part of standard or universal precautions designed to stop
the spread of infectious organisms; consists of specialized clothing or equipment such as
gloves, mask, eye protection, and gowns.
Loaded: 0%
Progress: 0%
Time Left 0:02

Personal Protective Equipment = PPE
Materials to Care for Wounds

You introduce yourself to the CNL who is putting on the PPE. She says, “Your staff RN is going
to need a good supply of dressings in this room. Please bring several packs of 2 by 2’s, 4 by 4’s
and 6 ABD’s into the room with you.” The CCRN takes you to the supply room to find the
dressings. She explains their varying size and use.
1) Surgical Dressings: Gauze and cotton dressings are referred to by their dimensions. The
most common are square and measure 2 inches or 4 inches on each side.
Abbreviation: dsg (written only)
2 inch by 2-inch surgical dressing (2 x2)
Example
 2x2 dsg
4 inch by 4-inch surgical dressing (4x4)
Example
 4x4 dsg
Listen to how these abbreviations would be heard on a clinical unit.
Loaded: 0%
Progress: 0%
Time Left 0:03
2. Abdominal Dressing: The abdominal dressing or ABD is a large thick more absorbent
sterile gauze and cotton dressing or pad. It is most often used on the abdomen but can be
used anywhere on the body. The size varies, usually 6 inches x 8 inches.
Abbreviations:
 ABD dressing
 ABD

Loaded: 0%
Progress: 0%
Time Left 0:02

You return to Mrs. Gerto’s room, put on the PPE and meet the staff RN who is busy with Mrs.
Gerto’s care. One of the tasks you assist with is changing surgical dressings. When she asks for
a four by four, you know just what she needs.
Loaded: 0%
Progress: 0%
Time Left 1:01

The R.N. produces the following nursing note about Mrs. Gerto.
Nursing Note:
Wound dressing saturated with serosanguinous fluid. No purulent exudate noted, although
the edges of the wound are erythematous and edematous. Dsg. changed. Dr. Diamond
notified of increasing serosanguinous drainage.
Be certain that you understand each of the terms used in the nursing note. Use the clinical
terminology dictionary to assist you.
Dr. Diamond enters the nursing station
Loaded: 0%
Progress: 0%
Time Left 0:17

Doctor’s Order:
Wound VAC to abdominal wound at 125 mmHg suction. Alternate pressure. On 5 min. off 2
min.
Equipment for Wound Care

1) 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

Loaded: 0%
Progress: 0%
Time Left 0:09
Providing Nourishment When a Patient Cannot Swallow

Listen to instructions about feeding Mrs. Gerto.
Loaded: 0%
Progress: 0%
Time Left 0:18
Equipment to Provide Nourishment or Treat Gastro-

Intestinal Problems
1. 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

Loaded: 0%
Progress: 0%
Time Left 0:10
Preventing Deep Vein Thrombosis or DVT when the patient

is immobile.
Listen to instructions about mobilizing Mrs. Gerto.
Loaded: 0%
Progress: 0%
Time Left 0:35
Equipment to Maintain Circulation in the Lower Extremities
1. 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
Loaded: 0%
Progress: 0%
Time Left 0:09

You have completed your learning experience with the surgical patient. Be certain you
understand why Mrs. Gerto required use of the wound vac and the SCD. Next take the practice
quiz for the surgical patient.
The Comatose Patient: Mr. Taggert

The Comatose Patient: Mr. Taggert
As you experience case 2 you will become more familiar with the terms and abbreviations for
treatments and equipment used in caring for a comatose patient. You will be presented with
visual and audio descriptions of the patient and his diagnosis and medical history.
Listen to the audio description of Mr. Taggert.

Loaded: 0%
Progress: 0%
Time Left 0:21

Equipment for Mr. Taggert’s Care
Learn about the specialized equipment needed to care for Mr. Taggert.
Loaded: 0%
Progress: 0%
Time Left 0:18

Providing Nourishment and Medications Directly into the
Stomach
Because he is unable to swallow and N/G tubes cause undue irritation, a special tube has
been placed through the skin into Mr. Taggert’s stomach.
Percutaneous Endoscopic Gastrostomy Tube or PEG tube: The Peg tube is used to provide
food and medications directly into the stomach. You will find the PEG tube at the patient’s left
upper abdomen.
Abbreviation: PEG tube
Unit 3
Guidelines for Safe Use of Abbreviations

Use of abbreviations can be a threat to patient safety. The Joint Commission on Accreditation
of Healthcare Organizations has banned specific abbreviations from being used in health care
facilities. The banned abbreviations are easily confused with other abbreviations and can
cause administration of a wrong dose or use of the wrong route of administration. Prescribing
physicians, nurses, and pharmacists have been asked to refrain from using the following
abbreviations.
Do not use U or u for Unit. An example, a term that you will see in Week 6 is International
Unit. This must be written as International Unit not IU.
Do not use Q.D. to indicate every day. This term should be written out as every day. (Q, O,
and D are similarly shaped can create confusion.)
Do not use Q.O.D. for every other day. This term should be written as every other day.
Do not use MS or MS04 or MgS04 for magnesium sulfate or morphine sulfate.
Recommended Do Not Use Abbreviations.

The following abbreviations are easily misinterpreted. When you see these on a physician’s
order or directive, ask for clarification. Several of the abbreviations below have been included
in the course content so that you will recognize them in clinical situations; however, when
you see these on a physician’s order, ask for clarification or if you are communicating with
another health care team member, be safe, use the entire term.
Avoid use of BT for Bedtime. May be mistaken as "BID" (twice daily). Use “bedtime.”
Avoid use of D/C for discharge or discontinue. Could result in premature discontinuation of
medications. Use "discharge" and "discontinue."
Avoid use of IN for Intranasal Easily mistaken as "IM" or "IV." Use "intranasal."
Avoid use of HS or hs for hour of sleep or half-strength. Obvious easy confusion. Use “hour
of sleep” or “half strength.”
Avoid q.d. or QD for every day. Can be mistaken for q.i.d. Use "daily."
Avoid qhs for nightly at bedtime. May be mistaken for qhr (every hour). Use “nightly at
bedtime.”
Avoid q.o.d. or QOD for every other day. May be confused with "q.d." (daily) or "q.i.d (four
times daily). Use "every other day."
Avoid SC, SQ, sub q for Subcutaneous. SC may be mistaken as SL (sublingual); the "q" in
"sub q" has been mistaken as "every". What if a medication order read, ”morphine 10 mg
sub q 2 hours before surgery" and was misunderstood as every 2 hours before surgery).
Use "subcutaneous.” Remember, if in doubt, ask for confirmation.
Loaded: 0%
Progress: 0%
Time Left 0:11
Maintaining an Open Airway

Loaded: 0%
Progress: 0%
Time Left 0:2
Key Terms
Key Terms
Review the list of key terms used in week 3. Use the PRS List to decode the complex terms
marked with an asterisk (*). Look up others that are unfamiliar to you in the Clinical
Dictionary before proceeding through the lesson.
 Resuscitate
 Arrhythmia*
 Cardiac arrest
 Ventricular fibrillation*
 Defibrillation*
 Seizure
 Neurological*
 Ventricular tachycardia*
5
Mr. Taggert is comatose and unable to clear his own secretions from the respiratory tract. A
tube has been placed in Mr. Taggert’s trachea to provide an airway and allow for removal of
secretions.
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
This is an image of the tracheostomy tube (top white article). Just below is the inner tube
liner or inner cannula, and at the bottom of the photo is the obturator, a closure device.
Loaded: 0%
Progress: 0%
Time Left 0:07

Maintaining an Open Airway: Care of the Tracheostomy
Listen to the instructions given to you by the R.N. and read the short note she added to Mr.
Taggert’s chart.
Nursing Note: Trach suctioned for thick white mucus

Loaded: 0%
Progress: 0%
Time Left 0:39
Equipment for Drainage of Urine from the Body
1. 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

Loaded: 0%
Progress: 0%
Time Left 0:08

2. 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.
Abbreviations:
 foley (written)
 Cath or foley (spoken)
Loaded: 0%
Progress: 0%
Time Left 0:17
Listen as the R.N. provides more information about the Foley Catheter.
Loaded: 0%
Progress: 0%
Time Left 0:28

Consider the following questions: You observed pale yellow urine. What does this tell you
about Mr. Taggert’s hydration status?
The nurse used the abbreviation i and o; be sure you understand this abbreviation. Discuss
any problems answering these questions on the discussion board.
Now you are ready for a short practice quiz about care of the patient who is comatose. Then
you can move on to Case 3, a medical patient.
Health Care Provider Titles

Abbreviation
Term Description
(Written)
A nurse with a 2-year associate to 4-year ba
R.N. Registered Nurse
Plans, organizes and provides direct patien
Clinical Coordinator RN who coordinates patient care activities
C.C.R.N. Registered Nurse or Clinician education/discharge and supervises RNs a
Case Manager patient care.
Certified Registered Nurse A nurse with a master’s or doctoral level ed
C.R.N.P.
Practitioner and medical diagnostic skills.
A nurse with a master’s degree often comb
C.N.S. Certified Nurse Specialist
supervision roles.
Nursing Assistant or Certified A technician with a high school education
N.A. or C.N.A.
Nursing Assistant certification with additional courses.
C.N.L Clinical Nurse Leader RN at master’s level provides administrativ
Dr. Physician (Doctor) Physicians are commonly called Doctor (D
name on their nametag. Example: Dr. John
M.D. (written Physicians are commonly called Doctor (D
Medical Doctor
only) name on their nametag. Example: Dr. John
A professional with 2-4 years of education
P.A. Physician Assistant skills for assessment and medical diagnost
physician. Seen most often on a surgical un
A professional with a master’s degree or hi
P.T. Physical Therapist
and rehabilitation of body movement and
Abbreviations and Terms Related to Emergency Situations

Abbreviations and Terms Related to
Emergency Situations
In this reading you will learn about various types of emergency situations.
1. Code Blue
Code blue is a term usually designating a cardiac emergency. This is often a general
announcement in the hospital calling a medical team to the site to revive or resuscitate the
patient.
Listen to how the term would be heard on a clinical unit:

Loaded: 0%
Progress: 0%
Time Left 0:12

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.
2. 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

Loaded: 0%
Progress: 0%
Time Left 0:15
3. Code
Code refers to cardiopulmonary resuscitation procedures. It can be used as a noun or verb.

Loaded: 0%
Progress: 0%
Time Left 0:09
4. Stat
Stat is derived from the Latin statim, meaning immediately.

Loaded: 0%
Progress: 0%
Time Left 0:07
5. Crash Cart
The crash cart is a set of trays and drawers on wheels, often red in color. It holds equipment
and medications for emergency use.
Loaded: 0%
Progress: 0%
Time Left 0:07
6. Defibrillator
The defibrillator provides electrical therapy that interrupts a fatal arrhythmia, allowing the
heart to reestablish an effective rhythm. Defibrillation is the related noun, and defibrillate is
the verb.
Loaded: 0%
Progress: 0%
Time Left 0:09

Loaded: 0%
Progress: 0%
Time Left 0:07
7. Automated External Defibrillator

The automated external defibrillator, abbreviated as AED, is a portable electronic device that
automatically diagnoses a life-threatening heart rhythm (such as ventricular tachycardia or
fibrillation) and treats the arrhythmia by defibrillation.
Loaded: 0%
Progress: 0%
Time Left 0:13

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. The AED pictured
above was located on the first floor of a large office building. Modern hospital units now use
an AED that has the automatic features plus a manual override so that the healthcare
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.
8. Endotracheal Intubation
Endotracheal intubation is the insertion of a plastic tube into the trachea in order to provide
an open airway.
Listen to how the terms would be heard on a clinical unit:
Loaded: 0%
Progress: 0%
Time Left 0:08
Related Terms
Intubate means to insert an endotracheal tube.
Endo tube is a common abbreviation for endotracheal tube.
9. Bag Valve Mask

A bag valve mask, or BVM, is 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.
Loaded: 0%
Progress: 0%
UUniu
U0:05
Unit 4
Guidelines for Understanding the

Abbreviations for Diseases and Medical
Conditions
As you become more familiar with the anatomy and pathophysiology related to various
diseases, the terms for naming them and the abbreviations used to designate them will
become easier for you. Here are a few guidelines to help as you get started.
1. The majority of abbreviations for diseases follow the first letter rule.
Example: Multiple Sclerosis= MS
This is a simple initialization or use of first letters.
2. When an initialization is easily verbalized it becomes an acronym.
Example: Acute Respiratory Disease Syndrome= ARDS
3. Other abbreviations for diseases are shortened versions of the word.
Examples: Atrial Fibrillation = A Fib
Cancer= CA
When spoken these are “A” “fib” and “C” “A”
These often use the first letters of a word
4. Others may use an abbreviation linked with a word referencing a full term.
Example: Glycated Hemoglobin= Hemoglobin A1C
5. Sometimes an abbreviation with little logical connection to the term is used.

Example: Glycated Hemoglobin= A1C
The briefest form of abbreviation, A1C , is frequently used either spoken “A, one, C” or written
A1C.
Key Terms
Review the list of key terms used in week 4. Use the PRS List to decode the complex terms
marked with an asterisk (*). Look up others that are unfamiliar to you in the Clinical
Dictionary before proceeding through the lesson.
 Arthritis*
 Autoimmune disease*
 Bronchitis*
 Carbon dioxide
 Cartilage
 Diaphragm
 Emphysema
 Flatus
 Glucose
 Lymph
 Mechanical ventilation
 Metabolic*
 Nausea
 Palpitation*
 Quiver
 Spinal cord
 Thoracotomy*
 Transient
 Tremor
Abbreviations and Terms Related to the

Neurological System
Also referred to as the nervous system, the neurological system consists of the brain, spinal
cord, and nerves.
Five Common neurological diagnosis are defined and abbreviations demonstrated below:
1. Cerebral Vascular Accident
Cerebral vascular accident is impaired brain function resulting from decreased flow of blood
to the brain. It is also known as a stroke.
You can break down the roots of the term:
 cerebr- = brain
 vas = vessel
 cular = relating to
Abbreviation: CVA
Listen to how the term would be heard on a clinical unit.

Loaded: 0%
Progress: 0%
Time Left 0:00
2. Transient Ischemic Attack

A transient ischemic attack is the temporary reduction of blood supply and adequate oxygen
to brain cells.
Abbreviation: TIA

Loaded: 0%
Progress: 0%
Time Left 0:00
3. Traumatic Brain Injury

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

Loaded: 0%
Progress: 0%
Time Left 0:00
4. Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis is progressive and fatal degenerative disease of the nerves that
control voluntary muscle function.
Abbreviation: ALS
Loaded: 0%
Progress: 0%
Time Left 0:12
5. Multiple Sclerosis
Multiple sclerosis is 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

Loaded: 0%
Progress: 0%
Time Left 0:09
Now increase your LEARNING POWER

You have been introduced to the following abbreviations for diseases. Read the abbreviation,
say the abbreviation and then say the full name of the disease.
 CVA
 TIA
 TBI
 ALS
 MS

Musculoskeletal System
The musculoskeletal system contains the bones and the cartilage, ligaments, muscles and
other connective tissue that work together to provide us with stability and movement.
Each of the abbreviations below are a form of arthritis and are characterized by joint
inflammation. You can break down the roots of the term:
 arthr- = joint
 -itis = inflammation
There are more than 100 forms of arthritis. We’ll only study two.
1. Osteoarthritis
Osteoarthritis is a 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
It is also called degenerative joint disease.
Abbreviation: DJD
Listen to how the terms would be heard on a clinical unit.

Loaded: 0%
Progress: 0%
Time Left 0:21

See an example of OA on the hands.
2. Rheumatoid Arthritis
Rheumatoid arthritis is a chronic systemic autoimmune disease that causes inflammation of
connective tissue, primarily affecting the joints of the wrists, hands, feet, and cervical spine.
Abbreviation: RA
Listen to how the terms would be heard on a clinical unit.
Loaded: 0%
Progress: 0%
Time Left 0:15

See an example of RA on the hand.
You have been introduced to three common abbreviations for diagnoses related to arthritis.
Read the abbreviation and speak the name of the arthritis.
 OA
 DJD
 RA

Cardiovascular System
The cardiovascular system is the organs and tissues responsible for circulating blood and
lymph throughout the body.
We will study 9 abbreviations for common diagnoses related to the cardiovascular system:
1. Myocardial Infarction
A myocardial infarction is the destruction of heart muscle cells resulting from an interruption
of blood supply to the heart muscle.
Abbreviation: MI
 myo = muscle
 cardi = heart
Loaded: 0%
Progress: 0%
Time Left 0:12

2. Coronary Artery Disease
Coronary artery disease describes narrowing or blockage of the arteries that provide oxygen
and nutrients to the cells of the heart.
Abbreviation: CAD

Loaded: 0%
Progress: 0%
Time Left 0:08
3. Coronary Artery Bypass Graft

A coronary artery bypass graft is 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

Loaded: 0%
Progress: 0%
Time Left 0:10
4. Congestive Heart Failure

Congestive heart failure occurs when the heart is unable to provide sufficient pump action to
maintain blood flow to meet the body needs.
Abbreviation: CHF

Loaded: 0%
Progress: 0%
Time Left 0:07
5. Deep Vein Thrombosis

Deep vein thrombosis is a blood clot in a major vein that usually develops in the legs and/or
pelvis.
Abbreviation: DVT

Loaded: 0%
Progress: 0%
Time Left 0:10
6. Abdominal Aortic Aneurysm

An abdominal aortic aneurysm describes an abnormal dilation of the abdominal aorta, often
asymptomatic. It may require repair to prevent or treat rupture.
Abbreviation: AAA or “triple A”

Loaded: 0%
Progress: 0%
Time Left 0:15

This image shows the location of a triple A:
7. Premature Ventricular Contractions

Premature ventricular contractions describe extra or additional heart beats originating from
one of the ventricles of the heart. These abnormal beats are usually harmless and are felt as a
palpitation or “skipped beat.”
Abbreviation: PVC

Loaded: 0%
Progress: 0%
Time Left 0:14
8. Atrial Fibrillation
A common cardiac arrhythmia produced by rapid unsynchronized movement of the atria and
consequent irregular pulse, atrial fibrillation is often asymptomatic. It is known to increase
risk of CVA or stroke.
Abbreviation: A-fib or (less commonly) AF

Loaded: 0%
Progress: 0%
Time Left 0:17
9. Ventricular Fibrillation
Ventricular fibrillation is an 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

Loaded: 0%
Progress: 0%
Time Left 0:11

You have been introduced to 9 diagnoses related to the cardiovascular system. First (1) read
the abbreviation. Then (2) speak the abbreviation. Lastly, (3) speak the abbreviation and say
the full name of the disease. Example: (1) MI, (2) “M” “I”, (3) “M I is myocardial infarction.”
Repeat this until it feels comfortable and established in your memory.
 MI
 CAD
 CABG
 CHF
 DVT
 AAA
 PVC
 A-fib

Hospital and Associated Clinical Units

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hospital and Associated Clinical Units

Uploaded by

Copyright:

Available Formats

The Hospital and Associated Clinical Units

Listen to how it would be heard on a clinical unit.

Time Left 0:02

Listen to how it would be heard on a clinical unit.

Time Left 0:02

Listen to how it would be heard on a clinical unit.

Time Left 0:02

Specialized Hospital Units

Time Left 0:03

Listen to how it would be heard on a clinical unit.

Time Left 0:02

Abbreviation (written) = PACU

Abbreviation (spokenl) = “Pac U”

Time Left 0:02

Other Care Facilities

1) Long Term Care: Facility that provides extended nursing care.

Listen to how it would be heard on a clinical unit.

Time Left 0:02

Abbreviation (written) = LTACH

Abbreviation (spoken) = "L Tack"

Listen to how it would be heard on a clinical unit.

Abbreviations and Terms Related to

Electronic Medical Record (EMR) is a system of electronic clinical documentation within an

Listen to how it would be heard on a clinical unit.

Time Left 0:12

 What is the heart's BPM?

1) Electronic Medication Administration Record

Listen to how it would be heard on a clinical unit.

Time Left 0:07

A Medication Cart is a portable work station containing a computer, patient medications,

Listen to how it would be heard on a clinical unit.

Time Left 0:15

Abbreviations and Terms related to the

Abbreviations in the History and Physical Exam

 History and physical: H & P

Chief complaint: Pain left lower leg

Patient Health Care Practitioner Notation

Abbreviations Related to the Patient’s Status or Care

Listen to how it would be heard on a clinical unit.

Pt confirmed DNR order.

Listen to how it would be heard on a clinical unit.

Time Left 0:10

Discussed DNI with pt.

3) Comfort Measures Only

Listen to how it would be heard on a clinical unit.

Time Left 0:10

4) Against Medical Advice

Listen to how it would be heard on a clinical unit.

Time Left 0:09

Listen to how it would be heard on a clinical unit.

Time Left 0:05

You will see: Pt c/o leg pain c amb.

Frequently used Latin term

Listen to how it would be heard on a clinical unit.

Time Left 0:05

Abbreviations and Terms Related to Clinical Assessment

 You will hear "Active range of motion is restricted by pain.

Listen to how it would be heard on a clinical unit.

Time Left 0:02

1) Pupils Equal, Round, React to Light and Accommodation

Listen to how it would be heard on a clinical unit.

Listen to how it would be heard on a clinical unit.

Time Left 0:02