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ERP Week 2

Standardized Client Assessment breakdowns

All entries in a medical record must include Date and MILITARY time (Ex 2200 hrs = 10pm)
Weight (WT): A quick approximation conversion lb-->kg is Halving the patients weight (WT)
Weight (WT): A exact conversion lb-->kg is achieved by Dividing the patients weight in pounds by 2.2
Ambulation assistance devices include; Cane, walker, extremity braces or wheelchairs
Sensory aids include; glasses, contacts, hearing aids
Lethargy / lethargic (NVS) Mental sluggishness
Stupor / stuporous (NVS) Mental grogginess
Unconscious (NVS) asleep but responds to stimili
Coma / comatose (NVS) Asleep but does not respond to stimili
Syncope / syncopal episode (NVS) To faint, pass-out
Orientation to the three spheres include; (NVS) person, place and time (x3)
Speech difficulties include; (NVS) Slurred, dysphasia, and aphasia
Gait (manner of walking) is described as; (NVS) Stable, unstable, or shuffling
Vertigo (NVS) Dizziness
Parasthesia (NVS) Numbness or tingling
Hand grasp (NVS) Strong, weak, and equal
PEARRLA (NVS) Pupils Equal and Round, Reactive to Light + Accomidation
Accommodation means; (NVS) The patients ability to focus / visual acuity
HOH stands for; (NVS) Hard of Hearing
Tinnitus Ringing or buzzing in the ears
When recording current medications, you should include; OTC, herbal medications and vitamins
Current prescription information should include; 1. Name 2. Dosage 3. Route of administration 4. Frequency
Dosage: mg milligram
Dosage: g gram
Dosage: gr grain
Dosage: supp suppository
Dosage: Tsp. teaspoon
Dosage: Tbsp. tablespoon
Dosage: oz. ounce
Route of administration: PO orally
Route of administration: SL sublingual
Route of administration: subQ subcutaneously
Route of administration: Transdermal Through the skin
Route of administration: INH inhalation
Route of administration: Top topical
Route of administration: PR per rectum
Freq. of Administration; Q.D everyday
Freq. of Administration; B.I.D. twice a day
Freq. of Administration; T.I.D. three times a day
Freq. of Administration; Q.I.D. four times a day
Freq. of Administration; a.c. before meal
Freq. of Administration; p.c after meal
Freq. of Administration; h.s bedtime / hours of sleep
The order that medications should be documented is; Routine medications first, followed by medications as needed (PRN)
Freq. of Administration; PRN as needed
Breath sounds are described as; Clear, Rales, Rhonchi, wheezing, stridor
Breath sounds; Rales Crackling heard on auscultation
Breath sounds; Rhonchi Whistling sound caused by airway constriction
Breath sounds; Stridor High pitched sound indicating obstruction
When auscultating Breath sounds as the patient to; Breath with the mouth open
Breathing descriptions include; 1.Eupnea/eupnic 2.Dyspnea/dyspnic 3.Hypoventiation 4.Bradypnea/bradypnic 5.Tachypnea/tachypnic 6.Orthopnea/orthopnic 7.SOB/shortness of breath 8.DOE/Dyspnea on exertion
Breathing descriptions; Eupnea/eupnic Normal breathing
Breathing descriptions; Dyspnea/dyspnic Difficult or painful breathing
Breathing descriptions; Hypoventilation Shallow breathing
Breathing descriptions; Bradypnea/bradypnic Slow breathing (Hypopnic)
Breathing descriptions; Tachypnea/tachypnic Fast breathing (Hyperpnic)
Breathing descriptions; Orthopnea/orthopnic Easier breathing when sitting straight
Breathing descriptions; DOE Dyspnea on exertion
Cough descriptions include; 1.Productive (producing sputum) 2.Non-productive
Sputum described as; Color, viscosity, and amount
Croup described as; A seal bark cough
Circulation descriptions include; 1.Warmth, color, cyanosis, capillary refill, pulse
Circulation; Capillary refill is described as; Refill from pink to white; slow measure time or immediate
Circulation; Weak pulse Thready or feeble
Circulation; Strong pulse Bounding pulse
Circulation; Apical pulse is located Just inferior to the left papilla
Circulation; Tachycardia / tachycardic Fast pulse or heart rate(HR)
Circulation; Bradycardia / bradycardic Slow pulse or heart rate
Circulation; Palpable pulses include: 1.Carotids 2.Radials 3.Brachials 4.Femorals 5.Popliteals 6.Posterior tibials (ankles) 7.Dorsalis pedis
Circulation; Doppler ultrasounds detect what? Blood flow within the arterys
Gastrointestinal description; Appetite Daily diet
Gastrointestinal description; Dentures Upper, lower, partial, and fit
Gastrointestinal description; Anorexia Loss of appetite
Gastrointestinal description; N+V Nausea and vomiting {F,D,R,}
Gastrointestinal description; F,D,R Frequency, Duration, Remedies
Gastrointestinal description; Fruity breath May indicate diabetes mellitus(DM)
Gastrointestinal description; Bowel sounds(BS) Present or absent
Gastrointestinal description; Bowel movements(BM) Frequncy,color,Form
Gastrointestinal description; Diarrhea Loose watery stools {F,D,R}
Gastrointestinal description; Constipation Difficult defecation {F,D,R}
Gastrointestinal description; Melena Black, tarry, pungent stools {F,D}
Gastrointestinal description; Eructation Belching {F,D}
Gastrointestinal description; Flatulence / flatus Gas expelled through the anus {F,D}
Gastrointestinal description; Dyspepsia Indigestion {F,D,R}
Gastrointestinal description; Fecal incontinence The inability to control defecation {F,D}
Gastrointestinal description; abdominal extension Measured as; abdominal circumference or girth
Gastrointestinal description; Soft abdomen is considered Optimal
Gastrointestinal description; Abdominal guarding Flinshing
Gastrointestinal description; Rigid abdomen indicates Gastrointestinal pathology
Genitourinary (GU) description; Urine Described as clear, yellow, amber, or cloudy
Genitourinary (GU) description; Dysuria Painful or difficult urination - Indicates possible UTI {F,D}
Genitourinary (GU) description; UTI Urinary tract infection {F,D}
Genitourinary (GU) description; Hematuria Blood in the urine {F,D}
Genitourinary (GU) description; Pyuria Pus in the urine - Indicates possible UTI {F,D}
Genitourinary (GU) description; Glucosuria Sugar in the urine - Indicates possible diabetes mellitus(DM)
Genitourinary (GU) description; Ketonuria Ketones (acetone) in the urine - Indicates possible diabetes mellitus(DM)
Genitourinary (GU) description; Urinary hesitancy Difficulty initiating urination - Indicates possible benign prostatic hypertrophy(BPH) {F,D}
Genitourinary (GU) description; Urinary frequency Frequent urge to urinate - Indicates possible UTI or pregnancy {F,D}
Genitourinary (GU) description; Urinary urgency Sudden urge to micturate - Indicates possible UTI or BPH
Genitourinary (GU) description; Urinary retention Inability to urinate - Indicates possible BPH {F,D}
Genitourinary (GU) description; Nocturia Chronic / persistant night urination - indicates possible BPH or UTI {F,D}
Genitourinary (GU) description; Enurisis Involuntary / uncontrolled micturation ; urinary incontinence
Genitourinary (GU) description; ED Erectile dysfunction / impotence
Genitourinary (GU) description; LMP Last menstrual period
Genitourinary (GU) description; Menses Description includes; regular, irregular, # of days, # pads, # tampons used
Genitourinary (GU) description; Vaginal discharge Description includes; color, leukorrhea, thrombi, pungent
Genitourinary (GU) description; Dyspareunia painful coitus
Genitourinary (GU) description; Gravida Number of pregnancies
Genitourinary (GU) description; Para Number of viable births (survivable)
Genitourinary (GU) description; Type of birth Vaginal delivery or cesarean cestion
Genitourinary (GU) description; Contraceptive Type and duration
Genitourinary (GU) description; Abortion information Spontaneous (miscarriage) or voluntary
Genitourinary (GU) description; PAP Last done and frequency
Genitourinary (GU) description; Mammogram Last done, results
Integumentary skin descriptions; Warm, cool, cold, dry, clammy, or diaphoretic
Integumentary descriptions; Turgor Skin elasticity and in indicator of hydration (immediate or slow)
Integumentary descriptions; Pruritus /pruretic Itching
Integumentary descriptions; Erythema / rubeosis Redness
Integumentary descriptions; Jaundice / icterus / xanthoderma Yellow skin and/or sclerea
Integumentary descriptions; Pallor Paleness
Integumentary descriptions; Macule /macular Flat, usually erythematous skin lesion
Integumentary descriptions; Papule / papular A raised lesion <1 centimeter(cm)
Integumentary descriptions; Nodule / nodular A raised lesion >1 centimeter(cm)
Integumentary descriptions; Abscess A collection of pus
Integumentary descriptions; Types of abscess 1.Pustule / pustular 2.Furuncle /boil 3.Carbuncle
Integumentary descriptions; Pustule A papule filled with pus
Integumentary descriptions; Furuncle An infection of a hair follicle and adjacent tissue AKA a boil
Integumentary descriptions; Carbuncle A cluster of furuncles
Integumentary descriptions; Vesicle /vesicular A raised lesion filled with a clear liquid (blisters)
Integumentary descriptions; Types of vesicles 1.Bleb <1 cm 2.Bulla(e) >1 cm
Integumentary descriptions; Crustation A scab
Integumentary descriptions; Abrasion Mechanical superficial damage to the skin (scrape)
Integumentary descriptions; Excoriation Chemical ssuperficial damage to the skin
Integumentary descriptions; Nevus / nevi Mole(s)
Integumentary descriptions; Verruca(e) Wart(s)
Integumentary descriptions; Ulcer An erosion (wearing away) of the skin or musous membrane
Integumentary descriptions; Decubitus ulcer Pressure ulcer (bed sore)
Integumentary descriptions; Xeroderma Dry skin
Integumentary descriptions; Ichthyosis Dry, scaly skin
Integumentary descriptions; Cyst A thickening or lump
Integumentary descriptions; Cicatrix /cicatrices Scars
Integumentary descriptions; Keloid Exaggerated or hypertrophied scar
Integumentary descriptions; Urticaria Hives or wheals
Integumentary descriptions; Urticaria indicates Allergic reaction
Integumentary descriptions; Vitiligo a localized loss of skin pigmentation
Integumentary descriptions; Albinism A genetic absence of skin pigmentation
Integumentary descriptions; Edema An accumulation of fluid (swelling)
Integumentary descriptions; Ecchymosis Bleeding under the skin, hematoma, contusion, or bruise
Integumentary descriptions; Initially a bruise will be Erythematous (red)
Integumentary descriptions; In 1-2 days a hematoma can become Blue or purplish
Integumentary descriptions; At day 6 a contusion can fade to Green
Integumentary descriptions; At day 8-9 a bruise will become Brownish - yellow
Integumentary descriptions; Petechia(e) Pinpoint hemorrhages
Integumentary descriptions; Purpura Combination of ecchymoses abd petchia
Integumentary descriptions; Alopecia Hair loss
Integumentary descriptions; Gangrene / gangrenous Tissue putrifaction (rot)
Integumentary descriptions; Gangrene is caused by Microbial proliferation
Integumentary descriptions; Fissure A crack or groove
Integumentary descriptions; Laceration A cut, rip, tear
Integumentary descriptions; Callus / callosities Hypertrophied skin
Integumentary descriptions; Comedo(nes) Whitehead / blackhead
Information to be documented about any skin lesion includes; Location, size, duration 1' = 2.54 cm
Pain Descriptions include; 1.Frequency 2.Duration 3.Sharp 4.Stabbing 5.Dull 6.Burning 7.Throbbing 8.Pressure 9.Achy 10.Radiating 11.Intermittent 12.Chronic (recurring) 13.Acute (sudden) 14.Continues 15.Numeric intensity 1-10
Patient history should include past surgeries including; Date of last surgery
Patient history should include past illnesses including; Date of last illness
Past Family and Social History (PFSH) should include; Bronchitits, asthma, emphysema, pneumonia, epilepsy, cirrhosis, mental illness, CA, CAD, MI, AP, CHF, TIA, CVA, PAD, URI, COPD, HTN, TB, STI, HIV, AIDS, CKD, OA, PID, PUD, GERD, HAV, HBV, HCV, OSA, UC, Alcohol consumption, Tabacco use, Exercise
Disease abbreviations: CA Cancer
Disease abbreviations: CAD Coronary artery disease
Disease abbreviations: MI Myocaridial infarction
Disease abbreviations: AP Angina pectoris
Disease abbreviations: CHF Congestive heart failure
Disease abbreviations: TIA Transient ischemic attack
Disease abbreviations: CVA Cerebral vascular accident
Disease abbreviations: PAD Peripheral artery disease
Disease abbreviations: URI Upper respiratory infection
Disease abbreviations: COPD Chronic obstructive pulmonary disease
Disease abbreviations: HTN Hypertension
Disease abbreviations: TB Tuberculosis
Disease abbreviations: STI Sexualy transmitted infection (STD)
Disease abbreviations: HIV Human immunodeficiency virus
Disease abbreviations: AIDS Aquired immune deficiency syndrome
Disease abbreviations: CKD Chronic kidney disease
Disease abbreviations: OA Osteoarthritis
Disease abbreviations: PID Pelvic inflammatory disease
Disease abbreviations: PUD Peptic ulcer disease
Disease abbreviations: GERD Gastroesophageal reflux disease
Disease abbreviations: HAV, HBV, HCV Hepatitis A/B/C
Disease abbreviations: OSA Obstructive sleep apnea
Disease abbreviations: UC Ulcerative colitis
Anatomical location: Anterior Front / ventral
Anatomical location: Posterior Back / Dorsal
Anatomical location: Superior Above
Anatomical location: Inferior Below
Anatomical location: Proximal Beginning of a structure
Anatomical location: Distal End of a structure
Anatomical location: Medial Middle
Anatomical location: Lateral Side
Anatomical location: Hypochondriac region Superior R+L lateral regions of the abdomen
Anatomical location: Lumbar region Medial R+L lateral regions of the abdomen
Anatomical location: Inguinal (iliac) region Inferior R+L lateral regions of the abdomen
Anatomical location: Epigastric region Superior medial region of the abdomin
Anatomical location: Umbilical region Medial region of the abdomin
Anatomical location: Hypogastric region Inferior medial region of the abdomin
Directional terms are always used from who's point of view? The patient's point of view
Created by: adrouillard