Medical Vocabulary List with Definitions and Context

1. Abduction: The movement of a limb away from the body’s midline. For example, hip abduction is the movement of the leg away from the midline of the body when getting out of bed.
   • Context: The physical therapist instructed the patient to perform hip abduction exercises to strengthen the muscles on the outer side of the thigh.
2. Active assist range of motion: Movement of a joint by an individual with partial assistance from an outside force.
   • Context: The nurse provided active assist range of motion therapy to help the stroke patient regain movement in his weakened arm.
3. Active listening: Listening while communicating verbally and nonverbally that we are interested in what the other person is saying and verifying our understanding with the speaker.
   • Context: The counselor demonstrated active listening by maintaining eye contact and repeating back what the patient had shared about their concerns.
4. Active range of motion: Movement of a joint by the individual with no outside force aiding in the movement.
   • Context: After weeks of physical therapy, the patient was finally able to perform active range of motion exercises independently.
5. Activities of daily living (ADLs): Daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).
   • Context: The occupational therapist assessed whether the elderly resident could safely perform activities of daily living without assistance.
6. Acute pain: Pain with limited duration and associated with a specific cause. It usually causes observable responses such as increased pulse, respirations, and blood pressure. The person may also have diaphoresis.
   • Context: The patient experienced acute pain following surgery, which was managed with prescribed pain medication for the first 48 hours.
7. Adaptive behavior: The skills and abilities to live independently.
   • Context: The rehabilitation team worked to improve the patient’s adaptive behavior skills so they could return to independent living.
8. Adduction: The movement of a limb towards the midline. For example, if a person has their fingers spread wide apart, bringing them back together is adduction.
   • Context: The physical therapist taught the patient shoulder adduction exercises to strengthen the muscles that pull the arm toward the body.
9. Advance directives: Legal documents including the health care power of attorney (POA) and living will.
   • Context: The social worker helped the family complete advance directives to ensure the patient’s wishes would be honored if they became unable to make medical decisions.
10. Agitation: Behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors.
    • Context: The nursing staff noticed signs of agitation in the dementia patient and implemented calming interventions to prevent escalation.
11. Agnosia: The failure to recognize or identify objects despite intact sensory function.
    • Context: Due to brain injury, the patient developed agnosia and could no longer recognize familiar objects like keys or glasses.
12. Airborne precautions: Transmission-based precautions used for clients with diagnosed or suspected pathogens spread by very small airborne particles from nasal and oral secretions that can float long distances through the air, such as measles and tuberculosis.
    • Context: The hospital implemented airborne precautions for the patient with suspected tuberculosis, requiring all staff to wear N95 respirators.
13. Ambulation: A medical term used for walking.
    • Context: The patient’s ambulation improved significantly after hip replacement surgery and physical therapy.
14. Angina: Sudden chest pain beneath the sternum (breastbone) associated with a heart attack (myocardial infarction), often radiating down the left arm in male patients.
    • Context: The patient described experiencing angina during physical activity, prompting the cardiologist to order further cardiac testing.
15. Anxiety disorder: A condition diagnosed when an individual experiences more than temporary worry or fear that interferes with their daily functioning.
    • Context: The patient was referred to a mental health specialist after being diagnosed with an anxiety disorder that was affecting their ability to work.
16. Anxiety: A universal human experience that includes feelings of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat.
    • Context: The patient expressed anxiety about the upcoming surgery, so the nurse provided detailed information about the procedure to help reduce their fears.
17. Aphasia: A condition with difficulty processing what one is hearing or responding to questions due to dementia, brain injuries, or strokes.
    • Context: Following his stroke, the patient developed aphasia and required speech therapy to regain communication abilities.
18. Apraxia: The impaired ability to carry out motor activities despite intact motor function. This means the person can understand instructions and has the ability to complete an action but cannot process the cue to perform the task.
    • Context: The occupational therapist worked with the patient who had apraxia to break down daily tasks into simple, manageable steps.
19. Aspiration: Inadvertently breathing fluid or food into the airway instead of swallowing it.
    • Context: The speech therapist evaluated the patient’s swallowing ability to prevent aspiration pneumonia during meals.
20. Assistive devices: Devices such as gait belts and walkers that are used when moving a patient.
    • Context: The physical therapist recommended assistive devices like a walker to help the patient maintain independence while ensuring safety.
21. Autonomy: Each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences.
    • Context: The healthcare team respected the patient’s autonomy by allowing them to make informed decisions about their treatment plan.
22. Bariatric lifts: Mechanical lifts that support a client weighing 600 or more pounds.
    • Context: The nursing staff used bariatric lifts to safely transfer the patient while preventing injury to both the patient and healthcare workers.
23. Belongingness: A human emotional need for interpersonal relationships, connectedness, and being part of a group.
    • Context: The recreational therapy program was designed to foster a sense of belongingness among residents in the long-term care facility.
24. Bipolar disorder: A condition that includes shifts in mood from abnormal highs (called manic episodes) to abnormal lows (i.e., depressive episodes) that cause significant impairment on the person’s functioning socially or at work.
    • Context: The patient’s bipolar disorder was well-managed with medication and regular psychiatric follow-up appointments.
25. Blood-borne pathogens: Infectious microorganisms in blood and body fluids that can cause disease, including hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV).
    • Context: All healthcare workers received training on blood-borne pathogens and proper procedures for handling potentially infectious materials.
26. Body alignment: Good posture principles that prevent musculoskeletal injuries.
    • Context: The ergonomics specialist taught proper body alignment techniques to reduce the risk of back injury among nursing staff.
27. Bolus: A slippery mass of partially broken-down food that moves down the digestive tract as you swallow.
    • Context: The speech therapist observed how well the patient could form and swallow a bolus during the swallowing assessment.
28. Bony prominences: Areas of the body where a bone lies close to the skin’s surface, such as the back of the head, shoulders, elbows, heels, ankles, tops of the toes, hips, and coccyx.
    • Context: The nurse carefully inspected the patient’s bony prominences for signs of pressure injury development during routine skin assessments.
29. Built-up handles: Specialized silverware that allows the use of utensils by individuals with limited functional ability of their fingers (such as severe arthritis) to hold a smaller handle.
    • Context: The occupational therapist provided built-up handles on eating utensils to help the arthritis patient maintain independence during meals.
30. Cardiac arrhythmias: Irregularities in a person’s heart rate and/or rhythm.
    • Context: The patient was placed on continuous cardiac monitoring to detect any dangerous cardiac arrhythmias.
31. Cardiopulmonary resuscitation (CPR): Emergency treatment provided when a patient’s blood flow or breathing stops and may involve chest compressions and mouth-to-mouth breathing, electric shocks to restart the heart, breathing tubes to open the airway, or cardiac medications.
    • Context: The nursing staff performed CPR immediately when the patient went into cardiac arrest, successfully restoring their heartbeat.
32. Carrier: An individual who is colonized with an infectious agent.
    • Context: The patient was identified as a carrier of MRSA and required special precautions to prevent transmission to other patients.
33. Cataracts: A vision condition causing clouding of the clear lens of the eye.
    • Context: The patient’s cataracts had progressed to the point where surgical intervention was necessary to restore clear vision.
34. Cerebrovascular attack (CVA): The medical term for what is commonly referred to as a “stroke,” caused by a lack of blood flow and oxygen to the brain.
    • Context: The patient was rushed to the stroke unit after experiencing a cerebrovascular attack that affected their speech and mobility.
35. Chain of infection: The process of how an infection spreads based on six links of transmission: Infectious Agent, Reservoir, Portal of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host.
    • Context: The infection control nurse educated staff about breaking the chain of infection through proper hand hygiene and isolation precautions.
36. Chemical digestion: Digestion of food by enzymes found in saliva that break down food particles into smaller components.
    • Context: The dietitian explained how chemical digestion begins in the mouth with enzymes in saliva breaking down starches.
37. Chemical restraint: A drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the patient’s ability to appropriately interact with their surroundings, that is not standard treatment or dosage for the patient’s condition.
    • Context: The facility strictly prohibited the use of chemical restraints except in emergency situations with proper physician orders.
38. Chronic pain: Ongoing and persistent pain for longer than six months. It typically does not cause a change in vital signs or diaphoresis.
    • Context: The patient’s chronic pain from arthritis required a comprehensive pain management plan including medication and physical therapy.
39. Citation: A problem or discrepancy found during a survey of a facility by the Department of Health Services.
    • Context: The nursing home received a citation for inadequate documentation and had to submit a plan of correction.
40. Coagulate: Form a clot.
    • Context: The blood began to coagulate at the injection site, forming a small clot that would help stop the bleeding.
41. Coccyx: Tailbone.
    • Context: The patient developed a pressure ulcer on their coccyx due to prolonged bed rest without proper repositioning.
42. Colonization: A condition when a person carries an infectious agent but is not symptomatic or ill.
    • Context: The screening test revealed colonization with MRSA, requiring the patient to be placed in contact isolation.
43. Colostomy: A surgically placed opening when a client’s colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch.
    • Context: The patient learned proper colostomy care techniques before being discharged home after bowel surgery.
44. Commode: A movable device with a bucket underneath the seat that is used for elimination when the client has difficulty getting to the bathroom.
    • Context: The nursing assistant placed a commode beside the patient’s bed to provide easier access during nighttime bathroom needs.
45. Communication: A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.
    • Context: Effective communication between the healthcare team and family members was essential for coordinating the patient’s care plan.
46. Comorbidities: Coexisting health conditions.
    • Context: The patient’s diabetes and hypertension were significant comorbidities that complicated their recovery from surgery.
47. Compression stockings: Stockings that apply gentle pressure to a limb to reduce edema; also referred to as thrombo-embolic-deterrent (TED) hose.
    • Context: The patient wore compression stockings during their hospital stay to prevent blood clots from forming in their legs.
48. Contact precautions: Transmission-based precautions used for clients with known or suspected infections transmitted by touch such as C-difficile (C-diff), methicillin-resistant staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE), or norovirus.
    • Context: All staff entering the patient’s room followed contact precautions by wearing gloves and gowns to prevent spreading the C-diff infection.
49. Cyanosis: Blue coloration around the mouth and in the extremities (i.e., feet and hands) that occurs when there is decreased oxygenated blood flow to the tissues.
    • Context: The nurse immediately called the physician when she noticed cyanosis around the patient’s lips, indicating poor oxygenation.
50. Daily weights: Client weight taken at the same time every day, on the same scale, in similar clothing, and before any food or fluids are consumed.
    • Context: The patient’s daily weights were monitored closely to assess their response to the new heart failure medication.
51. Dangle: Sitting up on the edge of bed for a few minutes before standing to prevent orthostatic hypotension and dizziness.
    • Context: The nursing assistant helped the patient dangle their legs before standing to prevent them from becoming lightheaded.
52. Delirium: Psychosis caused by medical conditions or substance use that starts suddenly and is reversible by treating the cause of the delirium.
    • Context: The elderly patient developed delirium during their hospital stay, which resolved once their urinary tract infection was treated.
53. Delusions: Unshakable beliefs in something that isn’t true or based on reality.
    • Context: The patient with dementia experienced delusions about strangers being in their room, requiring gentle redirection from staff.
54. Dementia: A general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. There are several types of dementia, including Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia.
    • Context: The family met with the doctor to discuss how dementia would progress and what care options were available.
55. Depressive episode: A condition where the person experiences a depressed mood (feeling sad, irritable, or empty) or a loss of pleasure or interest in activities they normally enjoy. Other symptoms may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling especially tired.
    • Context: The patient was experiencing a depressive episode and was referred to psychiatric services for evaluation and treatment.
56. Depth perception: The ability to determine distance between oneself and another object.
    • Context: The patient’s impaired depth perception following their stroke made it difficult for them to safely navigate stairs.
57. Developmental disorders: Disorders caused by impairments in the brain or central nervous system due to problems that occurred during fetal development.
    • Context: The child received specialized therapy services to address developmental disorders identified during early screening.
58. Diaphoresis: Excessive sweating.
    • Context: The patient experienced diaphoresis along with chest pain, prompting immediate cardiac evaluation.
59. Disinfection: The removal of microorganisms. However, disinfection does not destroy all spores and viruses.
    • Context: The environmental services team performed thorough disinfection of the patient room after discharge to prepare for the next admission.
60. Do-Not-Resuscitate (DNR) order: A medical order that instructs health care professionals to not perform cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or their heart stops beating. A DNR order is only written with permission by the patient (or the patient’s health care power of attorney, if activated).
    • Context: The family discussed the DNR order with the physician to ensure it reflected the patient’s wishes for end-of-life care.
61. Documentation: A legal record of patient care completed in a paper chart or electronic health record (EHR).
    • Context: Accurate documentation of the patient’s medication administration was essential for maintaining continuity of care.
62. Droplet precautions: Transmission-based precautions used for clients with a diagnosed or suspected pathogen that is spread in small droplets from sneezing or in oral and nasal secretions, such as influenza or pertussis.
    • Context: The healthcare team implemented droplet precautions for the patient with influenza, requiring surgical masks within three feet of the patient.
63. Dysphagia: Difficulty swallowing that can cause aspiration of liquids and food into one’s lungs and lead to life-threatening pneumonia.
    • Context: The speech therapist recommended a modified diet for the patient with dysphagia to reduce the risk of aspiration.
64. Edema: Fluid retention causing swelling in the extremities.
    • Context: The patient’s heart failure medication helped reduce the edema in their ankles and feet.
65. Elder abuse: An intentional act, or failure to act, that causes or creates a risk of harm to someone 60 or older. The abuse occurs at the hands of a caregiver or a person the older adult trusts.
    • Context: The nurse was trained to recognize signs of elder abuse and report any suspected cases to the appropriate authorities.
66. Elopement: An event when a resident who is incapable of protecting themselves from harm can successfully leave the facility unsupervised and unnoticed and possibly enter into harm’s way.
    • Context: The facility installed door alarms to prevent elopement of residents with dementia who might wander outside unsupervised.
67. End-of-life care: Term used to describe care provided when death is imminent, and life expectancy is limited to a short number of hours or days.
    • Context: The hospice team provided compassionate end-of-life care to ensure the patient’s comfort and dignity during their final days.
68. Epiglottis: The anatomical flap that covers the trachea and prevents liquids from entering the lungs when swallowing.
    • Context: The doctor explained how the epiglottis normally protects the airway during swallowing, but stroke can affect this protective mechanism.
69. Esophagus: The muscular tube from the mouth to the stomach.
    • Context: The barium swallow study showed that food was moving normally through the patient’s esophagus to the stomach.
70. Expressive aphasia: A speech disorder where a person understands what other people say but struggles to form words.
    • Context: The patient with expressive aphasia could understand questions but had difficulty expressing their thoughts verbally.
71. Extension: Movement that increases the angle between two bones. For example, extension occurs when doing a bicep curl and the arm is straightened back to starting position, increasing the angle between the elbow joint.
    • Context: The physical therapist guided the patient through knee extension exercises to strengthen the quadriceps muscles.
72. Eye protection: Face shields, visors attached to masks, and goggles that are used to protect the eyes from blood or body fluids.
    • Context: The surgeon wore eye protection during the procedure to prevent exposure to blood splatter.
73. FAST: An acronym used to remember the early signs of a stroke: Facial drooping, Arm weakness, Slurred speech, and Time (meaning the quicker the response, the better the outcome).
    • Context: The emergency department staff used the FAST assessment to quickly identify stroke symptoms in the patient.
74. Fever: A temperature of 38 degrees Celsius (100.4 degrees F).
    • Context: The patient developed a fever of 101°F, prompting the nurse to obtain blood cultures to check for infection.
75. Fine motor skills: Small movements such as those in the wrists and hands.
    • Context: The occupational therapist worked on fine motor skills with the patient to help them regain the ability to button clothing.
76. Flexion: Movement that decreases the angle between two bones. For example, contracting the bicep to lift a weight upwards is flexion.
    • Context: The patient performed elbow flexion exercises to rebuild strength in their arm muscles after the cast was removed.
77. Foam boots: Specialized soft boots used to support the ankles and keep the heels floated off the bed.
    • Context: The nurse applied foam boots to prevent pressure ulcers from developing on the patient’s heels during bed rest.
78. Foot cradle: A device used to keep the sheets and blankets off the tops of a client’s toes.
    • Context: A foot cradle was placed at the end of the bed to prevent the heavy blankets from putting pressure on the patient’s sensitive feet.
79. Fowler’s position: A position where the client is lying on their back with their head elevated between 30 and 90 degrees.
    • Context: The patient was positioned in Fowler’s position to ease their breathing difficulties and reduce shortness of breath.
80. Friction: Injury caused to skin when it is rubbed by clothing, linens, or another body part.
    • Context: The nurse used proper lifting techniques to prevent friction injuries when repositioning the patient in bed.
81. Glaucoma: A visual condition that occurs due to high pressure on the optic nerve that results in loss of peripheral vision, blind spots, or even blindness across the entire visual field.
    • Context: The patient’s glaucoma required regular eye pressure monitoring and daily eye drops to prevent further vision loss.
82. Grooming: Maintaining a resident’s appearance through shaving, hair, and nail care.
    • Context: The certified nursing assistant helped with the patient’s daily grooming routine to maintain their dignity and self-esteem.
83. Gross motor skills: Large movements controlled by the legs and trunk of the body.
    • Context: The physical therapist focused on gross motor skills to help the patient regain their ability to walk and maintain balance.
84. Hallucinations: A condition where a person senses things such as visions, sounds, or smells that seem real but are not.
    • Context: The patient with dementia experienced visual hallucinations and required medication adjustment to manage these symptoms.
85. Hand hygiene: The process of removing, killing, or destroying microorganisms or visible contaminants from the hands. There are two hand-hygiene techniques: handwashing with soap and water and the use of alcohol-based hand rub (ABHR).
    • Context: Proper hand hygiene before and after patient contact is the most effective way to prevent healthcare-associated infections.
86. Hand mitt: A large, soft glove that covers a confused patient’s hand to prevent them from inadvertently dislodging medical equipment such as a catheter, feeding tube, or intravenous (IV) catheter.
    • Context: The nurse applied hand mitts to prevent the confused patient from pulling at their IV line during the night.
87. Health Insurance Portability and Accountability Act of 1996 (HIPAA): Legislation that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
    • Context: All healthcare staff received annual HIPAA training to ensure patient privacy and confidentiality were maintained.
88. Heimlich maneuver: A procedure used for someone who is choking that uses abdominal thrusts to clear the airway so they can breathe.
    • Context: The dining room staff member performed the Heimlich maneuver when a resident began choking on their food.
89. Holistic care: Health care that addresses a patient’s physical, emotional, social, and spiritual needs.
    • Context: The interdisciplinary team provided holistic care by addressing not only the patient’s medical needs but also their emotional and spiritual concerns.
90. Hospice care: Care provided to patients who are terminally ill when a health care provider has determined they are expected to live six months or less. Hospice provides comfort to the client and supports the family, but curative medical treatments are stopped. It is based on the idea that dying is part of the normal life cycle.
    • Context: The family chose hospice care to focus on comfort and quality of life during the patient’s final months.
91. Hygiene: Keeping the body clean and reducing pathogens by performing tasks such as bathing and mouthcare.
    • Context: The nursing assistant helped the patient with daily hygiene care to prevent infections and maintain comfort.
92. Hypertension (HTN): Elevated blood pressure.
    • Context: The patient’s hypertension was controlled with daily medication and lifestyle modifications including diet and exercise.
93. Hypotension: Low blood pressure.
    • Context: The patient experienced hypotension after taking their blood pressure medication, requiring close monitoring by the nursing staff.
94. Impaired skin integrity: Skin that is damaged or not healing normally. An example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue.
    • Context: The wound care nurse developed a treatment plan to address the patient’s impaired skin integrity and promote healing.
95. Incontinence briefs or pads: Disposable products used for clients with little to no control over bladder or bowel function.
    • Context: The nursing assistant changed the patient’s incontinence briefs regularly to maintain skin integrity and comfort.
96. Incontinence: A lack of voluntary control over urination or defecation.
    • Context: The patient’s incontinence following surgery required the use of protective undergarments and frequent skin care.
97. Infection control: Methods to prevent or stop the spread of infections in health care settings.
    • Context: The infection control nurse implemented strict protocols to prevent the spread of the outbreak throughout the facility.
98. Infectious agent: Microorganisms, such as bacteria, viruses, fungi, or parasites that can cause infectious disease.
    • Context: Laboratory testing identified the specific infectious agent responsible for the patient’s pneumonia.
99. Inflammation: Redness, warmth, swelling, and tenderness associated with early signs of infection.
    • Context: The patient showed signs of inflammation around the surgical incision, prompting antibiotic treatment.
100. Insensible losses: Fluid loss that cannot be measured, such as fluids lost through the respiratory system, sweat, and stool.
     • Context: The dietitian calculated the patient’s insensible losses when determining their daily fluid requirements.
101. Intake and output (I&O): Fluid intake and output measured and documented every shift.
     • Context: The nurse carefully monitored the patient’s intake and output to assess their fluid balance during treatment for heart failure.
102. Involuntary muscle: Muscles controlled by the autonomic nervous system, including smooth muscle within the digestive system and respiratory system and the cardiac muscle in the heart that pumps blood throughout the body.
     • Context: The patient’s involuntary muscle contractions in their digestive system continued normally even while they were unconscious.
103. Isolation gowns: Protective garments worn to protect clothing from the splashing or spraying of body fluids and reduce the transmission of microorganisms.
     • Context: Healthcare workers donned isolation gowns before entering the room of the patient with a highly contagious infection.
104. Large intestine: The long, tube-like organ that is connected to the small intestine at one end and the anus at the other.
     • Context: The colonoscopy procedure allowed the doctor to examine the patient’s large intestine for any abnormalities.
105. Lateral (side-lying) position: A position that places the client on their left or right side to relieve pressure on the coccyx or increase blood flow to the fetus in pregnant women.
     • Context: The nurse positioned the patient in a lateral position to prevent pressure ulcers from developing on their tailbone.
106. Living will: A legal document that describes the patient’s wishes if they are no longer able to speak for themselves due to injury, illness, or a persistent vegetative state. The living will address issues like ventilator support, feeding tube placement, cardiopulmonary resuscitation, and intubation.
     • Context: The patient’s living will clearly stated their wishes regarding life support measures, helping guide the family’s difficult decisions.
107. Macronutrients: Carbohydrates, proteins, and fats that make up most of a person’s diet and provide energy, as well as essential nutrient intake.
     • Context: The registered dietitian reviewed the patient’s macronutrients to ensure they were receiving adequate nutrition for wound healing.
108. Macular degeneration: A visual condition that causes a blind spot in the center field of vision and is the leading cause of vision loss in people over 50.
     • Context: The patient’s macular degeneration made it difficult to read, so large-print materials were provided for medication instructions.
109. Malaise: A feeling of discomfort, illness, or lack of well-being that is often associated with infection.
     • Context: The patient complained of general malaise and fatigue, which prompted the doctor to order blood tests to check for infection.
110. Mandated reporter: Nursing assistants and other health care professionals are referred to as mandated reporters because they are required by state law to report suspected neglect or abuse of the elderly, vulnerable adults, and children. As a caregiver, you are required to report any signs or symptoms that are suspicious for abuse or neglect to the nurse.
     • Context: As a mandated reporter, the nursing assistant immediately notified the charge nurse when she observed unexplained bruising on the elderly resident.
111. Manic episode: An elevated or irritable mood with abnormally increased energy that lasts at least one week.
     • Context: The patient experiencing a manic episode required close monitoring and medication adjustment to stabilize their mood and behavior.
112. Maslow’s Hierarchy of Needs: A theory stating that unless basic human needs within a hierarchy are met, humans cannot experience higher levels of psychological and self-fulfillment needs.
     • Context: The care team used Maslow’s Hierarchy of Needs to ensure the patient’s basic physical needs were met before addressing their emotional concerns.
113. Mechanical digestion: Digestion that begins with chewing when teeth crush and grind large food particles into smaller pieces that are easy to swallow.
     • Context: The patient’s dental problems interfered with mechanical digestion, requiring a soft diet to aid in swallowing.
114. Medical asepsis: Techniques used to prevent the transfer of microorganisms from one person or object to another but do not eliminate microorganisms.
     • Context: The nursing staff practiced medical asepsis by washing their hands between patient contacts to reduce the spread of germs.
115. Military time: A standard for recording time that avoids confusion between daytime and nighttime hours because each hour of the day is represented by a number ranging from 00:00 to 24:59.
     • Context: The medication was scheduled for administration at 1400 hours using military time to avoid any confusion about AM or PM dosing.
116. Mobility: The ability to move one’s body parts, change positions, and function safely within the environment. It is one of the most important factors for remaining independent.
     • Context: The physical therapist assessed the patient’s mobility to determine what assistive devices would help maintain their independence.
117. Mode of transmission: The way an infectious agent travels to other people and places.
     • Context: Understanding the mode of transmission for COVID-19 helped healthcare workers implement appropriate protective measures.
118. Modified diet: Any diet altered to include or exclude certain components. For example, a low-salt diet is an example of a modified diet.
     • Context: The patient with kidney disease required a modified diet that restricted protein and phosphorus intake.
119. Moments of hand hygiene: Appropriate times during patient care to perform hand hygiene, including immediately before touching a patient; before performing an aseptic task; before moving from a soiled body site to a clean body site; after touching a patient or their immediate environment; after contact with blood, body fluids, or contaminated surfaces (with or without glove use); and immediately after glove removal.
     • Context: The infection control nurse educated staff about the five moments of hand hygiene to prevent healthcare-associated infections.
120. Myocardial infarction (MI): The medical term for what is commonly referred to as a “heart attack,” caused by a lack of blood flow and oxygen to the heart.
     • Context: The patient was rushed to the cardiac catheterization lab after being diagnosed with a myocardial infarction.
121. Neglect: Failure to provide care to oneself or to someone for whom you are enlisted to care.
     • Context: The social worker investigated reports of neglect when the elderly patient appeared malnourished and unkempt.
122. Neurotransmitters: Chemicals in the body used for nerve communication.
     • Context: The psychiatrist explained how certain medications work by affecting neurotransmitters in the brain to improve mood.
123. Nonskid footwear: Shoes or socks with rubberized soles used to prevent falls.
     • Context: All patients were required to wear nonskid footwear when ambulating in the hospital to reduce their risk of falling.
124. NPO: A common medical abbreviation referring to “nothing by mouth.”
     • Context: The patient was kept NPO after midnight in preparation for their morning surgery.
125. Objective information: Anything that can be observed through sight, touch, hearing, or smell, referred to as “signs.” An example of objective information is the client’s temperature was 98.6 degrees Fahrenheit.
     • Context: The nurse documented objective information including the patient’s blood pressure, temperature, and visible skin condition.
126. Obstructive sleep apnea: A condition where one’s breathing temporarily stops while sleeping.
     • Context: The patient’s obstructive sleep apnea required the use of a CPAP machine during sleep to maintain proper breathing.
127. Older adults: Adults aged 65 years old or older.
     • Context: The geriatric unit specialized in caring for older adults with complex medical needs and age-related conditions.
128. Orthostatic hypotension: A sudden drop in blood pressure that can cause clients to feel dizzy and increase their risk for falls.
     • Context: The patient experienced orthostatic hypotension when standing up quickly, so the nurse instructed them to rise slowly from bed.
129. Orthotic: A support, brace, or splint used to support, align, prevent, or correct the function of movable parts of the body.
     • Context: The patient wore an orthotic device on their ankle to provide support and prevent re-injury while walking.
130. Osteoarthritis: A medical diagnosis that refers to inflammation of joints due to wear and tear throughout one’s life.
     • Context: The patient’s osteoarthritis in their knees made walking painful, requiring pain management and physical therapy.
131. Output: Fluids that leave the body, including urine output that is measured.
     • Context: The nurse monitored the patient’s urine output hourly to assess kidney function after surgery.
132. Oxygen saturation (SpO2): Oxygenation status by a pulse oximeter based on how much of hemoglobin in red blood cells is “saturated” with oxygen.
     • Context: The patient’s oxygen saturation dropped to 88%, prompting the nurse to administer supplemental oxygen.
133. Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
     • Context: The nurse used a pain scale to assess the patient’s pain level and determine the appropriate pain management intervention.
134. Panic attacks: Sudden periods of intense fear that come on quickly and reach their peak within minutes. Attacks can occur unexpectedly or can be brought on by a trigger, such as a feared object or situation. People experiencing a panic attack may exhibit symptoms such as sweating, trembling, shortness of breath, chest pain, nausea, increased heart rate, or feelings of losing control.
     • Context: The patient experienced panic attacks when entering enclosed spaces, requiring gradual exposure therapy with a mental health professional.
135. Partial bath: Washing the face, underarms, arms, hands, and perineal area. Partial baths are given daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use.
     • Context: The bedridden patient received a partial bath each morning to maintain cleanliness and skin health.
136. PASS: An acronym for using a fire extinguisher that stands for the following: P: Pull the pin on the fire extinguisher; A: Aim the extinguisher nozzle at the base of the fire; S: Squeeze or press the handle; S: Sweep from side to side at the base of the flame until the fire appears to be out.
     • Context: During fire safety training, staff learned to remember PASS when using a fire extinguisher in emergency situations.
137. Passive communicator: Individuals who put the rights of others before their own when communicating.
     • Context: The passive communicator patient rarely expressed their needs directly, requiring staff to ask specific questions about their comfort.
138. Passive range of motion: When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part.
     • Context: The physical therapist performed passive range of motion exercises on the paralyzed patient’s limbs to prevent contractures.
139. Perineal: The genital and anal area.
     • Context: The nursing assistant provided thorough perineal care to prevent infection and maintain the patient’s dignity and comfort.
140. Peristalsis: Contractions that move the bolus through the esophagus, stomach, small intestine, and large intestine.
     • Context: The patient’s peristalsis was sluggish after surgery, so the doctor ordered medication to stimulate bowel movement.
141. Perseverating: The act of repeating a task or thought over and over.
     • Context: The patient with dementia was perseverating on wanting to go home, requiring gentle redirection and comfort measures.
142. Person-centered care: A care approach that considers the whole person, not just their physical and medical needs. It also refers to a person’s autonomy to make decisions about their care, as well as participate in their own care.
     • Context: The facility emphasized person-centered care by involving residents in care planning decisions and honoring their preferences.
143. Personal care: Care that a client needs to maintain hygiene, well-being, self-esteem, and dignity.
     • Context: The certified nursing assistant helped with personal care activities including bathing, grooming, and oral hygiene.
144. Personal protective equipment (PPE): Specialized clothing or equipment used to prevent the spread of infection, including gloves, gowns, facial protection (masks and eye protection), and respirators.
     • Context: All healthcare workers donned appropriate personal protective equipment before entering the isolation room.
145. Personality disorder: A pattern of inner experiences and behaviors that deviates from the expectations of the individual’s culture.
     • Context: The patient with a personality disorder required consistent care approaches and clear boundaries from all staff members.
146. Pharynx: The hollow tube that starts behind the nose and ends at the trachea and esophagus.
     • Context: The doctor examined the patient’s pharynx during the throat culture procedure to check for bacterial infection.
147. Phobia: An intense fear of specific objects or situations (such as flying, heights, spiders, or social events).
     • Context: The patient’s phobia of needles required special preparation and anxiety management before blood draws.
148. Physical therapists: Health specialists who evaluate and treat movement disorders.
     • Context: The physical therapists developed a comprehensive rehabilitation plan to help the stroke patient regain mobility and independence.
149. Pocketing: The act of keeping food or medications in one’s cheeks and not swallowing it.
     • Context: The speech therapist noticed the patient was pocketing food and recommended supervision during meals to prevent choking.
150. Portal of entry: The route by which an infectious agent enters a new host.
     • Context: Proper wound care was essential to prevent bacteria from using the surgical incision as a portal of entry for infection.
151. Portal of exit: The route by which an infectious agent escapes or leaves the reservoir.
     • Context: Covering coughs and sneezes helps block the portal of exit for respiratory pathogens like influenza.
152. Postmortem care: Care provided after death has occurred through transfer to a morgue or funeral provider.
     • Context: The nursing staff provided respectful postmortem care, preparing the body with dignity before the family’s final visit.
153. Presbycusis: Hearing loss that occurs due to the aging process.
     • Context: The patient’s presbycusis required staff to speak clearly and face the patient when communicating important information.
154. Pressure injuries: Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure and/or shear.
     • Context: The wound care nurse implemented a turning schedule and special mattress to prevent pressure injuries in the bedridden patient.
155. Prone position: A position where the client is placed on their stomach with their head turned to one side.
     • Context: The respiratory therapist placed the patient in prone position to improve oxygenation during severe pneumonia treatment.
156. Prosthetics: An addition or attachment to the body that replicates the function of a lost or dysfunctional limb.
     • Context: The amputee patient worked with an occupational therapist to learn how to use their new prosthetics effectively.
157. Psychosis: Conditions when a person experiences a loss of contact with reality and has difficulty understanding what is real and what is not real. Symptoms of psychosis include hallucinations and delusions.
     • Context: The patient experiencing psychosis required psychiatric evaluation and medication to help distinguish reality from their hallucinations.
158. Pureed diet: A diet order indicating all food is blended to smooth consistency.
     • Context: The patient with severe dysphagia was placed on a pureed diet to reduce the risk of aspiration while maintaining nutrition.
159. Purulent drainage: Yellow, green, or brown drainage associated with signs of infection.
     • Context: The nurse observed purulent drainage from the surgical wound and immediately notified the physician for antibiotic evaluation.
160. Quality of life: The degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events.
     • Context: The palliative care team focused on improving the patient’s quality of life through pain management and emotional support.
161. Receptive aphasia: A speech condition that causes difficulty in understanding conversations.
     • Context: The patient with receptive aphasia could speak but had trouble understanding spoken instructions from the healthcare team.
162. Rehabilitation: Therapy to help people regain body functions they lost due to medical conditions or injury.
     • Context: The patient entered a comprehensive rehabilitation program after their stroke to regain speech, mobility, and independence.
163. Reservoir: The host in which infectious agents live, grow, and multiply.
     • Context: Proper food storage prevents the refrigerator from becoming a reservoir for harmful bacteria that could cause foodborne illness.
164. Respirator masks: Masks with N95 or higher filtration worn by health care professionals to prevent inhalation of infectious small airborne particles.
     • Context: Healthcare workers wore respirator masks when caring for patients with tuberculosis to protect themselves from airborne transmission.
165. Respiratory distress: Problems breathing.
     • Context: The patient showed signs of respiratory distress with rapid, shallow breathing and use of accessory muscles.
166. Respiratory hygiene: Methods to prevent the spread of respiratory infections, including coughing/sneezing into the inside of one’s elbow or covering one’s mouth/nose with a tissue when coughing and promptly disposing of used tissues. Hand hygiene should be immediately performed after contact with one’s respiratory secretions. A coughing person should also wear a surgical mask to contain secretions.
     • Context: The hospital posted signs reminding visitors to practice respiratory hygiene during flu season to protect patients and staff.
167. Restraints: Devices used in health care settings to prevent patients from causing harm to themselves or others when alternative interventions are not effective.
     • Context: Physical restraints were used only as a last resort after other safety interventions failed, with frequent monitoring required.
168. Routine cares: Personal cares provided to every resident every day, such as assisting them in getting dressed for breakfast.
     • Context: The nursing assistant completed routine cares for all assigned residents, including assistance with dressing and grooming.
169. Scope of practice: Services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional license.
     • Context: The nursing assistant understood their scope of practice and referred medication questions to the licensed nurse.
170. Seclusion: The confinement of a patient in a locked room from which they cannot exit on their own. It is generally used as a method of discipline, convenience, or coercion.
     • Context: The facility’s policy strictly prohibited seclusion except in emergency situations with proper medical orders and monitoring.
171. Seizure: A transient occurrence of signs and/or symptoms due to abnormal neuronal activity in the brain.
     • Context: The nurse implemented seizure precautions by padding the bed rails and ensuring suction equipment was readily available.
172. Sepsis: Life-threatening infection that has spread throughout the body.
     • Context: The patient developed sepsis from an untreated urinary tract infection, requiring immediate intensive care treatment.
173. Shear: Injury to skin that occurs when skin moves one way, but the underlying bone and muscle stay fixed or move the opposite direction.
     • Context: Proper lifting techniques prevented shear injuries when repositioning patients who could not move independently.
174. Shortness of breath (SOB): Difficulty breathing or a feeling of not being able to catch one’s breath.
     • Context: The patient complained of shortness of breath when climbing stairs, prompting cardiac evaluation by the physician.
175. Signs: Objective information obtained through the senses of sight, hearing, smell, or touch.
     • Context: The nurse documented vital signs and other objective signs of the patient’s condition in the medical record.
176. Sims’ position: A position similar to the lateral position, but the client is always placed on their left side and their left arm is placed behind their body.
     • Context: The patient was positioned in Sims’ position for the rectal examination to provide optimal access and comfort.
177. Skeletal muscle: Muscle that produces movement, assists in maintaining posture, protects internal organs, and generates body heat.
     • Context: The patient’s skeletal muscle weakness required physical therapy to rebuild strength and prevent further deconditioning.
178. Skin breakdown: Damage to the skin due to common preventable causes like immobility and incontinence.
     • Context: The nursing staff implemented a comprehensive skin care protocol to prevent skin breakdown in high-risk patients.
179. Skin tear: A separation of skin layers caused by shear, friction, and/or blunt force.
     • Context: The elderly patient’s fragile skin was prone to skin tears, requiring gentle handling during all care activities.
180. Small intestine: A long tube-like organ that connects the stomach and the large intestine where nutrients are absorbed from a food bolus.
     • Context: The patient’s small intestine was examined during the CT scan to rule out any blockages or abnormalities.
181. Snellen chart: A common tool used for assessing distant vision.
     • Context: The patient read the letters on the Snellen chart during their annual eye examination to check for vision changes.
182. Speech therapists: Therapists who assess, diagnose, and treat communication and swallowing disorders.
     • Context: The speech therapists evaluated the patient’s ability to swallow safely before advancing their diet after the stroke.
183. Standard precautions: Precautions used by health care workers during client care when contact or potential contact with blood or body fluids may occur based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. These precautions reduce the risk of exposure for the health care worker and protect patients from potential transmission of infectious organisms.
     • Context: All healthcare workers followed standard precautions by wearing gloves when any contact with body fluids was anticipated.
184. Sterilization: A process used on equipment and the environment that destroys all pathogens, including spores and viruses. Sterilization methods include steam, boiling water, dry heat, radiation, and chemicals.
     • Context: All surgical instruments underwent sterilization in the autoclave before being used in the operating room.
185. Stoma: A surgically created opening in the abdominal wall where a healthy part of the intestine is attached.
     • Context: The patient learned proper stoma care techniques before discharge to prevent complications and maintain hygiene.
186. Substance use disorder (SUD): An illness caused by the repeated misuse of substances such as alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, or misuse of other prescription or over-the-counter medications. All these substances taken in excess have a common effect of intensely activating the reward system in the brain so much that normal life activities may be neglected.
     • Context: The patient entered treatment for substance use disorder after their addiction began interfering with their ability to work and maintain relationships.
187. Sundowning: Restlessness, agitation, irritability, or confusion that typically begins or worsens as daylight begins to fade and can continue into the night, making it difficult for patients with dementia to sleep.
     • Context: The nursing staff anticipated sundowning in the dementia patient and implemented calming activities in the early evening.
188. Supine position: A position where the client is lying flat on their back.
     • Context: The patient was placed in supine position for the chest X-ray to provide clear visualization of the lungs.
189. Surgical asepsis: The absence of all microorganisms during any type of invasive procedure; used for equipment used during invasive procedures, as well as the environment.
     • Context: The operating room maintained surgical asepsis through sterile technique and specialized air filtration systems.
190. Susceptible host: A person at elevated risk of developing an infection when exposed to an infectious agent.
     • Context: The immunocompromised patient was considered a susceptible host and required protective isolation measures.
191. Symptoms: Subjective information reported by clients or their family members. Symptoms are documented by using quotes around the exact words expressed by the client or their family member. For example, the client reported, “I have a headache.”
     • Context: The nurse documented the patient’s symptoms using direct quotes to accurately record their subjective complaints.
192. Tendons: Strong bands of dense, regular connective tissue that connect muscles to bones.
     • Context: The patient’s torn Achilles tendon required surgical repair and months of physical therapy for full recovery.
193. Therapeutic communication: A type of professional communication used with patients defined as the purposeful, interpersonal, information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to patient understanding and participation.
     • Context: The nurse used therapeutic communication techniques to help the anxious patient express their fears about the upcoming procedure.
194. Timed voiding: Encourages the patient to urinate on a set schedule.
     • Context: The patient with mild incontinence followed a timed voiding schedule to help retrain their bladder and reduce accidents.
195. Trachea: The hollow tube, otherwise known as the windpipe, that leads to the lungs.
     • Context: The patient required a temporary tracheostomy when swelling in their throat blocked the normal airway through the trachea.
196. Transfer status: Assistance the patient requires to be moved from one location to another, such as from the bed to a chair.
     • Context: The physical therapist assessed the patient’s transfer status to determine how much assistance they needed for safe mobility.
197. Transient ischemic attack (TIA): A medical term for what is commonly referred to as a ministroke. A TIA is a temporary period of symptoms similar to those of a stroke that usually last only a few minutes and don’t cause permanent brain damage.
     • Context: The patient’s transient ischemic attack served as a warning sign, prompting lifestyle changes and medication to prevent a full stroke.
198. Transmission-based precautions: Specific types of personal protective equipment (PPE) and practices used with clients with specific types of infectious agents based on the pathogen’s mode of transmission.
     • Context: The infection control nurse implemented transmission-based precautions for the patient with C. difficile infection.
199. Trauma: An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social, emotional, or spiritual well-being.
     • Context: The patient received trauma-informed care that recognized how past traumatic experiences might affect their response to medical treatment.
200. Tripod position: A position that people experiencing respiratory distress naturally assume by leaning forward and placing their arms or elbows on their knees or on a bedside table to help improve lung expansion.
     • Context: The patient with severe shortness of breath automatically assumed the tripod position to ease their breathing difficulties.
201. Trisomy: A condition of having an extra copy of a chromosome.
     • Context: The genetic counselor explained how trisomy 21 causes Down syndrome and discussed available support services for the family.
202. Urge incontinence: A condition where as soon as the person feels the need to empty their bladder they have very little time before urine escapes.
     • Context: The patient with urge incontinence needed to be positioned close to bathroom facilities and reminded to void regularly.
203. Urinary catheter: A device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag.
     • Context: The patient required a urinary catheter during surgery to monitor urine output and prevent bladder distension.
204. Urinary tract infection (UTI): A common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys.
     • Context: The elderly patient developed a urinary tract infection that caused confusion and required antibiotic treatment.
205. Urostomy: A surgically placed opening to collect urine from a person’s ureters when their bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag.
     • Context: The patient learned proper urostomy care and bag changing techniques before discharge from the hospital.
206. Validation therapy: A technique used when caring with individuals with dementia that involves supporting the reality the person is experiencing.
     • Context: The nursing staff used validation therapy to comfort the dementia patient who was calling for their deceased spouse.
207. Vertigo: A sensation that the room is spinning.
     • Context: The patient experienced vertigo when standing up quickly, requiring assistance with ambulation to prevent falls.
208. Voluntary muscle: Muscle that a person is able to consciously control.
     • Context: Physical therapy focused on strengthening the patient’s voluntary muscle control after their spinal cord injury.
209. Vulnerable populations: Patients who are children, older adults, minorities, socially disadvantaged, underinsured, or those with certain medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by unnecessarily inadequate health care.
     • Context: The community health center specialized in providing care to vulnerable populations who might otherwise lack access to healthcare services.
210. Wandering: The simple act of a person walking around with no purpose due to their confusion regarding their location or environment.
     • Context: The facility installed wandering alarms to ensure the safety of residents with dementia who might become lost or confused.
211. Weighted silverware: Specialized silverware with a weighted handle for individuals with tremors or unsteady hands.
     • Context: The occupational therapist provided weighted silverware to help the patient with Parkinson’s disease eat more independently.
212. Wet voice: Vocalization with sounds as if food or fluids remain in the mouth or throat.
     • Context: The speech therapist noted the patient’s wet voice after swallowing and recommended a modified diet to prevent aspiration.