Descriptive Terms Used in Documentation Flashcards by Elizabeth Danielson

Abdomen: large and extended outward

enlarged, protruding

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Abdomen: black and blue marks present

bruised, ecchymotic

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Abdomen: hard, board like

rigid

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Abdomen: soft, flabby, flat

relaxed, flaccid

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Abdomen: hurts when touched

sensitive to touch, tender

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Abdomen: appears swollen, rounded

distended

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Abdomen: presence of rash

rash present (mild, severe)

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Abdomen: filled with gas

typmanities

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Amounts: large amount

moderate, measured amount

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Amounts: moderate amount

moderate, measured amount

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Amounts: small amount

small amount, scanty, slight, very little, measured amount

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Appetite: very fussy about food, refused to eat many foods

has definite likes and dislikes concerning food

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Appetite: eats all food served

appetite 100%

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Appetite: eats very little

appetite %used

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Appetite: loss of appetite

anorexia

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Appetite: craving for certain foods

parorexia

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Appetite: refused to eat

refused food (state reason)

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Appetite: eats only small amount

Appetite %used

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Appetite: has desire to eat materials that are not food(chalk, dirt)

Craves chalk, dirt, etc.

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Arm: shoulder to elbow

Upper arm (right or left)

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Arm: elbow to wrist

Lower arm (right or left)

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Arm: with accumulation of fat

Plump

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Arm: appear puff or swollen

edamatous

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Arm: arm artificial

artificial arm (right or left)

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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

Faint: Fainting

Syncope

Feet: Reddened spots or places caused by pressure or friction

Pressure areas present

Feet: Puffy, enlarged, swollen

Swollen, edematous

Feet: Warm, cold

Warm cold

Fever: without fever

afebrile

Fever: fever, temperature above normal

Febrile, pyrexia

Fever: temperature greatly above normal (106)

Hyperpyrexia

Fever: fever suddenly returning to normal

Crisis

Fever: fever gradually returning to normal

Lysis

Fever: temperature below normal

Hypothermia

Fingers: Coming to fine point at end

Tapering

Fingers: Square across the end

Clubbed

Gas: Gas in the digestive tract

Flatus

Gas: Distention caused by accumulation of gas

Flatulence

Gums: Inflammation of the gums

Gingivitis

Gums: Pulling away from teeth

Receding, shrunken

Gums: Bleed when pressure is applied

Bleeding

Gums: Healthy looking

pink, firm

Gums: spongy

spongy

Hair: clean, good appearance

clean, glossy

Hair: unclean, coarse

Greasy, coarse

Hair: uncombed, neglected

Tangled, neglected

Hair: not normal color

bleach, dyed

Hallucination: sensory stim w/o external stimuli

Hallucination

Hallucination: of hearing

Auditory hallucination

Hallucination: of sight

Visual Hallucination

Hallucination: of smell

Olfactory hallucination

Hallucination: of taste

Gustatory hallucination

Hands: dirty, rough, nails broken

Show lack of care

Hands: abnormally large

Massive

Hands: show good care

well kept

Hands: wet, dry

moist, dry

Hands: hot, cold

hot, cold

Hands: shaking continuously

trembling

Head: forehead

frontal region

Head: region of temple

temporal region

Head: back of head

occipital region

Head: base of skull

Basilar region

Head: having a large head

Macrocephalous

Head: having a small head

microcephalous

Heartbeat: Irregularity of heartbeat

arrhythmia

Heartbeat: slowness of heartbeat

bradycardia

Heartbeat: fast heartbeat

tachycardia

Hives: Hives

Urticaria

Hives: Itching

Pruritus

Joints: bending

Flexion

Joints: To straighten

Extension

Joints: Turn downward

Pronation

Joints: Turn upward

Supination

Joints: Revolve around

Rotation

Joints: move away from median line

Abduction

Joints: move toward median line

Adduction

Joints: A stiff joint

Ankylosis

Joints: inflammation of joint

Arthritis

Joints: wrenching of a joint

Sprain

Legs: Thigh to knee

Upper leg (right or left)

Legs: Knee to ankle

Lower leg (right or left)

Lice: Head, body, pubic

Pediculi

Lice: Condition of lousiness

Pediculosis

Lips: Pale colorless

Pale

Lips: Blue in color

Cyanotic

Lips: Presence of tiny crack

Fissured, cracked

Lips: fever blister present

Presence of herpes simplex

Medications: by mouth

orally

Medications: by rectum

rectally

Medications: breathing in

inhaling

Medications: Rubbing into skin

topical, inunction

Medications: under the skin

subcutaneous

Medications: within the skin

intradermal

Medications: within the muscle

Intramuscular

Medications: within the spinal canal

intraspinal

Medications: within the vein

Intravenous

Medications: pouring into the body cavity

Instillation

Medications: into the artery

intra-arterial

Memory: loss of memory

Amnesia

Menstruation: onsent of menstruation

Menarche

Menstruation: Painful

Dysmenorrhea

Menstruation: total absence of

Amenorrhea

Menstruation: profuse of prolonged flow

Menorrhagia

Menstruation: occurring between periods

Menorrhagia

Menstruation: cessation of

Menopause

Mental Attitude: Hard to please

Irritable, fault-finding

Mental Attitude: Distrustful

Distrustful, suspicious

Mental Attitude: Happy

Optimistic, cheerful

Mental Attitude: Sad

Depressed, moody

Mental Attitude: Afraid

Apprehensive, anxious

Mental Attitude: Lacks emotional control

Hysterical, emotional liability

Muscle: A wasting

Atrophy

Muscle: Inflammation of

Myositis

Muscle: Stretching of

Strain

Nails: Blue in color

Cyanotic

Nails: Other descriptive terms

Brittle, clean, torn, manicured

Nourishment: very small amount of fluid

Sips of fluid

Nourishment: Small pieces of ice

Chipped Ice

Nourishment: Drink of Water

Water (number of cc's)

Odor: Pleasant

Agreeable

Odor: Like fruit

Fruity, sweet

Odor: very unpleasant

Offensive, foul

Odor: belonging to a particular substance

Characteristic

Pain: Great pain

Severe

Pain: Little

Slight

Pain: Comes in seizures

Paroxysmal, spasmodic

Pain: Spreads to distant areas

Radiating

Pain: Started all at once

sudden onset

Pain: other descriptive terms

Sharp, sudden, darting, gnawing, burning, stabbing, cramping, shooting, colicky, persistent, transient, constant, shifting, localized, deep, superficial

Paralysis: Of the muscles of the face

Facial

Paralysis: Of the legs

Paraplegia

Paralysis: Of one side of body

Hemiplegia

Paralysis: Of a single limb

Monoplegia

Paralysis: Of all limbs

Quadriplegia

Client admission of: walking

Ambulatory

Client admission of: carried(infant)

In arms

Client admission of: by wheelchair

Per wheelchair

Client admission of: by stretcher

Per stretcher

Client admission of: had a bedsore when admitted

Decubitus present on admission

Perspiration: large amount

Profuse, excessive

Perspiration: small amount

Scanty

Physical Exam: exam by observation

Visual Inspection

Physical Exam: exam by listening to sound

Auscultation

Physical Exam: exam by handling

Manipulation

Physical Exam: exam by palpating

Palpation

Physical Exam: exam by striking

Percussion

Physical Exam: exam by measuring

Mensuration

Positions: Flat on back, arms straight at sides

Dorsal

Positions: Lying on back

Supine

Positions: on side, knees flexed

Lateral

Positions: on left side with right leg flexed

Sims'

Positions: head elevated, knees flexed

Fowler's

Positions: Knees flexed, head slightly elevated

Semi-Fowler's

Positions: on back, buttocks near edge of table, knees flexed and separated

Lithotomy

Positions: on back, knees flexed and apart, feet on table

Dorsal recumbent

Positions: resting on knees and chest

Knee-chest

Positions: on back, pelvis higher than head

Trendelenburg

Positions: On abdomen, face turned to one side

Prone

Positions: Prone with hips over break in table and feet below level of head

Jackknife

Pulse: number of beats per minute

Rate

Pulse: Rhythm

Regular or irregular

Pulse: Beats missed at intervals

Intermittent

Pulse: Over 100 beats per min

Rapid, tachycardia

Pulse: very rapid, beats indistinct

Running

Pulse: a diminished rate

Infrequent

Pulse: slow in rate (under 60 bpm)

Slow, bradycardia

Pulse: Scarily perceptible

Thready

Pulse:"Double Pulse"

Dicrotic

Pulse: According to strength

Weak, Strong

Pulse: Readily perceived (felt)

Perceptible

Pulse: rapid, quite distinct beats

Pounding, bounding

Pulse: cannot be felt

Imperceptible

Reproductive Organs: External reproductive organs

Genitals (external) | Genitalia

Respiration: Act of Breathing

Ventilation

Respiration: Above 20 respirations/min

Accelerated, tachypnea

Respiration: Induced by artificial means

Artificial

Respiration: Snoring

Stertorous

Respiration: Difficult

Labored, dyspnea

Respiration: Alternate periods of apnea and of increasingly deep ventilations

Cheyenne-Stokes

Respiration: Other descriptive terms

Quiet, sighing, gasping, rapid, shallow, deep, costal, audible, noise

Respiration: Absent

Apnea

Restraint: Rails put on bed

4 side rails in place

Restraint: Tied down with sheet

Sheet restraint applied

Rings: Rubber rings to relieve pressure

Placed on rubber ring

Rings: Cotton rings applied under heels

Cotton ring applied to each heel

Scalp: Covered with dandruff

Dandruff present

Scalp: Covered with scales

Scaly

Scalp: Lice found

Presence of pediculi

Scalp: baldness

Alopecia

Scalp: other descriptive terms

Dry, oily, itching

Sensation: Tingling

Tingling

Sensation: Extreme heat, burning

Burning

Sensation: Stinging

Stinging

Sensation: Prickling

Prickling

Skin: Normal

Healthy

Skin: Pink, hot

Flushed

Skin: Blue in color

Cyanotic

Skin: very white

Extreme pallor, pale

Skin: Shines

Glossy

Skin: raw surface

Excoriation

Skin: Yellow in color

Jaundiced

Skin: Torn

Lacerated

Skin: Cold and moist

Clammy

Skin: birthmark

Nevi

Skin: Wart

Verruca

Skin: Boil

Furuncle

Skin: Other descriptive terms

mottled, discolored, moist, dry, hot, cold, warm, oily, calloused, wrinkled, tight, coarse, of fine texture, tanned

Skin: Indicate presence of

Rash, abrasion, laceration, insect bites, tumors, eruptions, acne, crusts, scars, ulcers, moles, fissures, abscess

Skin: a discolored spot

Macule

Skin: a pimple

Papule

Skin: blister

Vesicle

Skin: a pimple filled with pus

Pustule

Skin: containing colored areas

Pigmented

Skin: Wet

Moist

Skin: Scraped

Abraded

Skin: Small red spots on skin

Petechia

Skin: area where skin is rubbed off

Abrasion

Skin: redness off

Erythema

Skin: Hemorrhagic areas (bruises)

Ecchymosis

Sleep: Slept very little

Slept at short intervals

Sleep: Tired when waken

Awaken fatigued

Sleep: moans while sleeping

restless sleep, moaning

Sleep: Inability to sleep

Insomnia

Smoke: Smokes too much

Smokes excessively, ppd

Solution: having same tension as that of the blood

Isotonic

Solution: Of greater tension

Hypertonic

Solution: Of less tension

Hypotonic

Specimen: Sent to laboratory

Spec. to lab

Speech: Speaks normally

Normal Speech

Speech: Not understandable

Incoherent: difficult to understand

Speech: Meaningless, wandering

Rambling

Speech: Words run together

Slurring

Speech: Stammering, stuttering

Stammering, stuttering

Speech: Not speaking distinctly

Inarticulate

Speech: Speaks long and well

Fluent

Speech: Difficulty in speaking

Dysphasia

Speech: Unable to speak

Aphasia

Symptoms: Observed Only by Client

Subjective

Symptoms: Observed by someone other than client

Objective

Symptoms: Combination of signs/symptoms

Syndrome

Taste: As expected, as usual

Normal

Taste: Like metal

Metallic

Teeth: False teeth

Dentures

Teeth: Decay of teeth

Dental Caries

Teeth: Other descriptive terms

Natural, notched, decayed, crooked, protruding, crowded, irregular, broken, loose

Throat: Difficulty in swallowing

Dysphagia

Throat: Inability to swallow

Aphagia

Throat: Other descriptive terms

Red, swollen, inflamed, irritated

Tongue: Descriptive terms

Pink, moist, dry, cracked, coated, raw, swollen, inflamed, ulcerated, scarred

Treatment: Preventative

Prophylactic

Treatment: Offering temporary relief

Palliative

Therapy: Water as therapeutic agent

Hydrotherapy

Therapy: Sunlight as therapeutic agent

Heliotherapy

Therapy: X-ray, radium as therapeutic agent

radiotherapy

Therapy: Drugs a therapeutic agents

Chemotherapy

Therapy: Florescent lights as therapeutic agent

Phototherapy

Urination: To urinate

Void, micturate

Urination: No control over urination

Involuntary, incontinent

Urination: Burning when voids

Burning sensation on micturition

Urination: Large amount of urine voided

Diuresis

Urination: Total suppression of urine

Anuria

Urination: Frequent voiding at night

Nocturia

Urination: Increased amount voided

Polyuria

Urination: Painful urination

Dysuria

Urination: Pus in urine

Pyuria

Urination: Blood in urine

Hematuria

Urination: Hemoglobin in urine

Hemoglobinuria

Urination: Glucose in urine

Glucosuria

Urination: Albumin in urine

Albuminuria

Urination: Acetone in urine

Acetonuria

Urination: Bile in urine

Choluria

Urination: Scantiness of urine

Oliguria

Urination: Sugar in the urine

Glycosuria

Urination: Bedwetting

Enuresis

Urination: Stones in urine

Calculi

Weight: Overweight

Overweight

Weight: Obese

Obese

Weight: Thin, underweight

Emaciated

Wounds: Deep

Deep

Wounds: Slight, surface only

Superficial

Wounds: not infected

Clean

Wounds: Discharging pus

Suppurating

Wounds: Infected

Infected

Wounds: Torn

Lacerated