CRAZY MEDICAL TERMS
The position when someone lies on their back with the HOB up part way
What is Semi Fowler's position
The three times that nurses should use focus documentation to describe something with their patient
1. A current concern or behaviour (ie. decreased U/O) 2. A change in a client's condition or behaviour (ie. suddenly becomes disoriented to person, place & time) 3. A significant event in the client's treatment (ie. return from surgery)
"immediately"
What is STAT
Writing ongoing notes of everything that is happening to a patient
What is Narrative Charting?
as needed
What is PRN
The term used for ringing in the ears
What is tinnitus
The "focus" for the following data: moist breath sounds, coughing, breathing rate at 28/min
What is "Respiratory"
Taking blood
What is a phlebotomy (vein - cutting/opening)
The type of documentation that includes flowsheets, graphic VS sheets and fluid balance records
What is Permanent Documentation Tools
twice a day
What is BID
The medical term for dizziness
What is vertigo
The "focus" for the following condition of the patient: crying, holding abdomen
What is "Pain" (or more specifically "Abdominal Pain")
The terminology that a nurse would document "every four hours"
What is Q4H
A type of documentation form that is used in Residential Care for standardized Dr orders
What is Care Maps/Care Paths
Nothing by Mouth
What is NPO
The nursing skill being described when one uses flexion, extension, abduction and adduction
What is ROM (Range of Motion) exercises
The higher the acuity, the more frequently a nurse should document
What is the principle regarding frequency of documentation in relation to the acuity of the patient?
Kidney removal
What is a nephrectomy
Subjective Data, Objective Data, Assessments, Plan, Implementation, Evaluation, Revision.
What is meant by S.O.A.P.I.E.R documentation
pc
What is after meals
The medical term for looking very pale/bluish
What is cyanotic
The "focus" for the following patient assessment data: very short of breath, is receiving oxygen via nasal cannula at 3 litres/min. Pulse is 118/min, respirations are 36/min.
What is "Dyspnea"
Medical term for disease/suffering in the heart muscle
What is cardiomyopathy
D- Data, A - Action, R - Response, E- Expected Outcome
What is D.A.R.E. focused documentation
Bathroom Privileges
What is BRP