The Clinical Placement:
Students’ essential guide to
frequently used terminology
and abbreviations
P. Halligan, F. Howlin, R. Joye & K. Frazer
School of Nursing, Midwifery & Health Systems
University College Dublin
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Healthcare Professionals and Medical Terms in a Hospital Setting, Study notes of Nursing
An overview of various healthcare professionals and their roles in a hospital setting, as well as common medical terms and procedures used in patient care.
Typology: Study notes
2021/2022
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The Clinical Placement:
Students’ essential guide to
frequently used terminology
and abbreviations
P. Halligan, F. Howlin, R. Joye & K. Frazer
School of Nursing, Midwifery & Health Systems
University College Dublin
Dear Student,
Welcome to the world of clinical practice. This booklet aims to quickly
familiarise you with the common terms and abbreviations used in the
clinical area and to smooth your transition into the clinical practice.
Ideally, it should be used in conjunction with your DoCAT/MidCAT© and
the nurses’ dictionary. The booklet is divided into three sections:
Section A: Who’s who will introduce you to the main hospital personnel
with whom you will interact with on a daily basis. Many of the staff titles
are commonly abbreviated and are often referred to by this abbreviation.
For example, MIOC means Medical Intern on Call. Both team structures
are illustrated in Figure 1 and 2 at the end of this section.
Section B: Terminology includes the most frequently used terms by all
professionals in clinical practice.
Section C: Abbreviations includes the most frequently abbreviated
terms and conditions used by all professionals. Please note that
abbreviations should be avoided if at all possible, but in the event of
abbreviations being used, only those approved by the Quality & Clinical
Care Directorate and contained within the HSE document are permitted
(HSE 2010). A reduced number of these abbreviations are also included in
this booklet.
Multidisciplinary Team (MDT): a team of professionals representing different disciplines who coordinate the care of the patient in order to improve patient care. Sometimes referred to as Interdisciplinary Team (IDT)
Nursing/Midwifery Intern: A nursing/midwifery student in fourth year of college and in clinical practice
Occupational Therapist (OT): a professional who treats patients whose abilities to cope with the tasks of everyday living that are threatened or impaired by physical illness or injury, psychosocial disability, or developmental deficits
Phlebotomist: member of hospital staff trained to take blood from patients for further testing
Physiotherapist: a professional who treats injury or dysfunction with exercises and other physical treatments for the disorder
Porter: a person assigned to assist hospital staff with tasks such as moving equipment, transporting patients and many other important tasks. Sometimes called an ‘orderly’
Practice Development: a term used to describe particular approaches to supporting and promoting change in nursing/midwifery in hospitals
Preceptor: is a registered nurse/midwife who has been specially prepared to guide and direct student learning during clinical placement
Radiographer: a professional who takes patients’ x- rays and scans
Registered General Nurse (RGN): a nurse who is registered with Irish Nursing and Midwifery Board (INMB)
Registrar: a doctor who is receiving advanced training in a specialist field of medicine or surgery
Respiratory Therapist: a professional who assists patients with respiratory difficulties
Surgical Intern on Call (SIOC): Surgical intern on call for surgical patients
Senior House Officer (SHO): a junior doctor undergoing training within a certain specialty
Senior Registrar (SR): a senior doctor in a division of the hospital medical staff devoted to a particular specialty
Speech Therapist: a professional that helps individuals overcome communication conditions such as aphasia, swallowing difficulties and voice disorders
Figure 1. Typical Structure of Nursing and Midwifery team in a
Hospital
Figure 2. Typical structure of a Medical team in a Hospital
Director of Nursing/Midwifery
Clinical Nurse/Midwifery Manager 3 Clinical Nurse/Midwifery Manager 2 Clinical Nurse/Midwifery Manager 1 Staff Nurse /Midwife Nursing/Midwifery Intern
Student Nurse/Midwife
Assistant Director of Nursing/Midwifery
Consultant
Senior Registrar
Registrar
Senior House Officer (SHO)
Medical/ Surgical Intern
Impairment: a patient diminished mental capacity, such as difficulty with short- term memory
Congestive Heart Failure (CHF): a type of heart disease characterized by inadequate pumping action of the heart
Decubitus: see pressure ulcers
Dehydration (Dee-hy- dray - shun): when there's not enough fluid in the patient's body
Dementia: progressive mental disorder that affects memory, judgement and cognitive powers.
Diabetic: a patient diagnosed with diabetes mellitus
Discharge Planning: a plan to assist patients and their families with arrangements following discharge from a hospital stay
Dysphagia: a swallowing disorder
Dysphasia: difficulty in speaking
Elastic Stockings: stockings designed to help blood circulate from the legs to the heart to prevent clots
Emergency Response: a system (bell/buzzer/pulley) that provides an automatic alert to medics and others to respond to an emergency
End-Stage Renal Disease (ESRD): a medical condition in which a person's kidneys no longer function
Enuresis (en-yuh- ree - sis): means wetting the bed while asleep
Epistaxis (eh-puh- stak - sus): bleeding from the nose
Extubation (eks′tū-bā′shŭn): the removal of a tube that has been inserted to assist a patient to breath
Febrile: a fever or high temperature
Foley Catheter: a tube placed in the bladder to drain urine
Gastrostomy Tube: surgically placed tube that goes directly into the stomach for feeding and/or drainage
G Tube: a tube inserted surgically through an opening in the stomach for patients who are unable to use their mouths or swallow
Geriatrics: a branch of medicine that focuses on providing health care for the elderly
Haemovac: a tube placed near an incision during surgery to drain excess fluid
Hospice: a place where patients and their family receive palliative care to enhance their life while dying
Incentive Spirometer (spih- rah - muh-tur): an instrument that measures how well your lungs are working
Incontinent: partially or totally unable to control bladder and/or bowel functions
Intravenous infusion (IVI): liquid solution/ liquid medication that are administered directly into the blood stream through an intravenous catheter inserted into a vein in the body. Sometimes referred as ‘a drip’
Intubation: the insertion of a tube into the trachea to assist patients to breath
Ketoacidosis (Kee-toh-ah-sih- DOH - sis): a condition that can happen to people with diabetes
Length of Stay (LoS): the length of time a patient stays in a hospital
Long-term Care (LTC) : the medical/nursing and support services provided to patients over a prolonged period of time
Lung Function Tests (lung funk - shun tests) (LFTs): a test to tell how patients’ lungs function
Nausea (New -zee-uh): a feeling patients gets when they feel like they are going to be sick
Nursing Home: a place that provides continuous nursing care and other health- related services to residents who are not in an acute phase of illness
Oedema: a collection of fluid in tissues which causes swelling
Outpatients (OPD): an area of the hospital where a patient receives care without being admitted
Palliative: relieving the symptoms or pain of a disease or disorder
Peak Flow Meter (peek flo mee - tur): an instrument that tells you how well the lungs are functioning
Pre-admission Screening: a screening assessment of a patient to determine if he/she should be admitted to the hospital usually for a procedure
Pre-existing Condition: a medical condition that existed, or was diagnosed or was treated in the past
Pressure Ulcers: A breakdown of the skin integrity. Also referred to as pressure sores or decubitus ulcers
SECTION C ABBREVIATIONS
A
ABC Airway breathing, circulation Abd. Abdominal ABg Arterial blood gas ABO Blood group system Abs. Absorbable ACH After coming head ACS Acute coronary syndrome ACT Airway clearance technique AD Alzheimer’s Disease Add. Adduction ADL Activities of daily living Adm. Admission/admitted ADOM/N Assistant Director of Midwifery/Nursing AE Air entry AF Artificial feed AFR Average flow rate AFV Amniotic fluid volume Ag Abdominal girth AgA Appropriate gestational age Ak Above knee AkI Acute kidney injury Alb. Albumin Alk. Phos. Alkaline Phosphatase ALL Acute lymphoblastic leukaemia a.m. Morning before twelve AMI Acute myocardial infarction AML Acute myeloid leukaemia AMP Advanced Midwife Practitioner Anaes. Anaesthetic ANP Advanced Nurse Practitioner Ant. Anterior Anti-DVT Anti deep venous thrombosis Ant. Lat. Anterolateral Ant. Tibs. Anterior tibialis AP Antero-posterior APH Ante partum haemorrhage Approx. Approximately Appt. Appointment ARF Acute renal failure ARM Artificial rupture of membranes ASAP As soon as possible Asc. Ao. Ascending aorta ASD Atrial septal defect ASL Alternate side-lying Ass. Assistance AST Aspartate amino transferase Ausc. Auscultation Avl. Available AVSD Atrioventricular septal defect
Ax. Assessment
B Ba. Barium BC Blood cultures b.d./b.i.d. Twice daily BF Breast feed/fed/feeding Bg Blood glucose/blood gases BgL Blood glucose level BHx. Birth history BIBA Brought in by ambulance Bk Below knee BkA Below knee amputation BLS Basic life support BMA Bone marrow aspirate BMI Body mass index BMR Basal metabolic rate BNO Bowels not open BO Bowels opened BOS Base of support BP Blood pressure BPD Biparietal diameter BPM Beats per minute BSA Body surface area BSS Blood sugar series BTL Bilateral tubal ligation BT Blalock-Taussig Shunt BuN Blood urea nitrogen Bx. Biopsy
C C2H5OH Alcohol Ca. Carcinoma CA2+ Calcium CAD Coronary artery disease CANC Combined Antenatal care CBD Common bile duct CBT Cognitive behaviour therapy C&C Collar and cuff cc Copied to CCF Congestive cardiac failure CCT Controlled cord traction CCu Coronary Care unit CD Catheter draining C.diff. Clostridium difficile CEA Carotid endarterectomy CEO Chief Executive Officer CF Cystic fibrosis CFM Cerebral function monitoring CgA Contact guard assistance CHD Coronary heart disease Chemo Chemotherapy
DDx. Differential diagnosis Dept. Department Desc. Ao. Descending aorta DHx. Diet history Disp. Displacement Dka. Diabetic ketoacidosis DM Diabetes mellitus DNA Did not attend DOA Dead on arrival DOB Date of birth DOE Dyspnoea on exertion DOM/N Director of Midwifery/Nursing DPM Drops per minute Dr. Doctor DRVs Dietary reference values DSH Deliberate self harm DTs Delirium tremens D&V Diarrhoea & vomiting DVT Deep vein thrombosis DW Discussed with Dx/ Diagnosis
E EA Elective admission EAC External auditory canal EBL Estimated blood loss EBM Expressed breast milk ECg Electrocardiogram ECHO Echocardiogram E. Coli Escherichia coli ECT Electroconvulsive therapy ECV External cephalic version ED Emergency Department EDD Estimated date of delivery EEg Electroencephalogram EER Estimated energy requirements EFM Electronic fetal monitoring EFW Estimated fetal weight EgA Estimated gestational age EMg Electromyography EMS Elderly mobility scale EMu Early morning urine EN Enteral nutrition Enc. Enclosed ENT Ear nose and throat EOM External ocular movements EOR End of range EPS Electrophysiology studies ERot. External rotation ERPC Evacuation of retained product of conception ESkD End stage kidney disease ESR Erythrocyte sedimentation rate
EST Exercise stress test Est. Req. Estimated requirements ET Endotracheal Etc. Etcetera ETCO2 End tidal CO EuA Examination under anaesthetic EV Eversion Ex Prem. Ex premature Exs. Exercises Ext. Extension
F FA Fetal anomaly FAS Fetal assessment scan FB Foreign body FBC Full blood count FBM Fetal breathing movement FBS Fasting blood sugar FES Functional electrical stimulation FET Forced expiratory technique FH Fetal heart FHH Fetal heart heard FHHR Fetal heart heard and regular FHNH Fetal heart not heard FHR Fetal heart rate FHx. Family history Fi02 Fractioned inspired oxygen FLP Fasting lipid profile FM Fetal movement FMF Fetal movement felt FNA Fine needle aspiration FNAB Fine needle aspirate biopsy FOB Faecal occult blood Fr. French (catheter measurement) FROM Full range of movement/motion FS Frozen section FSE Fetal scalp electrode FT Full term FTA Failure to advance FTND Full term normal delivery FTT Failure to thrive Fu Follow up FVC Forced vital capacity FWB Full weight bearing
G g Gram gA General anaesthetic gAMMA gT Gamma glutamyl transferase gBS Group B streptococcus gCS Glasgow coma scale gCT Glucose challenge test
IBW Ideal body weight ICP Intracranial pressure ICu Intensive Care unit I&D Incision & drainage ID Infectious disease I:E Ratio Inspiratory to expiratory ratio IHD Ischemic heart disease IHF Irish Heart Foundation IM Intramuscular IMB Intermenstrual bleeding Imp. Impression Incl. Including/included Ind. Independent Inf. Inferior Info. Information iNO Inhaled nitric oxide In Pt. In Patient INR International normalised ratio Int. Rot. Internal rotation I&O Intake and output IOL Induction of labour IP Intraperitoneal IPD Intermittent peritoneal dialysis ISC Intermittent self catheterisation ISQ In Status Quo IT Inspiratory time ITT Insulin tolerance test ITu Intensive Therapy unit Iu International unit IcD Intrauterine contraceptive device IuD Intrauterine death IugR Intrauterine growth retardation/restriction IV Intravenous IVC Inferior vena cava IVDu Intravenous drug user IVF In vitro Fertilisation IVH Intraventricular haemorrhage IVI Intravenous infusion IVP Intravenous pyelogram IVS Interventricular septum IVT Intravenous therapy IVu Intravenous urogram IVuS Intravascular ultrasound IWA Irish Wheelchair Association Ix. Investigation
J JIA Juvenile idiopathic arthritis JVP Jugular venous pressure
K k+ Potassium
kAFO knee ankle foot orthosis kcal kilocalorie kCL Potassium chloride kg. kilogram kJ kilo joules kuB kidneys, ureters and bladder kVO keep vein open
L L Litre LA Local anaesthetic Lab. Laboratory Lat. Lateral Lat. Rot. Lateral rotation LBP Low back pain lbs. Pounds weight LDH Lactate dehydrogenase LDL Low density lipoprotein LFTs Liver function tests LgA Large for gestational age LIF Left iliac fossa LIH Left inguinal hernia LL Lower limb LLQ Left lower quadrant LMP Last menstrual period LOA Left occipito-anterior LOC Loss of consciousness LOP Left occipito-posterior LOR Loss of resistance LP Lumbar puncture LRot. Left rotation LRTI Lower respiratory tract infection LSA Left sacro-anterior LSCS Lower segment caesarean section LSF Left side flexion LSL Left sacro-lateral LSpine Lumbar spine LTC Long term care LTM Long term memory LTS Lateral tarsal strip LuQ Left upper quadrant LuS Lower uterine segment LVF Left ventricular failure LVS Low vaginal swab Ly. Lying
M m2 Square Metres body surface Mane Morning MAS Motor assessment scale Max. Maximum MDA Misuse of Drugs Act
Ng Naso-gastric NH Nursing Home NHL Non Hodgkin’s lymphoma NIBP Non invasive blood pressure NICu Neonatal Intensive Care unit NIEL Not in established labour NIV Non invasive ventilation NJ Naso-jejunal NkA No known allergies NkDA No known drug allergies NND Neonatal death No. Number Nocte Night NOF Neck of femur NOk Next of kin NP New patient NPL No perception of light NPO Nil per oral NPu Not passed urine NTD Neural tube defect NTT Nasotracheal tube Nullip. Nulliparous N&V Nausea and vomiting NWB Non weight bearing
O O2 Oxygen OA Osteoarthritis OAusc. On auscultation Obj. Objective Obs. Observations Occ. Occasional Occ. Health Occupational Health OCP Oral contraceptive pill OD Overdose OE On examination OFC Occipito-frontal circumference OgTT Oral glucose tolerance test Onc. Oncology O&P Ova and parasites OP Outpatient OPD Outpatient Department Ortho. Orthopaedics OT Occupational Therapy/Therapist
P Paeds. Paediatrics Para Parity -total number of delivered pregnancies PC Presenting complaint PCA Patient controlled analgesia PD Peritoneal dialysis PE Pulmonary embolus/embolism
PFA Plain film of abdomen PFO Patent foramen ovale PFR Pelvic floor repair PFTs Pulmonary function tests PgE Prostaglandin E PHN Public Health Nurse PHT Pulmonary hypertension Physio. Physiotherapist/Physiotherapy PICu Paediatric Intensive Care unit PID Pelvic inflammatory disease Pku Phenylketonuria PL Perception of light PLTS Platelets p.m. Afternoon PMB Post menopausal bleeding PMHx. Past medical history PMs. Passive movements P&N Pins and needles PN Parenteral nutrition PND Paroxysmal nocturnal dyspnoea PO Per oral PO4 Phosphate POD Progression of disease PON&V Post operative nausea &vomiting POP Plaster of Paris Pos. Positive Post. Posterior Post Op. Post operation PPH Post-partum haemorrhage PR Per rectum Prem. Premature Premed. Premedication Pre Op Pre operation p.r.n. As required Prox. Proximal PSW Psychiatric Social Worker PT Prothrombin time PTSD Post traumatic stress disorder Pu Passed urine PuD Peptic ulcer disease Pul.V Pulmonary veins PuO Pyrexia of unknown origin PV Per vagina PVD Peripheral vascular disease PWB Partial weight bearing
Q q.d.s./q.i.d. Four times daily Quads. Quadriceps