Personal Characteristics



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Column I Column II


___1. A patient/client has fainted. A. “The patient/client appears jaundice.”


___2. A patient/client is losing a large B. “The patient/client appears to be

amount of blood (500 cc). having a headache.”


___3. A patient/client is rubbing his/her C. “The patient/client appears to be un-

forehead. conscious.”


___4. A patient/client is very talkative and D. “The patient/client appears to have

chain smoking. dermatitis.”


___5. A patient/client is profusely E. “The patient/client appears cyanotic.”

perspiring.


___6. A patient’s/client’s skin is yellow. F. “The patient/client appears to be having

a fever or is in pain.”


___7. A patient’s/client’s skin is bluish is G. “The patient/client appears to be

color. nervous.”


___8. A patient/client is having difficulty H. “The patient/client appears to be

breathing. hemorrhaging.”


___9. A patient’s/client’s body is I. “The patient/client appears to be

rigidly jerking having a seizure.”


___10. A patient’s/client’s skin is reddish J. “The patient/client appears to be having

in color and itching. dyspnea.”




Medical Abbreviations



ac before meals

ad lib as desired

ADL activities of daily living

bid twice a day

BP blood pressure

BR bedrest

BRP bathroom privileges

c with

CAT computerized axial

tomography

CBC complete blood count

CBR complete bed rest

cc cubic centimeter

CC chief complaint

CCU coronary or critical care unit

CHF congestive heart failure

cm centimeter

c/o complains of

COPD chronic obstructive

pulmonary disease

C&S culture and sensitivity

CVA cerebral vascular accident

D/C or dc discontinued, discharge

Diff differential white count

DNR do not resuscitate

DOA dead on arrival

DOB date of birth

Dx diagnosis

EEG electronencephalogram

EENT ear, eyes, nose and throat

EKG or ECG electrocardiogram

FBS fasting blood sugar

Fe iron

FF force fluids

Fx fracture

FUO fever of unknown origin

GI gastrointestinal

Gm gram

gr grain

gtt drop

GU genitourinary

Gyn gynecology

HBV hepatitis B virus

hct hematocrit

Hg mercury

Hgb hemoglobin

HOB head of bed

Hr, h hour

HS hour of sleep

Ht height

I&D incision and drainage

I&O intake and output

ICU intensive care unit

IM intramuscular

inj injection

Kg or kg kilogram

KUB kidney, ureter and bladder

x-ray

L&D labor and delivery

lb pound

LLQ left lower quadrant

LP lumbar puncture

LUQ left upper quadrant

mEq millequivalent

mg milligram

MI myocardial infarction

ml milliliter

mm millimeter

MN midnight

MRI magnetic resonance imaging

Na sodium

ng nasogastric

NPO nothing by mouth

N/S normal saline

N&V nausea and vomiting

O2 oxygen

OD right eye

OOB out of bed

OR operating room

OS left eye

OU both eyes

oz ounce

p after

PAP Papanicolaou smear

Pc after meals

PDR Physician’s Desk Reference

per by or through

pH measure of acidity/alkalinity

po by mouth

pre-op before an operation

prn as necessary

pt patient or pint

q every

qd every day

qh every hour

q2h every 2 hours

qhs every night at bedtime

qid four times a day

qs quantity sufficient

qt quart

R respiration or rectal

R right

RBC red blood cell

RLQ right lower quadrant

R/O rule out

ROM range of motion

RR recovery room

RUQ right upper quadrant

Rx prescription, take

s without

sc subcutaneous

SOB short of breath

sp gr specific gravity

ss one half

stat immediately

T&A tonsils and adenoids

TB tuberculosis

tbsp tablespoon

TIA transient ischemic attack

tid three times a day

TLC tender loving care

TPR temperature, pulse and respiration

tsp teaspoon

tx traction

UA or U/A urinalysis

URI upper respiratory infection

UTI urinary tract infection

VS vital signs

WBC white blood count

w/c wheelchair

wt weight

x times (2x is 2 times)

x-match cross match

> greater than

< less than

  • increase, elevate, higher

  • decrease, lower

# number or pound sign

I one

V five

X ten

L fifty

C one hundred

D five hundred

M one thousand


Subjective/Objective Quiz


How do you report subjective information on a legal document?


How do you report objective information on a legal document?



Are the following findings/statements objective or subjective? Write S in the blank in front of the statements for subjective and O for objective.
___1. The patient states, “I have a headache.”
___2. The patient has a temperature of 100.4º rectally.
___3. You have taken the patient’s blood pressure and it is 150/100.
___4. The patient states he/she feels nauseated after eating.
___5. The patient states he/she is having burning on urination and frequency of urination.
___6. A teen tells you he/she feels that he/she is overweight.
___7. A teenager is 30% over his/her normal body weight for his/her height and frame and weighs 160 pounds.
___8. A patient’s urine culture is positive for bacteria.
___9. When you took the patient’s respirations, they were 35.
___10. A patient reports to you that he/she has been having difficulty with rapid breathing and chest pain.

Fundamentals of Nutrition

Nutrition: those processes that allow the body to use food for energy, maintenance of health, and growth.



Nutritional status: the state of one’s nutrition
Wellness: state of good health with optimal body function (requires good nutrition)
Malnutrition: lack of necessary or proper food substances in the body or improper absorption and distribution of them.

ESSENTIAL NUTRIENTS


  • Composed of chemical elements found in food







  • Nutrients in foods replace those used by the body




  • Categorized into six groups


CARBOHYDRATES


  • Contain the atoms carbon, hydrogen, and oxygen




  • 1 gram of carbohydrate = 4 calories




  • Simple carbohydrates: dissolve readily in cold water

Examples include: glucose, fructose, sucrose, and lactose


  • Complex carbohydrates: do NOT dissolve readily in cold water and do not taste particularly sweet.




  • Certain complex carbohydrates, like oats and barley, have been proven to reduce cholesterol.

Examples include: starches, fiber/cellulose, and glycogen


  • Primary source of energy for the body




  • Cellulose/fiber provide bulk, acting as a natural broom for the intestinal tract (cellulose is indigestible)

Diets high in fiber may reduce risks of colon cancer.


  • Food sources:

Examples include: fruit, table sugar, syrups, bread, cereals, pasta, crackers, potatoes, corn, peas, etc.

FATS/LIPIDS

  • Contain the atoms carbon, hydrogen, and oxygen




  • Source of energy—twice as many calories as the same amount of carbohydrates or protein




  • 1 gram of lipid = 9 calories




  • Saturated fats are usually solid at room temperature. This form of fat tends to raise blood cholesterol levels.

Shortening, animal fat, coconut oil, and palm oil are all examples of saturated fats.


  • Polyunsaturated fats are usually liquid at room temperatures. Most vegetable oils are good examples. Fatty fish (herring, mackerel, salmon, lake trout, and whitefish) are good examples of Omega-3 and is the polyunsaturated fat that is linked to lowering cholesterol and blood pressure.




  • Monounsaturated fats are thought to lower total cholesterol and LDL. Evidence shows that monounsaturated fats are safe and effective in lowering heart disease risk. Examples include: avocadoes, flounder, olive oil, almonds, peanut oil, cottonseed oil, haddock, etc. This is your BEST choice of fats.


CHOLESTEROL(Fats/Lipids continued)


  • Cholesterol is a fatty substance only found in animal products like meat, cheese, and eggs.







  • Recommended blood level under 200 mg/dl




  • LDL is low density lipoproteins or BAD cholesterol. Carries fat to cells




  • HDL high density lipoproteins or Heavenly/good

cholesterol; removes excess cholesterol from cells and carries it back to the liver to be broken down/eliminated


  • FUNCTIONS OF FAT:

*Essential component of every cell membrane

*Most concentrated form of energy

*Helps to maintain body temperature through insulation

*Helps to cushion organs and bones

*Aids in the absorption of fat-soluble vitamins

*Provides flavor to food




  • Food sources include: fatty meats, egg yolks, cheeses, oils, creams, whole milk, butter, margarine, nuts, etc.


PROTEINS




  • Contain the atoms carbon, hydrogen, oxygen, and nitrogen




    • 1 gram of protein = 4 calories




  • Amino acids are the building blocks of proteins.





The body is incapable of producing these amino acids.
They must be supplemented through the diet and are found in almost all animal sources.


  • Thirteen non-essential amino acids or incomplete proteins

The body has the capacity to make these amino acids.




  • Body cannot store excess amino acids---excreted as urea

(Proteins continued)


  • The three general categories of protein functions are:

1. Provide structure (building and repairing tissue)



Particularly important for post-op patients
2. Regulate body processes through enzymes, hormones, carrier proteins, and antibodies. All of these are proteins or contain protein parts.


  1. Body’s final energy source



  • Complete protein food sources: meat, fish, milk, cheeses, and eggs



  • Incomplete protein sources: legumes, soybeans, dry beans, peas, peanuts and tofu


VITAMINS


  • VITA “ means vital; vitamins are vital for life



  • Vitamins are organic, (carbon containing) compounds essential to life.




  • Functions include but are not limited to:

*Metabolism; help release energy from other nutrients


*Vital role in almost every chemical reaction within the body

*Co-enzyme for normal health and growth; some behave like hormones


THIRTEEN VITAMINS

  • Four fat-soluble: A, D, E, K

  • Nine water-soluble:

  • Eight B-complex and C



  • Vitamin A

*Assists in the formation of healthy skin, mucous membranes, proper bone growth and reproduction


*Aids in the ability of the eye to see in dim light
*Low intake of Vitamin A can result in night blindness
*SOURCES: yellow/orange veggies, dark green veggies and fruits

Vitamin D
*Essential for the absorption and use of calcium and phosphorous = strong bones and teeth
*Skin produces vitamin D when exposed to sunlight.
*Vitamin D deficiency can result in rickets.
*SOURCES : fortified milk, tuna, salmon, cod liver oil
Vitamin D deficiency can result in rickets/osteomalacia
Vitamin E
*Protects essential fatty acids from oxidation = ANTIOXIDANT
*Helps to prevent cancer and other diseases. Prevents cell membrane damage.
*Vegetable oils, nuts, wheat germ, whole grains, green leafy veggies and margarines.
Vitamin K

*Essential for the normal clotting of blood


*Deficiency results in bleeding problems
*SOURCES: green peas, broccoli, spinach, and greens
Vitamin C
*Collagen formation
*Aids in the absorption of iron
*Antioxidant for other vitamins
*Low intake can result in scurvy
*SOURCES: citrus fruits, berries, melons, dark green veggies, tomatoes, green peppers, cabbage, and potatoes
Vitamin B-Complex
Thiamin

Riboflavin

Niacin

Pyridoxine



Folic acid (essential during pregnancy)

Pantothenic acid

Biotin

Vitamin B/12


*Essential for formation of DNA, maintains myelin sheath, promotes healthy mucous membranes, erythropoesis, aids in use of other nutrients

*Promotes normal function of nervous system

*Promotes metabolism, and aids in the formation of hormones
SOURCES: liver, dark green leafy veggies, milk, cheese, eggs, enriched breads and cereals, organ meats, peanuts, poultry and fish
Low intake of specific B –complex vitamins can result in:
*Thiamin = Beriberi; fatal if not treated
*Riboflavin = Skin inflammations, growth failure, eye problems
*Pyridoxine = anemia, muscular weakness, nervousness, insomnia, and facial skin disorders
*B/12 = Pernicious anemia
*Biotin = Alopecia and skin problems

MINERALS



  • More than one-third of the dietary nutrients needed each day are minerals.




  • Of the 92 chemical elements found on the earth, 50 are found in the body.




  • Oxygen, carbon, hydrogen, and nitrogen make-up 96% of our elemental composition; the remaining 4% represents minerals.




  • Only a fraction of our body weight is made-up of minerals; however, they are integral to human health.




  • Most important are sodium, potassium, calcium, iron, phosphorus, and zinc.

  • MAJOR MINERALS


Calcium
Used for the formation of strong bones and teeth, muscle contractions, blood clotting, and maintaining cell membranes
Deficiency accelerates age-related loss of bone. Decrease in estrogen (menopause) causes decreased calcium absorption in small intestines.
SOURCES: dairy products, dark green leafy veggies, canned fish, nuts, dried fruits

Phosphorous
Enzyme formation, component of all cell membranes, forms genetic material, releases energy, assists in the formation of bones and teeth
SOURCES: sunflower seeds, beans, milk products, poultry, fish, and lean meat.
Magnesium
Normal bone structure, enzyme formation, normal functioning of the central nervous system and reproductive system functions
SOURCES: sunflower and pumpkin seeds, dried fruit, lean meats

Sodium
Regulates body-fluid volume and osmotic pressure

Assists in regulations of blood acidity


Affects transmission of nerve impulses
SOURCES: table salt, condiments, processed meats, etc.

Chloride
Component of gastric juice; specifically hydrochloric acid
Aids in acid-base balance
SOURCES: seafood, salt, milk, eggs, meat
Potassium
Assists in muscle contraction, pH balance, fluid balance, and transmission of nerve impulses
SOURCES: fruits, veggies, beans, nuts, and seeds
MINOR MINERALS


  • Only four are needed in such significant doses that they have RDA requirements



  • Iron

Needed for hemoglobin formation, part of several enzymes


SOURCES: dried fruits, fortified cereals, nuts, beans, poultry, fish, and lean meats


  • Zinc

Wound healing, preventing infections, formation of protein


SOURCES: whole grains, seeds, nuts, poultry, fish, and lean meats



  • Iodine

Needed for the formation of thyroxin
Sources: table salt, shellfish, fish and fortified dairy products


  • Selenium

Essential antioxidant; may be a deterrent to cancer.
SOURCES: nuts, whole grains, lean pork, cottage cheese, milk, molasses, squash.


  • WATER




  • Found in all body tissues

  • Essential for digestion

  • Makes up most of blood plasma

  • Helps body tissue absorb nutrients

  • Helps remove waste material from body

  • Average person should drink 6-8 glasses of water a day

  • 55-65% of body weight

  • Only nutrient we sense a need for---thirst


Benefits of Proper Nutrition

Immunological

Good Nutrition = Good Immune System
The ability of your immune system to fight off invading pathogens varies depending on a number of preventative factors. Perhaps the most important is good nutrition.
When you fail to take in adequate nutrients, you can jeopardize your immune system.
This is one reason poorly planned weight-loss programs can make a person ill.
Benefits of Proper Nutrition

Psychological/Emotional

Good Attitude

Enthusiasm

Freedom from Anxiety

Proper Sleep Patterns

Increased Mental Ability

Benefits of Proper Nutrition

Physical

Proper Growth and Development

Improved Strength and Endurance

Healthy Appearance

Proper Bowel Habits

High Energy Level

Prevent or Delay Diseases/Conditions
The Food Guide Pyramid
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