week 1 Introduction to Clinical Terms and Abbreviations

Learning Objectives

Our study of clinical terminology begins with abbreviations related to assessing vital signs, a procedure familiar to anyone living in a developed country. We all have been the recipient of measurement of vital signs and/or the person doing the measuring.

Upon completion this module, you should be able to:

Recognize abbreviations and terms related to vital signs.

Recognize complex medical terms related to vital signs.

Use abbreviations and terms related to vital signs.

Guidelines for Understanding Clinical Abbreviations

Abbreviations evolve as clinicians seek ways to communicate quickly and efficiently. However, as these are a part of language, patterns of use are evident. Understanding these patterns of use will help you to identify what word, term or phrase is being abbreviated.

The structure of an abbreviation may be:

A shortened form of a word. For example, temperature= temp.

The first letters of each word in a term or phrase. For example, chronic obstructive pulmonary disease = COPD. Each letter is pronounced individually.

First letters that form a pronounceable word. For example, the term acquired immune deficiency syndrome, becomes the word "AIDS".

First letters of the major syllables of a term. For example, nasogastric = NG or gastrointestinal = GI. Each letter is pronounced individually, for example "N", "G".

First letters and a syllable is common. For example, ventricular fibrillation = V fib and is pronounced “V” “fib”.

Being aware of context is essential to understanding abbreviations. When you read or hear an abbreviation ask yourself: What is going on? What is the conversation or the progress note about? Understanding the context in which an abbreviation is used will provide clues to the meaning of the term. For example, the abbreviation BS can refer to bowel sounds or breath sounds. Is the person using this term talking about the lungs or about the abdomen? Does the patient have a diagnosis wherein the health problem is related to the lungs or related to the abdomen? The meaning comes from the situation.

Ask for confirmation of your understanding. Abbreviations that are misinterpreted can be dangerous! When an action can directly effect a patient, make sure that you correctly understand the meaning of an abbreviation. When in doubt, use the entire word form.

Week 1 Key Terms

Before you begin your reading for Week 1 review the list of terms below. These common terms are used to communicate course content and will be familiar to many learners. If you are not familiar with a term, clarify the meaning before you begin your study of Week 1 materials. Use the Clinical Terminology Dictionary for Beginning International and U.S. Health Care Providers. Knowing the definitions of these terms will facilitate your learning process.

Artery

Axilla

Confusion

Dehydration

Deteriorated

Diarrhea

Dissipate

Dizziness

Groin

Intracranial

Intracranial pressure

Metabolism

Non-invasive

Pallor

Palpable

Rectum

Shivering

Therapeutic