Nursing Terminology: QuickStudy Laminated Reference Guide

Basic Definitions of Tools, Equipment, Products & More!

GENERAL TOOLS & EQUIPMENT

Bandage scissors: Highly polished surgical steel scissors with a blunted end. Used to safely remove first-aid bandages and dressings.

Forceps: For removal of small foreign objects with needle-point sharpness. Available in a variety of styles for different uses; mosquito forceps, dressing forceps, curved or straightline forceps, and Kelly forceps are just some examples.

Needle: Different types of needles exist. Each type has a specialized use.

Hypodermic needle: A hollow needle common­ly used with a syringe to inject substances into the body.

Surgical needle: A needle with holes or eyes; supplied to the hospital separate from its suture thread.

Tuohy needle: A hollow needle suitable for inserting epidural catheters.

Tourniquet: A device, typically a tightly encircling bandage, used to check bleeding by temporarily stopping the flow of blood through a large artery in a limb. Also used to distend a vein prior to venipuncture.

DOCUMENTATION & CHARTING

Charting: The act of documenting information about a client, focusing on the assessment and treatment of the disease process and the client’s call for and response to nursing care. The goal of charting is communication.

Charting by exception: A focus on deviation from the norm or significant findings.

Computer assisted: Entering client-specific data into a computer for storage and retrieval.

Electronic medical record (EMR) or electronic health record (EHR): A medical record in digital format.

Flow sheets: Recording or graphing of data to demonstrate patterns, trends or alteration in findings.

Narrative charting: Charting by discipline using a narrative to document activity based on chronology rather than systems.

Problem-oriented medical records (POMR): The record is organized according to the individual’s specific problems.

SOAP Note: The acronym S-O-A-P stands for – Subjective (what the client feels or his/her symptoms); Objective (what the nurse observes or signs); Assess (what the nurse assesses the situation to be); Plan (what the nurse is doing).

SOAPIER Note: Similar to SOAP, with the addition of – Implementation (nursing actions in response to the symptoms and signs or carrying out the plan); Evaluation (how the client responded); Revision (how the plan changes based on the client’s response).

ASSESSMENT TECHNIQUES, TOOLS & EQUIPMENT

Vital Signs (VS) – Temperature Scales Temperature: Body temperature is one VS a nurse must assess. It is measured with thermometers that may be calibrated to a variety of temperature scales.

Fahrenheit: A temperature scale still in use for most non-scientific purposes in the United States. In this scale, the freezing point of water is 32°F and the boiling point is 212°F (at standard atmospheric pressure), placing the boiling and freezing points of water exactly 180 degrees apart. A degree on the Fahrenheit scale is 1/180th part of the interval between the freezing point and the boiling point.

Celsius: A temperature scale that is devised by dividing the range of temperature between the freezing and boiling temperatures of pure water