Descriptive Terms Used in Documentation Flashcards
Abdomen: large and extended outward
enlarged, protruding
Abdomen: black and blue marks present
bruised, ecchymotic
Abdomen: hard, board like
rigid
Abdomen: soft, flabby, flat
relaxed, flaccid
Abdomen: hurts when touched
sensitive to touch, tender
Abdomen: appears swollen, rounded
distended
Abdomen: presence of rash
rash present (mild, severe)
Abdomen: filled with gas
typmanities
Amounts: large amount
moderate, measured amount
Amounts: moderate amount
moderate, measured amount
Amounts: small amount
small amount, scanty, slight, very little, measured amount
Appetite: very fussy about food, refused to eat many foods
has definite likes and dislikes concerning food
Appetite: eats all food served
appetite 100%
Appetite: eats very little
appetite %used
Appetite: loss of appetite
anorexia
Appetite: craving for certain foods
parorexia
Appetite: refused to eat
refused food (state reason)
Appetite: eats only small amount
Appetite %used
Appetite: has desire to eat materials that are not food(chalk, dirt)
Craves chalk, dirt, etc.
Arm: shoulder to elbow
Upper arm (right or left)
Arm: elbow to wrist
Lower arm (right or left)
Arm: with accumulation of fat
Plump
Arm: appear puff or swollen
edamatous
Arm: arm artificial
artificial arm (right or left)
Attitude mental: not interested in surroundings
indifferent
Attitude mental: has “don’t care” attitude
apathetic
Attitude mental: doesn’t believe anything said
suspicious, distrustful
Attitude mental: quarrelsome, disagreeable, wants to argue
Belligerent, quarrelsome, disagreeable
Attitude mental: afraid, worried
anxious, fearful
Attitude mental: seems to have weight of world on his shoulders
worried
Attitude mental: happy, carefree, cheerful
cheerful, optimistic
Back areas: upper back
interscapular region, shoulder area
Back areas:small of spine
lumbar region
Back areas: end of spine
sacral region
Back areas: gluteal area
buttocks
Back areas: hump back
Kyphosis
Back areas: sway back
Lordosis
Back areas: lateral curvature of spine
scoliosis
Backrest: Backrest raised
Head of bed elevated (indicate angle, degree)
Baths: Given when client is admitted
Admission bath
Baths: All inclusive bath
Complete bath
Baths: including face, arms, back, axilla, genitals
Partial bath
Baths: special baths (treatment)
Name of the bath (sitz)
Baths: taken in tub
Tub Bath
Baths: taken in bed, by client
Self-administered
Belch: Belching
Eructation
Bleeding: spurting of blood
in spurts
Bleeding: very little
oozing
Bleeding: noseblood
epistaxis
Bleeding: blood in vomitus
hematemesis
Bleeding: blood in urine
hematuria
Bleeding: when bleeding is stopped
hemorrhage controlled
Blister: Blister
Vesicle
Blood Pressure: Blood Pressure 120/74
B.P. 120/74
Breast: inflammation of
mastitis
Breast: each of same size
of equal size
Breast: satisfactory in appearance
Developed normally
Breast: nipple always depressed
inverted nipple
Breast: nipple always depressed
inverted nipple
Breath: unpleasant
Halitosis
Breath: Foul
Fetid
Breath: with sweet, fruitlike odor
fruity, sweet
Breathing: Act of breathing
Ventilation
Breathing: Act of inhaling
Inspiration
Breathing: Act of exhaling
Expirations
Breathing: Difficult breathing
Dyspnea, retracting, grunting, flaring of nares, head bobbing
Breathing: Short period when breathing ceases
Apnea
Breathing: Inability to breathe when lying down
Orthopnea
Breathing: Normal Breathing
Eupnea
Breathing: Rapid Breathing
Hyperpnea, tachypnea
Breathing: Increasing ventilations with period of apnea
Cheyne-Stokes respiration
Breathing: Large volume of air inspired
Deep Breathing
Breathing: small volume of air inspired
Shallow Breathing
Breathing: abnormal variations in rhythm
Irregular respiration
Breathing: Suffocation
Asphyxia
Chest: Looks abnormally small
Shrunken
Chest: abnormally shaped
Deformed
Chest: Hurts when moving or breathing
Pain on moving, pain on breathing
Chill: Blanket
External Heat Applied
Chill: Severity (degree of)
Severe, moderate, slight
Chill: Duration
Protracted, persistent, of short duration
Color: Colorless
Clear
Color: Of normal urine
Amber
Color: Resembling clay
Clay-colored
Color: Tinged with Blood
Blood-tinged
Coma: Partly in coma
Semi-comatose
Coma: In deep coma
Profound coma: does not respond to stimuli
Consciousness: Fully conscious, aware of surroundings
Alert fully conscious
Consciousness: Only partly conscious
Semi-conscious
Consciousness: Unconsciousness, but can be aroused
Stuporous - does respond to painful stimuli
Consciousness: Unconsciousness, cannot be aroused
Comatose
Consciousness: Drowsy but easily aroused
Lethargic
Consistency: Retains its shape
Formed
Consistency: Watery
Liquid
Consistency: Thick, sticky or glue-like
Concentrated, tanacious
Consistency: Containing or resembling mucous
Mucoid
Convulsion: Continuous shaking
Tonic tremor
Convulsion: Shaking with intervals of rest
Clonic tremor
Convulsion: Began without warning
Sudden onset
Convulsion: Spasm or convulsive seizure
Paroxysm
Convulsion: Convulsive seizure with loss of consciousness
Grand mal seizure
Cough: coughs all the time
Continuous cough
Cough: Coughing over a long period of time
Persistent cough
Cough: Coughs up material
Productive cough
Cough: Occurring in spasms
Spasmodic cough
Cough: coughs quite often
Frequent coughing
Cough: cough that doesn’t produce material
nonproductive cough
Cough: with characteristic “whoop”
Whooping Cough
Cough: occurs in paroxysms or attacks
Paroxysmal cough
Cough: other self-explanatory terms
Tight, loose, deep, dry, hacking, harsh, painful, rasping, explosive, exhaustive
Decay: Of teeth
Dental caries
Decay: Of tissue
Necrosis
Defecation: Bowel Movement (material)
Feces, stool
Defecation: Bowel Movement (act of)
Defecation
Defecation: Excessive defecation
Diarrhea
Defecation: Gray Colored Stool
Clay-colored stool
Defecation: Dark brown liquid stool
Highly colored liquid stool
Defecation: Formed, yet soft stool
Soft-formed stool
Defecation: Formed with hardened feces
Hard-formed stool
Defecation: Black, tenacious stool
Tarry stool
Dizziness: Dizziness
Vertigo
Drainage: Water, from nose
Coryza
Drainage: Containing pus
Purulent
Drainage: Bloody
Saquineous
Drainage: Consists of feces
Fecal
Drainage: Of lymphatic fluid
Serous
Drainage: Contains mucus and pus
Mucopurulent
Drainage: Tough, Sticky
Tenacious
Drainage: From vagina (post-delivery)
Lochia
Drainage: Serum and blood combined
Sero-sanguineous
Dressings: A second dressing aded to the first
Dressing reinforced
Dressings: dressing removed, another applied
Dressing changed
Ears: wax in the ears
Cerumen
Ears: Ringing in the ear
Tinnitus
Ears: Abnormal in shape
Deformed
Emesis: Produced by effort of client
Induced
Emesis: Ejected to few feet distant
Projectile
Emesis: If blood is only noticeable
Blood-tinged
Emesis: Agent given to produce emesis
Emetic
Emesis: Return of solids or fluid to the mouth from the stomach
Regurgitation
Enemas: To induce bowel movement
Cleansing enema
Enemas: to supply nourishment
Nutritive enema
Enemas: to relieve distention caused by gas
Carminative enema
Enemas: to be retained for several minutes
Retention enema
Enemas: to aid in fluoroscopy examination
Barium enema
Expectoration: a great deal
Profuse
Expectoration: very little
Scant
Expectoration: spitting up blood
hemoptysis
Eyes: Sharpness of vision
Visual acuity
Eyes: Yellow in Color
Jaundiced
Eyes: Puffy, swollen
Edematous
Ears: Dizziness
Vertigo
Eyes: drooping of lids
Ptosis of lids
Eyes: Motionless, not moving, staring
Fixed
Eyes: Unusually sensitive to light
Photophobia
Eyes: Double Vision
Diplopia
Eyes: Quinting-crossed
Strabismus
Eyes: abnormal protrusion of the eyeball
Exophthalmos
Eyes: inflammation of the conjuctiva
Conjunctivitis
Eyes: Dilation of the pupil
pupil dilated
Eyes: Contraction of the pupil
pupil contracted
Eyes: nearsightedness
myopia
Eyes: farsightedness
hyperopia
Eyes: sees objects indistinctly
blurred vision
Eyes: other characteristics terms (self-explanatory)
Bright, clear, dull, inflamed, sunken, blood shot, burning, smarting
Eyes: Sty of eyelid
Hordeolum
Face: without color
pale
Face: pink
flushed
Face: broken out
presence of rash, acne
Face: black and blue
Bruised, ecchymosis
Face: Characteristic expressions worn
Anxiety, defiance, anger, pain, boredom, fear, worry, happiness, apathy, dissatisfaction
Face: marked with pits and scars
Pock-marked