Nurses play a critical role in the healthcare field. Their role is centered around effective communication, patient care, and medical documentation. Whether you're a nursing student, a healthcare professional, or simply curious about medical terminology, understanding these common nursing terms is essential. In this article, we'll explore some of the most common nursing terms that you should be familiar with if you go into the nursing field.
Assessment:
The systematic collection and analysis of patient information, including physical, psychological, and social factors, to determine their healthcare needs.
Blood pressure:
Blood pressure measures the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. This is one of the most standard vital signs nurses use to monitor patients.
Clinicals:
Clinical rotations allow students to work on practical nursing skills in various settings under the supervision of an RN clinical instructor.
Chart:
This is a medical documentation that follows a patient’s journey at the hospital. This is normally a digital document and it includes medical history, test and imaging results, diagnosis, medication, and a record of events through each shift.
Charting:
The process of adding to a patient’s chart to keep it up to date and accurate. Nurses often use medical acronyms and abbreviations in their chartings.
Code blue:
A medical emergency, such as a cardiac arrest, that requires immediate attention from a team of healthcare providers. Healthcare workers may shorten code blue to "coding."
Diagnosis:
The process of identifying a patient's health condition or medical problem based on their signs, symptoms, and medical history.
Documentation:
The detailed recording of patient information, care provided, and treatment outcomes in medical records, ensuring accurate communication and legal compliance.
Oxygen saturation:
Measure of how much hemoglobin is bound to oxygen in the bloodstream, which is an indication of how much oxygen is available to the tissues.
Heart rate:
The speed at which the heart beats. It is recorded in beats per minute.
Ileus:
An intestinal blockage that can happen after surgery, with certain medications, infections, or health conditions; may resolve spontaneously or may require surgery.
Infection control:
Practices and protocols designed to prevent the spread of infections within healthcare settings, including proper hand hygiene, isolation precautions, and sterilization techniques.
Respiratory rate:
The number of times a patient breathes in one minute.
Specimen:
A sample of something from a patient’s body, such as urine, blood, skin or other tissue, that is taken for testing and analysis.
Patient centered care:
A holistic approach to healthcare that prioritizes the individual patient's preferences, values, and needs, involving them in their care decisions.
Pain scale:
A scale used to measure a patient’s level of pain. Patients are normally given a choice of one to 10.
Post-op:
Post-op stands for post operation. It includes any care, interventions, and education given after surgery to prepare a patient for discharge or to return to the hospital unit.
Vital signs:
Basic indicators of a patient’s health that typically includes heart rate, respiratory rate, body temperature, pain level, and blood pressure.
ABC:
This is the simple way to remember “airway, breathing, circulation,” which is the order in which nurses assess and prioritize a patient who is unresponsive or unconscious.
CAB:
Following the CAB acronym helps nurses remember “chest compressions, airway and breathing” as the correct order for performing CPR.
CPR:
Cardiopulmonary resuscitation is an emergency procedure commonly used when a patient has stopped breathing.
NCLEX:
Refers to the nursing exam one must pass to become either a licensed practical nurse (LPN) or a registered nurse (RN).
OTC:
Over-the-counter medication that does not require a prescription.
PPE:
PPE stands for protective personal equipment. This includes specialized gear, such as gloves, masks, and face shields which are meant to protect both patients and nurses from contagious bacteria and illness.
Rx:
Prescription
WNL:
"Within normal limit" This means that a patient's test results or activity level are normal.
Nursing is a dynamic profession that requires a solid understanding of effective patient care. By familiarizing yourself with the most important terminology, you'll not only enhance your ability to communicate within the field but also gain a deeper understanding of nursing practices. Whether you're a student, a healthcare professional, or someone seeking to learn more about the medical world, these terms will give you a solid foundation for your journey into nursing.
