___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-
___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.”
___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
___8. A patient/client is having difficulty H. “The patient/client appears to be
___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.”
ac before meals
ad lib as desired
ADL activities of daily living
bid twice a day
BP blood pressure
BRP bathroom privileges
CAT computerized axial
CBC complete blood count
CBR complete bed rest
cc cubic centimeter
CC chief complaint
CCU coronary or critical care unit
CHF congestive heart failure
c/o complains of
COPD chronic obstructive
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
EENT ear, eyes, nose and throat
EKG or ECG electrocardiogram
FBS fasting blood sugar
FF force fluids
FUO fever of unknown origin
HBV hepatitis B virus
HOB head of bed
Hr, h hour
HS hour of sleep
I&D incision and drainage
I&O intake and output
ICU intensive care unit
Kg or kg kilogram
KUB kidney, ureter and bladder
L&D labor and delivery
LLQ left lower quadrant
LP lumbar puncture
LUQ left upper quadrant
MI myocardial infarction
MRI magnetic resonance imaging
NPO nothing by mouth
N/S normal saline
N&V nausea and vomiting
OD right eye
OOB out of bed
OR operating room
OS left eye
OU both eyes
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
qd every day
qh every hour
q2h every 2 hours
qhs every night at bedtime
qid four times a day
qs quantity sufficient
R respiration or rectal
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
SOB short of breath
sp gr specific gravity
ss one half
T&A tonsils and adenoids
TIA transient ischemic attack
tid three times a day
TLC tender loving care
TPR temperature, pulse and respiration
UA or U/A urinalysis
URI upper respiratory infection
UTI urinary tract infection
VS vital signs
WBC white blood count
x times (2x is 2 times)
x-match cross match
> greater than
< less than
# number or pound sign
C one hundred
D five hundred
M one thousand
increase, elevate, higher
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.
Composed of chemical elements found in food
Nutrients in foods replace those used by the body
Categorized into six groups
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.
Examples include: fruit, table sugar, syrups, bread, cereals, pasta, crackers, potatoes, corn, peas, etc.
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 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
*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.
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
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.
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
“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
Four fat-soluble: A, D, E, K
Eight B-complex and C
*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
*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
*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.
*Essential for the normal clotting of blood
*Deficiency results in bleeding problems
*SOURCES: green peas, broccoli, spinach, and greens
*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
Folic acid (essential during pregnancy)
*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
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.
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
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.
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
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.
Component of gastric juice; specifically hydrochloric acid
Aids in acid-base balance
SOURCES: seafood, salt, milk, eggs, meat
Assists in muscle contraction, pH balance, fluid balance, and transmission of nerve impulses
SOURCES: fruits, veggies, beans, nuts, and seeds
Only four are needed in such significant doses that they have RDA requirements
Needed for hemoglobin formation, part of several enzymes
SOURCES: dried fruits, fortified cereals, nuts, beans, poultry, fish, and lean meats
Wound healing, preventing infections, formation of protein
SOURCES: whole grains, seeds, nuts, poultry, fish, and lean meats
Needed for the formation of thyroxin
Sources: table salt, shellfish, fish and fortified dairy products
Essential antioxidant; may be a deterrent to cancer.
SOURCES: nuts, whole grains, lean pork, cottage cheese, milk, molasses, squash.
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
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
Freedom from Anxiety
Proper Sleep Patterns
Increased Mental Ability
Benefits of Proper Nutrition
Proper Growth and Development
Improved Strength and Endurance
Proper Bowel Habits
High Energy Level
Prevent or Delay Diseases/Conditions
The Food Guide Pyramid