Ncm lec

• ABD: abdomen
• AC: before meals
• AD: admitting diagnosis
• A&D: admission and discharge
• AD LIB: as desired, if the patient so desired
• ADL: activities of daily living
• AA: of each, equal parts
• Disch or dish or D/C: discharge
• D&C: dilatation and curettage
• QID: four times a day
• ABG: aterial blood gases
• AKA: above knee amputation
• Fowler’s position: 45-60degree
• Subjective: This section includes what the patient said, such as, “I have a headache.” It can also contain information related to pertinent medical history and why the patient is in need of care.
• Objective: This section contains the observable and measurable data collected during a patient assessment, such as the vital signs, physical examination findings, and lab/diagnostic test results.
• Assessment: This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
• Plan: This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
• Interventions: This section describes the actions implemented.
• Evaluation: This section describes the patient’s response to interventions and if the planned outcomes were

  met.
• INSPECTION: • Involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.
• PALPATION: Consists of using parts of the hand to touch
• PERCUSSION: Involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.
• AUSCULTATION: A type of assessment technique that requires the use of a stethoscope
• Emergency: A very rapid assessment performed in life-threatening situations to provide prompt treatment
• Focused/Problem-Oriented:

  Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.