TYPE|Ebase|Ibase|COMMENT|PHRASAL USE adj|abdomino-jugular|||"Abdomino-jugular reflux" adj|abducens|||"VI: Abducens" n|ability|||"Limited ability to move in bed" adj|able|||"Serial sevens, able" "Not able to recall/return demonstration" "Able to recall/demonstrate with some verbal cueing" "Able to recall/demonstrate with much verbal cueing" "Able to recall/demonstrate minimal information" "Able to recall information/return demonstration" "Able to move extremities voluntarily on command" "Able to move distal phalanges" "Able to move 2 extremities on command" "Able to demonstrate skill(s)" "Able to deep breathe and cough freely" "Able to answer questions correctly" n|abscess|ascesso||"Abdominal Abscess" n|absence|||"absence of stool" n|abuse|||"substance abuse" "Drug abuse" "Alcohol abuse" vp|accelerated|||"Accelerated Junctional" "Accelerated Idioventricular" "Accelerated Idioventricular Rhythm" "Accelerated Idiojunctional Rhythm" vp|accentuated|||"Accentuated S2" "Accentuated S1" n|access|||"Vascular Access" "Vascular Access Line Insertion" "Peritoneal Access" "Hemodial Access" "Difficult Access to Health Care" "DIALYSIS ACCESS" n|accessibility|||"Lack of Wheelchair Accessibility" n|accessory|||"XI: Spinal Accessory" "use of accessories" adj|accessory|||"Uses accessory muscles" "Breathing without accessory muscles" "Accessory Muscles " n|accomodation|||"Unreactive to accomodation" n|accumulation|||"fluid accumulation" adv|accurately|||"unable to answer questions or follow directions accurately" n|acid|acido||"Folic acid" "Amino acid" adj|additional|||"Additional instruction" "Additional instruction needed" adj|adequate|adeguato||"Needs supervision for adequate intake" "Adequate protein intake" "Adequate protein & caloric intake" "Adequate dietary intake" "Adequate caloric intake" v|administer|||"Monitor I&O: Administer fluids" "Monitor I&O: Administer diuretics" "Administer supplementary O2" "Administer pharmacological agents" "Administer expectorants/bronchodilators" vp|administered|||"Medication administered" "Laxative administered" "Fluid bolus administered" "Diuretic administered" "Digoxin administered " "Cough suppressant administered" "Cough suppressant - expectorant administered" "Cough expectorant administered" "B/O suppository administered" n|administration|||"Order completed for self medication administration" "Increase O2 administration" n|admission|||"Admission Assessment" n|adult||| adj|adult|||"Standard adult vitamins" "Standard adult trace" adj|adverse|||"Adverse Reactions" n|aerosol|aereosol||"Heated Aerosol " "Cool Aerosol " "Aerosol nebulizer tx" "Aerosol nebulizer treatment" n|affect|||"Flat affect" "Flat Affect " n|afternoon|||"Yesterday afternoon" n|age|||"Age 65 or older" n|agent|||"restraints/paralytic agents" "NSAI agents" "Administer pharmacological agents" n|agglutination|agglutinazione||"Latex Agglutination" vp|aggravating|||"AGGRAVATING FACTORS" v|agree|||"failure to agree on decisions" n|aid|||"Uses hearing aid" n|airflow|||"Posative Airflow" "Negative Airflow" n|airplane|||"Airplane Splint" n|airway|||"unprotected airway" "inability to remove airway secretions" "Oral airway" "Dyspnea or limited breathing, mechanic airway" "Continuous Positive Airway Pressure " "Artificial airway (T)" "Airway with some secretions" "Airway with mod amt secretions" "Airway remains patent" "AIRWAY ASSIST DEVICE" n|alignment|||"Body Alignment" adj|allergic|||"allergic reaction" n|allergy|||"Betadine allergy protocol" v|allow|||"Allow pt to discuss feelings" "Allow family/friends frequent visitation" n|alteration|||"Taste alterations" "Smell alterations" vp|altered|alterato||"altered LOC" "No altered LOC" "Altered venous pattern" vp|alternating|||"Alternating hand movements" vp|ambulating|||"Pain when ambulating" n|ambulation|||"c/o Dizziness with ambulation" "Abdominal pain with ambulation" n|amphetamine|||"Uses amphetamines" adj|anaphylactic|||"Anaphylactic Reaction" adj|anatomical|anatomico||"Repositioned to correct anatomical position" "Maintains correct anatomical position" n|anesthetic|||"Local Anesthetic" n|aneurysm|aneurisma||"Cerebral Aneurysm" "Cerebral Aneurysm Clips" "Abdominal Aortic Aneurysm" adj|aneusrysmal|||"Aneusrysmal Dilatation" n|angioma|corioangioma; angioma; emangioma||"Spider angioma" n|angioplasty|||"Post angioplasty" n|angle|angolo; angolare||"Right Angle " "Present at 45 degree angle" "Distended at 45 degree angle" "Costal vertebral angle tenderness" "Absent at 45 degree angle" adj|angry|||"Seems angry" n|anisocoria|||"Anisocoria ???" n|anitagitation|||"Anitagitation medication" n|anomaly|||"Multiple anomalies" n|anosmia|||"R anosmia" "L anosmia" n|answer|||"unable to answer questions or follow directions accurately" "Unable to answer questions correctly" "Able to answer questions correctly" adj|anterolateral|||"R Anterolateral thigh" "L Anterolateral thigh" adj|antiagitation|||"Antiagitation medication" adj|antianginal|||"Antianginal medication" adj|antianxiety|||"Antianxiety medication" adj|antiarrhythmic|||"Antiarrhythmics not effective" "Antiarrhythmics given" "Antiarrhythmics effective" vp|anticipated|||"anticipated loss" adj|antifungal|||"Topical antifungal medication applied." adj|antiviral|||"Topical antiviral medication applied." n|aorta|aorta||"Abdominal Aorta" adj|aortic|||"Prominent lateral aortic pulsation" "Aortic pulsation palpated" "Aortic Impulse" "Aortic Ejection sound" "Abdominal Aortic Aneurysm" adj|apparent|||"No apparent Injury" adj|applicable|||"Not Applicable" vp|appreciated|||"S4 not appreciated" "S3 not appreciated" "Palpable pulse not appreciated" adj|approximate|||"Eye lids do not approximate completely" "Eye lids approximate completely" vp|approximated|||"Wound margins approximated" n|area|area||"reddened area" "Whitened area" "Umbilical area" "Thoracic Area" "Sacral Area" "Pressure Area noted at:" "Patchy area" "Open area" "Lumbar Area" "Clustered area" "Closed area" "Chest area" "Cervical Area" "Pressure Areas" "Open areas" "No pressure areas noted" adj|areata|||"Alopecia areata" "Alopecia areata (multiple)" adj|areolar|||"Areolar region" adj|arousable|||"Drowsy, but arousable." "Drowsy but arousable" v|arouse|||"S = sleep (normal sleep; easy to arouse)" "3 = severe (somnolent; difficult to arouse)" "2 = mod (freq drowsy; easy to arouse)" "1 = mild (occ drowsy; easy to arouse)" adj|arterial|||"Arterial Survey" "Arterial Line Insertion" v|articulate|||"unable to articulate thoughts/words" adj|artificial|artificiale||"Artificial airway (T)" v|ask|||"Asks many questions" vp|assessed|||"V/S assessed as response to pain" "Assessed stage: depression" "Assessed stage: denial" "Assessed stage: anger" "Assessed stage: acceptance" n|assessment|||"Shift Assessment" "Neuro Assessment" "LABORATORY ASSESSMENT" "BREAST ASSESSMENT" "Assessment weight" "Assessment unchanged" "Admission Assessment" "ASSESSMENT WEIGHT" "Physical assessments" vp|assigned|||"Original ID temporarily assigned; New ID permanently assigned" vp|assistance|||"Up with Assistance only" "Total Assistance" "Requires assistance" "Moderate Assistance" "Minimal Assistance" "Maximal Assistance" "Level of Assistance" "Assistance required" "Ambulatory without assistance" "Ambulatory with assistance" vp|assisted|||"Ventilator assisted" "Ventilator Assisted" "Bath, Assisted" "Apneic, assisted breathing (mechanical/manual)" adj|assistive|||"Assistive Equipment" vp|associated|||"Associated Info" "Associated Factors:" "Associated Dx" n|atresia|imperforazione congenita; atresia congenita||"Atresia (Rt. ear)" "Atresia (L ear)" adj|atrial|||"Wandering Atrial Pacemaker" "Paroxysmal Atrial Tachycardia" "Multifocal Atrial Tach" "Atrial Triggered" "Atrial Triggered (VDD)" "Atrial Tachycardia" "Atrial Synchronous" "Atrial Rhythms" "Atrial Gallop" "Atrial Flutter" "Atrial Fibrillation" "Atrial Demand" "Atrial Demand (Triggered)" "Atrial Demand (Inhibited)" "Atrial Asynchronous" n|atrium|atrio||"Atrium (RAP)" "Atrium (LAP)" n|atropine|||"Atropine bolus (type amount)" n|attempt|||"Reluctant to attempt movement" v|attend|||"Needs to attend formal class" "Attended formal class related to topic" n|attention|||"Limited attention span" n|attorney|||"Power of Attorney" adj|audible|||"Not audible" "Audible with doppler" adj|available|||"Suction available" v|avoid|||"Avoids eye contact" n|axiom|||"Axiom sump" n|axis|epistrofeo||"All parameters on this axis" adj|backward|dorso del; indietro; dietro; dorsale; retro-; posteriore||"Backward Lean" n|bag|sacca||"Fecal drainage bag" "Fecal bag" "Fecal bag removed" "Fecal bag applied" "Bag and Tubing Changed" "Bag Changed" n|balance|equilibrio; bilanciato||"positive fluid balance" "NITROGEN BALANCE" "Assess fluid balance" n|balloon|||"Cuff balloon up" "Cuff balloon down" n|band|||"Band keratopathy" n|bandage|||"Occlusive Bandage" "Adhesive Bandage" "Ace Bandage" n|band|||"Transverse white bands" n|barium|bario||"Recent Barium Study" "Barium swallow (ordered)" "Barium swallow (completed)" "Barium enema (ordered)" "Barium enema (completed)" n|barrel|||"Barrel chest" n|bath|||"Bath, Tepid" "Bath, Partial" "Bath, Full" "Bath, Assisted" "Tepid bath" "Tepid ETOH bath" "Sitz bath" v|bathe|||"Bathes Self" n|bathroom|||"Bathroom Privileges" n|beat|||"Ventricular Escape Beats" "Junctional Escape Beats" v|became|||"Became cyanotic" vp|bending|||"Lateral Bending" adj|benign|benigno||"Normal/BENIGN ???" adj|best|||"Best Verbal Response" "Best Motor Response" adj|better|||"Somewhat better" "Much better" adv|better|||"Somewhat better" "Much better" adj|bifasicular|||"Bifasicular Block" adv|bilaterally|||"Equal bilaterally" n|bile|bile||"Bile, green" "Bile, dark, golden" "Bile, clear" adj|biliary|||"Biliary tube" adj|bilious-type|||"Bilious-type drainage" n|biopsy|biopsia||"Previous Biopsy" n|bite|morso||"Bite block inserted" adj|bitemporal|||"Bitemporal hemianopsia" adj|bivalved|||"Bivalved Cast" adj|blanched|||"Blanched / White" n|blanket|||"Warming blanket " "Hypothermia blanket" "Cooling blanket " "> 102 Cooling blanket" n|bleed|||"GI Bleed" n|blindness|||"R blindness" "L blindness" n|blink|||"Blink (present)" "Blink (absent)" n|blocker|||"Calcium channel blockers given" n|blow|||"Blow By" n|board|||"Board rigidity" vp|boiling|||"Boiling Water" n|bone|||"Bone exposed" "Bone Marrow Transplant" "Bone Marrow Aspiration" "Bone Exposed" "Degenerative Bone/Joint Disease" adj|bony|||"Bony Prominence" n|bounding|||"4+ (bounding)" n|brain|encefalo||"Brain Cancer" n|branch|||"Right Bundle Branch Block" "Left Bundle Branch Block" vp|branched|||"Branched chain" n|breath|||"adventitious breath sounds" "Shortness of breath" "Short of Breath" "Distant breath sounds" "Dec Breath Sounds" "Breath sounds unchanged" "Breath sounds present" "Breath sounds diminished" "Breath sounds clear" "BREATH SOUNDS" "Assess Heart & Breath sounds" "Adventitious Breath Sounds" "Absent breath sounds" v|breathe|||"Able to deep breathe and cough freely" vp|breathing|||"Dyspnea or limited breathing, mechanic airway" "Pursed lip breathing" "Purse lip breathing" "Pain with breathing" "Difficulty breathing" "Coughing and deep breathing" "C/O difficulty breathing" "Breathing without ventilator" "Breathing without accessory muscles" "Breathing without abd. muscles" "Breathing tx not effective" "Breathing tx effective" "Breathing Pattern" "BREATHING PATTERN" "Apneic, assisted breathing (mechanical/manual)" "Teach breathing/cough techniques" adj|bright|||"Bright red" "Bright red with clots" "Bright red drainage" "Bright Red" n|bring|||"Bring transport equipment" vp|brought|||"Not brought to hospital" vp|bruising|||"Bruising " n|bubble|||"Air bubbles" vp|bulging|gonfio; rigonfio; tumefazione; tumescenza; gonfiore; rigonfiamento||"Umbilical bulging " "Bulging " n|bulk|||"decreased dietary bulk" n|bundle|||"Right Bundle Branch Block" "Left Bundle Branch Block" n|button|||"Kistner button" n|bypass|||"Cardiopulm Bypass" v|calculate|||"Calculate hemodynamic measurements" vp|calculated|||"Calculated protein goal" "Calculated fluid requirement" "Calculated caloric goal" v|call|||"Unable to use call system" "SBP < 90 call H.O." "DBP > 100 call H.O." "> 102 Call house officer" "> 101 Call house officer" "< 8/min DC PCA, call H.O. stat" adj|caloric|||"Protein/caloric goals" "Inadequate caloric intake" "Excessive caloric intake" "Caloric goal" "Calculated caloric goal" "Adequate protein & caloric intake" "Adequate caloric intake" n|canal|||"External Canal" n|cane|||"Uses cane" "Cane (3 points)" "Cane (1 point)" n|cannon|||"Cannon 'a' wave" n|cannula|cannula||"Nasal Cannula (NC)" "A-V Cannula" n|cap|||"decreased cap refill" "Cap refill > 3 secs" "Cap refill > 3 sec" "Cap refill < 3 sec" n|capacity|||"Functional capacity" n|capillary|capillare||"Capillary refill < 3 secs" "Capillary hemangioma" "Capillary hemangioma (plural)" "Capillary filling, poor" "Capillary filling, good" "Capillary Refill" "CAPILLARY REFILL" "Assess capillary refill" vp|captured|||"L kidney captured" vp|capturing|||"Not Capturing" n|carbonate|||"Calcium carbonate" "Calcium carbonate + Vit D" adj|cardiopulm|||"Cardiopulm Bypass" adj|cardiopulmonary|||"S/P Cardiopulmonary Arrest" n|care|||"interference with care" "Wound care" "Wound Care" "Tracheostomy care" "Summary Plan of Care" "Provide supportive care" "Plan of Care Assoc Notes" "Peri Care" "Oral Care" "Foley Care" "Eye care" "Extended care facility" "Difficult Access to Health Care" "Back Care" "Active Plan of Care" "Trach cares done" n|cast|agglomerato||"Spica Cast" "Half Cast" "Full Cast" "Bivalved Cast" n|castor|||"Castor Oil" adj|catabolic|||"Severe catabolic state" n|cataract|cataratta||"Right cataract " "Left cataract" "Has cataracts" n|category|||"Category III Isolation" "Category II Isolation" "Category I Isolation" n|catheter|catetere||"Uldall Catheter:" "Peritoneal Catheter:" "Triple lumen catheter" "TEP catheter" "Swan Ganz catheter" "Swan Ganz Catheter" "Suprapubic catheter to gravity drain" "Suprapubic catheter clamped" "Pigtail catheter" "Pigtail catheter" "PD catheter" "Hickman catheter" "Foley catheter irrigated" "Foley catheter inserted" "Foley catheter changed" "Dialysis catheter" "Condom catheter" "Catheter patent" "Catheter Type" "Catheter Status" n|catheterization|||"Straight catheterization" vp|causing|causante||"Drugs (causing physical changes)" "Drugs (causing mental changes)" n|cell|cellula||"Cell Count" adj|central|centrale||"R central palsy" "L central palsy" "Check Central Venous Line" "Central pressures increased" "Central cyanosis" "Central Supply" "Central PN" "Central Line Placement" "Central Line Insertion" "Central Line Dressing Tray" "Central Cyanosis" adj|cerebral|||"Cerebral Contusion" "Cerebral Concussion" "Cerebral Aneurysm" "Cerebral Aneurysm Clips" n|chain|||"Branched chain" n|chair|||"Up in chair" "Sitting in Chair" n|chamber|||"Universal Dual Chamber" n|channel|||"Calcium channel blockers given" v|check|||"RN not check" "RN check" "Check Shunt Function" "Check NG Tube" "Check ET Tube Placement" "Check Central Venous Line" "Check CT Placement" "Check Broviac " vp|checked|||"Circulation Checked" n|child|||"As a child. " n|chloride|clorato (sale del cloro)||"Potassium chloride" "Maximum chloride" "Magnesium chloride" "Calcium chloride" n|cholangiogram|||"Cholangiogram (ordered)" "Cholangiogram (completed)" "Cholangiogram (ordered)" adj|chronic|cronico||"Chronic condition" "Chronic Renal Failure" "acute/chronic infection" n|circulation|||"Circulation Checked" vp|clamping|||"Clamping tolerated" n|class|||"Object Class " "Needs to attend formal class" "Education class" "Attended formal class related to topic" "ASA Class E" "ASA Class 6" "ASA Class 5" "ASA Class 4" "ASA Class 3" "ASA Class 2" "ASA Class 1" vp|cleansed|||"Cleansed with" vp|cleared|||"Secretions cleared" adj|clerical|||"Clerical Orders Pending" n|click|||"Valvular click" "Midsystolic click" "Ejection click" "Click (Valve)" vp|climbing|||"Climbing stairs" adj|clinical|clinico||"Clinical Presentation" "Clinical Cancer" n|clinician|||"Page nutrition clinician" "Page nutrition clinician " n|clip|||"Cerebral Aneurysm Clips" adj|clonic|||"Clonic movements" n|clonus|||"Ankle clonus" vp|closed|chiuso||"Closed, purulent D/C" "Closed, inflamed, serous D/C" "Closed, inflamed, no D/C" "Closed, inflamed" "Closed by swelling (C)" "Closed area" "Closed Head Injury" vp|closing|||"Closing in" n|cocaine|||"Uses cocaine" n|code|||"No Code" "Full Code" n|coffee|||"Coffee ground-type material" "Coffee ground" n|collar|||"Trach Collar Mist " "Clavicle Collar-Hard" "Clavicle Collar-Soft" n|colonoscopy|||"Colonoscopy (ordered)" "Colonoscopy (completed)" vp|colored|||"Yellow colored" "Yellow colored drainage" "White colored drainage" "Tea colored" "Tan colored drainage" "Straw colored" "Rusty colored drainage" "Pink colored drainage" "Lt. yellow colored" "Light brown colored drainage" "Grey colored drainage" "Green colored drainage" "Gray colored drainage" "Dark green colored drainage" "Dark brown colored drainage" "Dark Green colored drainage" "Dark Brown colored drainage" "Cream colored drainage" "Clear colored drainage" "Brown colored" "Brown colored drainage" "Blue colored" "Black colored drainage" "Amber colored" "Amber colored drainage" n|combination|combinazione; combinato||"COMBINATION THERAPY ADEQUACY" "A combination of" vp|combined|combinato||"Combined Incisions" "Combined Census (by Name)" "Combined Census (by Date)" n|comfort|||"Taught comfort measures/relaxation" n|command|||"Unable to move extremities voluntarily on command" "Opens eyes to command" "Open to verbal command" "Obeys verbal command" "Obeys verbal command (6)" "Able to move extremities voluntarily on command" "Able to move 2 extremities on command" "Obeys verbal commands (6)" "Does not follow commands" n|command|||"Obeys verbal commands (6)" "Does not follow commands" n|comment|||"See comment" "Other(enter comment)" n|communication|||"Effective for communication" "inappropriate behavior/communication" vp|complaining|||"Complaining of pain" n|complaint|disturbo||"Subjective Complaints" "SUBJECTIVE COMPLAINTS" "Patient Complaints" "No complaints" "No complaints of pain" adv|completely|||"Eye lids do not approximate completely" "Eye lids approximate completely" "Completely dependent" adj|compliant|||"Partially compliant with diet" "Compliant with diet" n|compound|composto||"compound fractures " "Compound nevus" "Compound nevus (plural)" v|comprehend|||"inability to learn/comprehend" vp|compressed|compresso; tamponamento; struttura compressa; compressione||"Low Compressed Volume (LCV)" v|concentrate|||"inability to concentrate" "Unable to concentrate" "unable to concentrate/perform tsks" n|conciousness|||"Level of Conciousness" n|concussion|||"Cerebral Concussion" n|condom|preservativo; profilattico anticoncezionale||"Condom catheter" "Condom cath intact" "Condom cath applied" n|conduction|||"Intra Ventricular Conduction Defect" "Conduction Defects" n|conduit|||"Ileal conduit" "Ileal Conduit" vp|configured|||"As Configured" n|congestion|congestione||"Notified MD re: pulmonary congestion" adj|congestive|||"Congestive Heart Failure" n|consciousness|||"Loss of consciousness" "LEVEL OF CONSCIOUSNESS" v|consult|||"Physician consult" "Patient/Family consult" "Pain Service consult" "Nutrition consult" "Nursing consult" n|contacts|||"Requires glasses or contacts" n|content|||"Inappropriate content" "Fecal contents" "Fecal contents drainage" n|contractility|||"decreased contractility" n|contraction|contrazione||"Palpable or visible contraction (1)" "No muscle contraction (0)" "Flicker of voluntary muscle contraction (1)" n|contraindication|||"Contraindication to hyperventilation" n|contrast|||"Rectal Contrast" "Oral Contrast" "IV Contrast" "Contrast Dye" vp|controlled|controllato||"Rate controlled A-Fib" "Controlled Mechanical Ventilation " v|converse|||"Oriented and converses" "Oriented and converses (5)" "Disoriented and converses" "Disoriented and converses (4)" n|cooperation|||"lack of cooperation" adv|correctly|||"Unable to answer questions correctly" "Able to answer questions correctly" vp|correlating|||"SaO2 not correlating" adj|costal|||"Spleen felt L costal margin" "Lateral Costal " "Costal vertebral angle tenderness" "Costal " vp|coughing|||"Coughing suppressed" "Coughing and deep breathing" "Air leak with coughing" n|counselor|||"Discuss with counselor" n|count|||"Monitor calorie count" "Cell Count" n|crack|||"Uses crack" adj|cranial|||"Cranial Trauma" "Cranial Surgery" "Cranial Nerves" n|crest|||"Iliac crest" "Iliac Crest" n|crisis|crisi||"crisis situation" n|crunch|||"Mediastinal crunch" "Mediastinal crunch (Hamman)" vp|cueing|||"Able to recall/demonstrate with some verbal cueing" "Able to recall/demonstrate with much verbal cueing" n|culture|||"> 102 Order Blood culture stat" "> 101 Order Blood culture stat" adj|current|||"current illness" "current hospitalization" "Current Clinic" "Current Census" vp|cushioned|||"Head cushioned" n|cycle|||"Timed Cycle " "Pressured Cycle " n|cystogram|||"Cystogram (ordered)" "Cystogram (complete)" v|dangle|||"Dangle at bedside" v|dark|||"Bile, dark, golden" "Dark red" "Dark green colored drainage" "Dark brown colored drainage" "Dark amber" "Dark Green" "Dark Green colored drainage" "Dark Brown colored drainage" n|date|||"Inactive Census (by Date)" "Combined Census (by Date)" adj|deaf|||"Deaf in R ear" "Deaf in L ear" n|death|morte||"Recent death in family" n|decannulation|||"Decannulation site" n|decision|||"failure to agree on decisions" n|decubitus|||"Lateral decubitus" "Decubitus Size (Dimensions)" "Color Decubitus Bed" n|defect|difetto||"Intra Ventricular Conduction Defect" "Conduction Defects" n|defibrillation|||"Defibrillation completed" vp|defined|||"Poorly defined" "Ill defined edges" adv|definitely|||"Definitely true" "Definitely False" adj|degenerative|degenerativo; degenerato; modificazioni degenerative; degenerazione||"Degenerative Bone/Joint Disease" n|degree|||"3rd Degree: Complete" "Present at 45 degree angle" "Distended at 45 degree angle" "Absent at 45 degree angle" "3rd degree" "3rd degree burn" "3rd degree A-V Block" "2nd degree" "2nd degree burn" "2nd degree A-V Block Type II" "2nd degree A-V Block Type I (Wenckebach)" "2nd Degree Block Type II" "2nd Degree Block Type I" "1st degree" "1st degree burn" "1st degree A-V Block" "1st Degree Block" "HOB elevated 45 degrees" "HOB elevated 30 degrees" "HOB elevated 10 degrees" vp|delimited|||"Well delimited" v|deliver|||"deliver to patient room" n|delivery|||"next routine delivery" v|demonstrate|||"Demonstrates a thorough understanding" "Unable to demonstrate skill(s)" "Able to demonstrate skill(s)" "Able to recall/demonstrate with some verbal cueing" "Able to recall/demonstrate with much verbal cueing" "Able to recall/demonstrate minimal information" "Demonstrated skill(s) to be learned" n|denial|||"denial /anger" "Assessed stage: denial" n|dentition|||"Poor dentition" n|dentures|||"Uses Dentures" "Dentures not with patient" vp|depleted|depleto; deplezione||"Severely depleted protein" "Moderately depleted protein" "Mildly depleted protein" n|deprivation|||"sleep deprivation" adj|dermal|||"Dermal nevus" "Dermal nevus (plural)" n|dermatitis|dermatite||"Stasis dermatitis" "Contact dermatitis" n|detail|||"Show Detail" vp|deviated|deviato; spostato; deviazione; spostamento||"Deviated Up " "Deviated R" "Deviated R and Up " "Deviated R and Down " "Deviated R " "Deviated L" "Deviated L and Up" "Deviated L and Down " "Deviated L " "Deviated Down " n|deviation|deviazione; spostamento||"Ulnar Deviation" "Right deviation" "Radial Deviation" "R jaw deviation" "R deviation" "Left deviation" "L jaw deviation" "L deviation" n|diagnosis|||"Working Diagnosis" n|diagram|||"Heart Diagram" n|dialysis|||"Dialysis catheter" "DIALYSIS ACCESS" n|diastasis|diastasi; separazione; distacco||"Diastasis recti" n|diet|||"Uses diet pill" "Restrictive diet order" "Partially compliant with diet" "Observe diet intake" "Noncompliant with diet" "Monitor diet transition" "Monitor diet tolerance" "Initiate diet education" "Fad diet" "Diet tolerated" "Diet restrictions" "Diet order" "Diet not tolerated" "Diet education" "Diet changed" "Diet change" "Diet Review" "DIET TOLERANCE/ADEQUACY" "Compliant with diet" n|difficulty|||"Voiding without difficulty" "Irrigates with difficulty" "Difficulty breathing" "Difficulty Starting Stream" "C/O difficulty breathing" n|dilatation|dilatazione||"Aneusrysmal Dilatation" n|dimension|||"SIZE (DIMENSIONS)" "Decubitus Size (Dimensions)" n|directions|||"unable to answer questions or follow directions accurately" n|discomfort|||"Gas discomfort" "C/O gas discomfort" "c/o pain/discomfort during procedure" v|discriminate|discriminato||"Unable to discriminate" v|discuss|||"Discuss with counselor" "Discuss with MD." "Discuss with MD" "Allow pt to discuss feelings" vp|discussed|||"Topics Discussed" n|disease|||"disease process" "Paget's disease" "End Stage Renal Disease" "End Stage Liver Disease" "Disease pathology" "Disease Process" "Degenerative Bone/Joint Disease" "neuromuscular diseases" n|dislike|||"Food dislikes" n|dismissal|||"Ready for Dismissal" "Cancel Dismissal" n|disorder|||"psychotic disorder" "valvular disorders" n|dissection|||"Radical Neck Dissection" n|disturbance|||"Blind spot-visual disturbance" adj|diversional|||"Diversional activity" vp|done|||"Trach cares done" "Not Done" "Not Done - No Dressing" "Not Done - Dressing dry and intact" n|donor|||"Skin Graft(donor)" "Skin graft (donor)" "DONOR DRAINAGE" "DONOR COLOR" n|dose|||"Mega dose of vitamin/mineral supplements" adj|double|doppio||"Double clamped" adj|double-barreled|||"Double-barreled colostomy" adv|down|subgiacente; al di sotto; sotto; gił; infra-; sub-; inferiore||"Lying down" "Deviated R and Down " "Deviated L and Down " "Deviated Down " "Cuff balloon down" vp|drawn|||"CSF studies drawn" n|drift|||"Right drift" "No drift" "Left drift" v|drink|||"Drink fluids" "Does not drink alcohol" "Drinks socially" "Drinks daily" n|drip|||"Insulin drip" "Bolus/gravity drip" n|drop|||"Wrist drop" "Foot drop" n|drug|farmaco||"Drug abuse" " Titrate vasoactive drugs" "Drugs (causing physical changes)" "Drugs (causing mental changes)" adj|dual|||"Universal Dual Chamber" n|dye|||"Contrast Dye" "Blue dye" "Blue Dye" n|dysfunction|disturbo funzionale||"Motility disfunction" "Motility disfunction of the GI tract" adj|disfunctional|||"disfunctional unit" adj|early|precoce||"Early systolic" "Early satiety" "Early diastolic" adv|easily|||"Reducible, easily" "Fatigues easily" n|education|||"Initiate diet education" "Education class" "Diet education" "Diabetic education" adj|effective|effetto||"Vaspressive therapy effective" "Vasopressive therapy not effective" "Vasopressive therapy effective" "Suppository not effective" "Suppository effective" "Suctioning not effective" "Suctioning effective" "Pacemaker not effective" "Pacemaker effective" "O2 change effective" "Mucolytic tx not effective" "Mucolytic tx effective" "Laxative not effective" "Laxative effective" "Enema not effective" "Enema effective" "Effective for communication" "Cough suppressant not effective" "Cough suppressant effective" "Colostomy irrigation effective" "Breathing tx not effective" "Breathing tx effective" "B/O suppository effective " "Antiarrhythmics not effective" "Antiarrhythmics effective" n|effort|||"ineffective cough effort" n|effusion|versamento||"New effusion" "Effusion resolved" "Effusion partially resolved" n|ejection|||"Systolic ejection murmur" "Pulmonic Ejection sound" "Ejection click" "Aortic Ejection sound" n|elastoplast|||"Elastoplast tape" adj|elective|||"Elective Postoperative Patient (2)" adj|electrographical|||"Electrographical seizures as per EEG tech" n|element|elemento; elemento chimico||"VIT/TRACE ELEMENTS/ADDITIVES" v|elevate|||"Elevate HOB" vp|eliminated|||"Moves with gravity eliminated (2)" n|embolus|embolia||"Pulmonary Embolus" n|emergency|||"Nonoperative or Emergency Postoperative (5)" adj|emotional|||"Emotional upset" "Emotional support" "Emotional Upset" n|emphysema|enfisema||"Subcutaneous emphysema" "Subcutaneous emphysema extends to" "SUBCUTANEOUS EMPHYSEMA" "SQ emphysema unchanged" "SQ emphysema resolved" "SQ emphysema increased" "SQ emphysema decreased" n|employment|||"Change in employment status" n|emulsion|||"LIPID EMULSION" n|encephalopathy|encefalopatia||"hepatic encephalopathy" v|encourage|||"Encourage pt. to express fears" adj|end|||"End ileostomy" "End colostomy" "End Stage Renal Disease" "End Stage Liver Disease" n|end|||"Distal end" n|endoscopy|||"Endoscopy (ordered)" "Endoscopy (completed)" n|enlargement|aumento di volume; ipertrofia||"Moderate enlargement" "Mild enlargement " "Marked enlargement" v|enter|||"Sent home with (enter name & relationship)" "Low Salt (enter amount)" "Low Calorie (enter amount)" "Diabetic (enter amount)" adj|enteral|||"enteral feedings" "Enteral tube inserted" "Enteral feeding stopped" "Enteral feeding started" "Enteral feeding resumed" "ENTERAL NUTRITION STATUS" v|enter|||"Other(enter comment)" vp|entered|||"Original ID entered in error" adj|entire|||"Entire precordium" "Entire lung fiels (plural)" "Entire lung field" "Entire lung field (plural)" "Entire lung field (plural) " n|environment|||"unfamiliar environment" "hospital environment" n|enzyme|enzima||"Monitor CK enzymes and lab values" adj|epidural|||"Epidural Continuous" "Epidural Bolus" n|episode|||"syncopal episode" n|equipment|||"Bring transport equipment" "Assistive Equipment" n|error|||"Original ID entered in error" n|escape|||"Ventricular Escape Beats" "Junctional Escape Beats" n|eschar|||"Eschar present" "Eschar (soft)" "Eschar (hard)" n|estrogen|||"Estrogen Therapy" vp|evaluated|||"Not evaluated" n|evidence|||"Evidence of edema" "Evidence of JVD" n|exam|||"Routine Exam" n|examination|||"Fundoscopic Examination" "External Examination" n|excess|||"Excess Plantar flexion" "Excess Flexion" adj|excessive|||"excessive output" "excessive ADH" "Excessive sugar intake" "Excessive protein intake" "Excessive lipid intake" "Excessive fat intake" "Excessive dextrose intake" "Excessive cholesterol intake" "Excessive caloric intake" "Excessive alcohol intake" "Excessive Na intake" "Excessive K+ intake" n|excursion|||"decreased chest excursion" n|exercise|||"Kegel exercises" n|exertion|sforzo||"On exertion" n|exophthalmos|||"Exophthalmos " n|expansion|||"Symmetric expansion" "Expansion Right side only" "Expansion Left side only" "Expansion > on right" "Expansion > on left" "Chest expansion equal" vp|expected|||"Lab values within expected range" "> 50% of expected movement" "< 50% of expected movement" n|expectorant|||"Cough suppressant - expectorant administered" "Cough expectorant administered" "Administer expectorants/bronchodilators" v|expectorate|||"Unable to expectorate secretions" n|experience|||"new experiences" adj|expiratory|||"Expiratory wheezes" "Expiratory Wheezes" vp|exposed|esposto; esposto a; esposizione a||"Bone exposed" "Bone Exposed" n|exposure|||"prolonged exposure to cold" v|express|||"Encourage pt. to express fears" "Expresses suicidal intentions" adj|expressive|||"Expressive Aphasia" "Aphasia - Expressive" vp|extended|||"Extended care facility" v|extend|||"Subcutaneous emphysema extends to" "Extends to:" "Extends to" "EXTENDS TO" adj|extra|||"Extra Assist" adj|extraocular|||"Extraocular Muscles" "Extraocular Muscle Function" n|facility|||"Other Facility" "Extended care facility" n|factor|||"Precipitating Factors:" "Associated Factors:" "RELIEVING FACTORS" "PRECIPITATION FACTORS" "AGGRAVATING FACTORS" n|factory|||"Factory worker" n|failure|mancato funzionamento; disfunzione||"renal failure" "failure to agree on decisions" "Renal Failure" "Organ Failure" "Liver Failure" "Congestive Heart Failure" "Chronic Renal Failure" "Cardiac Failure" "Acute Renal Failure" n|fall|caduta||"Fall History" adj|false|falso||"Mostly false" "Definitely False" n|family|||"With family" "To Family" "Sent home with family or S.O." "Recent death in family" "Illness in family" "Allow family/friends frequent visitation" "Patient/Family consult" n|fascia|fascia||"Fixed to fascia" adj|fasicular|||"Fasicular Block" v|fatigue|||"Fatigues easily" v|feed|||"Feeds Self" v|feel|||"C/O feeling sick" n|feeling|||"No Feeling" "Allow pt to discuss feelings" vp|felt|||"Spleen felt L costal margin" n|fibrillation|||"Ventricular Fibrillation" "Atrial Fibrillation" n|fibrosis|fibrosi||"Subcutaneous fibrosis" n|field|||"Entire lung field" "Entire lung field (plural)" "Entire lung field (plural) " "Lung fields not clear" "Lung fields clear, no JVD or edema" vp|filled|||"Fluid filled" vp|filling|||"Capillary filling, poor" "Capillary filling, good" "Opening filling pressure" n|film|||"Hazy film (Rt)" "Hazy film (L)" adj|financial|||"financial stress" n|fire|fuoco||"House Fire" n|fixation|||"external fixation device" vp|flaring|||"flaring nares" "Nasal Flaring" vp|flexed|||"Lateral flexed right" "Lateral flexed left" "Forward flexed" n|flicker|||"Flicker of voluntary muscle contraction (1)" n|floor|||"floor stock needed" n|flow|||"decreased blood flow" "Cont. flow pressure limited" n|flowsheet|||"I&O Flowsheet" vp|fluctuate|||"Fluctuates with respirations" n|fluctuation|||"No fluctuation with respiration" "No fluctuation seen" n|foam|||"GEL Foam Matress" "Foam cuff" v|focus|||"inability to focus" n|fold|piega||"Skin folds" adj|folic|||"Folic acid" v|follow|||"unable to answer questions or follow directions accurately" "Does not follow commands" n|follow-up|||"Routine follow-up" "Follow-up instructions" adj|fore|||"Fore foot Inversion" "Fore foot Eversion" n|forefoot|||"Forefoot Inversion" "Forefoot Eversion" adj|foreign|||"speaks foreign language" n|form|||"Wave form" "Use Form Value" "Consent Form" adj|formal|||"Needs to attend formal class" "Attended formal class related to topic" n|formula|||"PN formula" "PN FORMULA" "Hepatamine formula" n|fracture|frattura||"Fracture Table" "F/U Fracture" "compound fractures " "Multiple Extremity Fractures" vp|fractured|fratturato; frattura||"Fractured Ribs" "Fractured Hip" n|frame|||"Wilson Frame" "Relton Hall Frame" "Andrews Frame" adj|frank|||"Frank blood" adj|free|||"Free water" "Free H2O" "Free H20" adv|freely|||"Irrigates freely" "Able to deep breathe and cough freely" n|fremitus|||"Increased fremitus" "Decreased fremitus" "Absent fremitus" n|friction|||"Pericardial friction rub" "Friction rub" n|friend|||"Allow family/friends frequent visitation" n|frost|||"Uremic frost" "Uremic Frost noted" adv|fully|||"Fully oriented" adj|functional|funzionale||"No functional movement" "Movement returned to functional level" "Functional capacity" vp|functioning|||"Assess neuro functioning" adj|fundoscopic|||"Fundoscopic Examination" n|funnel|||"Funnel chest" "Funnel chest (pectus excavatum)" n|gait|||"Abnormal gait" n|gallop|||"Ventricular gallop" "Summation gallop" "Summation gallop " "Atrial Gallop" n|garbled|||"Garbled speech" n|gas|gas||"absent gas" "Natural Gas" "Gas discomfort" "C/O gas discomfort" adj|gastric|gastro-; gastrico; stomaco||"Oral gastric" "Gastric lavage" n|gauge|||"8 gauge (pigtail)" n|gauze|||"Sterile Gauze" "Gauze dressing" n|gaze|||"Gaze limited" "Gaze absent" n|genitalia|||"GENITALIA APPEARANCE" "External genitalia" "EXTERNAL GENITALIA" "EXTERNAL GENITALIA DRAINAGE" n|girth|||"Abdominal girth unchanged" "Abdominal girth measured" "Abdominal girth increased" "Abdominal girth decreased" v|give|||"< ___ and Phos < ___ give ___ meq Kphos IV x1" "< 4.0 give 2 U PRBC" "< 3.8 & >= 3.6 give 20 meq KCL IV x1" "< 3.6 give 40 meq KCL IV x1" "< 2.5 give 2 U PRBC stat" "Living Will-given to nurse" vp|given|||"Patient may be given Chloral Hydrate" "Medication given" "Given to nurse" "Diuretics given as ordered." "Calcium channel blockers given" "Antiarrhythmics given" n|glasses|||"Requires glasses or contacts" "Requires glasses for reading only" adj|global|globale; generale; generalizzato||"Global Aphasia" "Aphasia - Global" n|globe|||"Ocular Globe" adj|glosopharyngeal;|||"IX: Glosopharyngeal; X:Vagus" n|glycerine|||"Glycerine Mineral Oil" n|goal|||"Protein goal" "Caloric goal" "Calculated protein goal" "Calculated caloric goal" "Protein/caloric goals" adj|golden|||"Bile, dark, golden" n|goods|||"Unkept, dirty goods" n|gooseflesh|||"sweating/gooseflesh above level of injury" n|graft|trapianto di organo; innesto; organo trapiantato; tessuto trapiantato; trapianto||"Skin graft" "Skin graft (donor)" "Gortex Graft" "GRAFT DRAINAGE" "GRAFT COLOR" n|grasp|||"Hand grasp (bilateral)" "Hand Grasp" adj|great|pił esteso; pił grande; pił largo; grande; largo; grosso; maggiore||"Great toe" "Great toe plantar flexion" "Great toe dorsiflexion" "Great Toe" adj|greater|pił esteso; pił grande; pił largo; grande; largo; grosso; maggiore||"R Greater saphenous" "L Greater saphenous" adj|greenish-black|||"Greenish-black " vp|grimacing|||"facial grimacing" n|groove|||"Transverse grooves" n|ground|||"Coffee ground" n|group|||"Muscle Group" n|growth|||"Hair growth, normal" "Hair growth, diminished" n|habit|||"Poor nutritional habits" n|half|||"Superior half" "Medial half" "Lateral half" "Inferior half" "Half Cast" n|half-moon|||"Red half-moons" n|handout|||"Handouts/pamphlets provided" adj|hazy|||"Hazy film (Rt)" "Hazy film (L)" n|header|||"Item to Header" "Header to Item" vp|healing|riparazione||"Healing well" n|health|||"Difficult Access to Health Care" adj|healthy|||"Periostomal skin healthy and intact" "Healthy skin" vp|heard|||"Pulse heard with doppler" "Murmur heard at" "Heard with doppler" "Heard w/doppler" vp|hearing|||"Uses hearing aid" "Hard of Hearing, R" "Hard of Hearing, L" "Hard of Hearing, Bilat." n|heart|cuore||"Pre-op heart cath" "Muffled heart sounds" "Irregular heart rhythm" "Heart rate" "Heart Sounds" "Heart Murmur" "Heart Diagram" "HEART SOUNDS" "Congestive Heart Failure" "Assess Heart & Breath sounds" "Abnormal heart sound" "ABNORMAL HEART SOUNDS" vp|heated|||"Heated Aerosol " n|heaves|||"dry heaves" "Dry heaves" n|helix|||"Right helix" "Left helix" n|hemangioma|emangioma||"Capillary hemangioma" "Capillary hemangioma (plural)" adj|hemodial|||"Hemodial Access" adj|hemodynamic|||"Calculate hemodynamic measurements" n|hemothorax|emotorace||"Hemothorax resolved" "Hemothorax partially resolved" n|hepatamine|||"Hepatamine formula" adj|hepatic|epato-; epatico; fegato||"hepatic encephalopathy" adj|hepatojugular|||"Positive Hepatojugular reflux" n|heroin|||"Uses heroin" n|hesitancy|||"C/O hesitancy" adj|hesitant|||"Hesitant speech" adj|hind|||"Hind foot Inversion" "Hind foot Eversion" n|hindfoot|||"Hindfoot Inversion" "Hindfoot Eversion" n|histogram|||"I&O Histogram" n|historian|||"Unreliable historian" "Reliable historian" n|history|||"Tumor history" "Patient History" "Other pertinent history / neuro hx." "Order History" "Fall History" n|hockey|||"R hockey stick" "L hockey stick" adj|homonymous|||"R homonymous hemianopsia" "L homonymous hemianopsia" "Homonymous hemianopsia" n|hood|||"Pediatric Hood or Tent " n|hordeolum|orzaiolo||"Hordeolum (sty)" adj|horizontal|orizzontale||"Horizontal Adduction" n|hospital|||"hospital environment" "Orientation to Hospital setting" "Not brought to hospital" "Hospital Personnel" n|hydrogen|idrogeno||"Hydrogen Peroxide" n|hygiene|||"inadequate hygiene" adj|hypermetabolic|||"hypermetabolic state" n|hyperreflexia|||"Hyperreflexia present" "Hyperreflexia " n|hypertrichosis|||"Hypertrichosis (local)" "Hypertrichosis (generalized)" n|hyperventilation|||"Contraindication to hyperventilation" n|hypoacusia|||"R hypoacusia" "L hypoacusia" n|hypochondrium|ipocondrio; regione ipocondriaca||"R hypochondrium" "L hypochondrium" adj|hypoglossal|||"XII: Hypoglossal" n|hypothermia|||"Hypothermia blanket" n|ice|ghiaccio||"Ice packs " n|idealization|||"idealization of pt" adj|idiojunctional|||"Junctional (Idiojunctional) Rhythm" "Accelerated Idiojunctional Rhythm" adj|ileal|ileo-; ileali; ileo||"Ileal conduit" "Ileal Conduit" adj|iliac|||"R iliac" "R iliac " "R Iliac" "L iliac" "L Iliac" "Iliac crest" "Iliac Crest" adj|ill|||"Ill defined edges" n|illness|||"current illness" "Terminal Illness" "Illness in family" adj|imaginable|||"10 = Worst Imaginable Pain" n|imbalance|||"O2 imbalance" n|impaction|impaccamento||"Fecal impaction" vp|impaired|||"absent,impaired gag/cough reflex" "Remote memory impaired" "Recent memory impaired" "Impaired mental status" "Impaired coordination" "EOM Impaired" n|impairment|deficit||"physical impairment" "neuromuscular impairment" "neuro impairment" "No Respiratory impairment" vp|implied|||"Implied Consent" vp|improved|||"Movement improved" vp|improving|||"ECG improving" "ABG's not improving" "ABG's improving" n|impulse|||"Point of Maximal Impulse" "Aortic Impulse" n|inability|||"inability to void" "inability to rest" "inability to remove airway secretions" "inability to perform ADL" "inability to learn/comprehend" "inability to focus" "inability to concentrate" "C/O inability" adj|inadequate|inadeguato||"inadequate ventilation/perfusion" "inadequate intake" "inadequate hygiene" "inadequate fiber intake" "inadequate C.O." "Inadequate protein intake" "Inadequate lipid intake" "Inadequate intake" "Inadequate caloric intake" "Inadequate Flexion" "Inadequate Dorsi flexion" adv|inappropriately|||"Responds inappropriately" n|incentive|||"Incentive spirometry" n|incidence|||"gang related incidence" v|increase|||"Increases with inspiration" v|indicate|||"Sent home with S.O. (indicate name & relationship)" "Weight indicates" n|indigestion|||"Indigestion relieved" "Indigestion not relieved" "C/O indigestion" adj|ineffective|||"ineffective cough" "ineffective cough effort" "Suppository ineffective" "O2 change ineffective" "Laxative ineffective" "Enema ineffective" "Colostomy irrigation ineffective" n|infarction|infarto||"Myocardial Infarction" vp|infected|||"Open, infected" n|information|||"Verbalized understanding of information presented" "Able to recall/demonstrate minimal information" "Able to recall information/return demonstration" adj|ingrown|||"Ingrown nail" n|inhalation|||"inhalation injury" "Smoke Inhalation" vp|inhibited|||"Ventricular Demand (Inhibited)" "Atrial Demand (Inhibited)" "Ventricular Inhibited" "QSR Inhibited" "QRS Inhibited" n|injury|trauma||"sweating/gooseflesh above level of injury" "inhalation injury" "Some injury noted" "No apparent Injury" "Closed Head Injury" adj|inner|dentro a; al di dentro; interno||"Upper inner" "R upper inner" "R lower inner" "Lower inner" "L upper inner" "L lower inner" n|inotropes|||"negative inotropes" n|insertion|||"Vascular Access Line Insertion" "Temporary Pacemaker Insertion" "Straight Cath Insertion" "PA Line Insertion" "NG Tube Insertion" "IV Insertion" "Foley Cath Insertion" "Feeding Tube Insertion" "Chest Tube Insertion" "Central Line Insertion" "Blind Insertion" "Arterial Line Insertion" adj|inspiratory|||"Inspiratory wheezes" "Inspiratory Wheezes" n|installation|||"Use NS installation" n|instillation|||"by air instillation" vp|instructed|||"Instructed pt. to notify if chest pain" n|instruction|||"Verbal instruction" "Reinforcement of previous instruction needed" "Provided reinforcement of previous instruction" "Provided instruction related to topic" "Additional instruction" "Additional instruction needed" "Post Procedure Instructions" "Follow-up instructions" "Discharge instructions" n|intention|||"Expresses suicidal intentions" adj|intercostal|||"Retractions, intercostal" "No intercostal retractions" "Intercostal retractions" "Intercostal movement" n|interest|||"loss of interest" n|interference|||"interference with care" n|interval|||"QT Interval" "QRS Interval" "PR Interval" adj|intractable|intrattabile||"Intractable vomiting" "Intractable diarrhea" adj|intratracheal|||"Intratracheal Cath " adj|involuntary|||"Involuntary movement" adj|iodoform|||"Iodoform packing" n|irradiation|||"Previous Irradiation" vp|irrigated|||"Nephrostomy tube irrigated" "Foley catheter irrigated" "Colostomy irrigated" "Bladder irrigated" v|irrigate|||"Irrigates with resistance" "Irrigates with difficulty" "Irrigates freely" n|irrigation|||"Vaginal irrigation" "Colostomy irrigation ineffective" "Colostomy irrigation effective" n|irritation|||"Signs of Peritoneal Irritation" n|ischemia|ischemia||"myocardial ischemia" "ECG-no signs of ischemia" adj|ischial|||"Ischial tuberosity" vp|isolated|isolato||"Isolated Ultrafiltration" "Isolated Rural" n|isolation|||"Category III Isolation" "Category II Isolation" "Category I Isolation" n|isosource|||"Isosource HN" n|isotein|||"Isotein HN" n|issue|||"Safety issues" "Safety Issues" adj|jagged|||"Wound margins jagged" n|jar|||"Markle (heel jar)" n|jet|||"High Frequency Jet Ventilation " n|joint|capsula articolare||"Joints swollen" "Degenerative Bone/Joint Disease" n|jugular|||"Right internal jugular" "Right external jugular" "R internal jugular" "R external jugular" "Left internal jugular" "Left external jugular" "L internal jugular" "L external jugular" "Jugular distention" "Jugular Venous Pulse" "Internal jugular" "Internal Jugular" "External jugular" "External Jugular" n|keratopathy|||"Band keratopathy" n|ketoacidosis|ketoacidosi||"Diabetic Ketoacidosis" n|knee|ginocchio||"Both Knees" v|know|||"Don't know" "Does not know" n|koilonychia|||"Spoon nail (koilonychia)" adj|labile|||"Labile BP" n|laboratory|||"LABORATORY ASSESSMENT" n|lack|||"lack of understanding" "lack of strength" "lack of purposeful movement" "lack of cooperation" "Lack of Wheelchair Accessibility" n|lag|||"Ptosis or Lid lag (Rt. eye)" n|lap|||"Atrium (LAP)" n|lapse|||"memory lapses" n|laryngectomy|||"Laryngectomy tube" adj|last|||"Last night" n|last|||"Lasted >15 min" "Lasted <5 min" "Lasted <15 min" "Lasted <10 min" adj|late|tardivo||"Late systolic" vp|lateralized|||"Non lateralized Weber" n|lavage|||"Gastric lavage" v|lavage|||"Saline lavaged with suctioning" vp|leaked|||"Air leaked noted" n|lean|||"Backward Lean" v|learn|||"decreased willingness to learn" "inability to learn/comprehend" vp|learned|||"Demonstrated skill(s) to be learned" adj|lesser|pił piccolo; minuto; piccolo; minore||"R Lesser saphenous" "L Lesser saphenous" vp|leveled|||"Transducer Leveled" n|lid|||"Ptosis or Lid lag (Rt. eye)" "Eye lids do not approximate completely" "Eye lids approximate completely" n|life|||"pt prognosis or life style changes" "life style changes" n|life-style|||"Life-style change" n|light|luce||"Unreactive to light" "Reaction to Light" "Light brown colored drainage" "Decreased light touch sensation" "Absent light touch sensation" vp|lighted|||"Lighted Stylet" vp|limited|||"Yes, limited a lot" "Yes, limited a little " "No, not limited at all" "Limited attention span" "Limited ability to move in bed" "Gaze limited" "Dyspnea or limited breathing, mechanic airway" "Cont. flow pressure limited" n|line|linea; lineare||"Vascular Access Line Insertion" "PA Line Insertion" "Midclavicular line" "Left midclavicular line" "Left Axillary line" "L axillary line" "Check Central Venous Line" "Central Line Placement" "Central Line Insertion" "Central Line Dressing Tray" "Arterial Line Insertion" n|linen|||"Linen Change" n|list|||"Use List Value" "Standard List" "Simple List " "Problem List" "Discriminant List " "Custom List" n|lobe|||"Upper Lobe" "Right Upper Lobe" "Right Lower Lobe" "Right Liver Lobe" "Middle Lobe" "Lower Lobe" "Left upper lobe" "Left lower lobe" "Upper lobes" "Upper Lobes" "Right lobes" "Lower lobes" "Lower Lobes" "Left lobes" "All other lobes" "All lobes" adj|local|locale||"Hypertrichosis (local)" "Local Anesthetic" v|localize|||"Localizes to pain (5)" "Localizes pain" "Localizes pain (5)" n|log|||"Log Rolled" "Log Copy" adj|long|lungo||"Memory Loss - Long Term " "Long term memory loss" adv|longer|||"Secretions no longer frothy" adj|longitudinal|longitudinale||"Longitudinal white streaks" "Longitudinal Plane" n|loop|||"Loop ileostomy" "Loop colostomy" "A-V shunt, loop" n|loss|||"recent weight loss" "recent loss" "loss of time orientation" "loss of interest" "fluid/blood loss" "blood loss" "anticipated loss" "Short term memory loss" "Severe unintentional wt. loss" "Moderate unintentional wt. loss" "Mild unintentional wt. loss" "Memory Loss - Short Term " "Memory Loss - Long Term " "Loss of liver dullness" "Loss of consciousness" "Long term memory loss" "Hair Loss" n|lumen|||"Triple lumen" "Triple lumen catheter" "Single lumen" "Quadruple lumen" vp|lying|||"Side lying" "Lying down" n|macule|macula||"Macule (plural)" vp|made|||"Ventilator changes made" vp|maintained|||"Bulb suction not maintained" "Bulb suction maintained" "BP maintained as ordered." v|make|||"Makes eye contact" n|malnutrition|||"Severe protein calorie malnutrition" "Risk for malnutrition" "Perioperative with severe malnutrition" "No risk for malnutrition" "Moderate protein calorie malnutrition" "Mild protein calorie malnutrition" "MALNUTRITION RISK" adj|mandatory|||"Mandatory Minute Ventilation" "Intermittent Mandatory Ventilation " adj|manual|||"Apneic, assisted breathing (mechanical/manual)" n|margin|marginale; margine||"Spleen felt L costal margin" "Right sternal margin" "Left sternal margin" n|marijuana|||"Uses marijuana" n|markle|||"Markle (heel jar)" n|marrow|||"Bone Marrow Transplant" "Bone Marrow Aspiration" n|mask|||"Simple Face Mask " "Non-Rebreather Mask" "Mist Mask" adj|mastoid|||"Tender at mastoid process" n|material|||"Written material" "Coffee ground-type material" n|mattress|||"Air Mattress (Clinicare)" adj|maximal|massimale||"Point of Maximal Impulse" "Maximal Assistance" adj|maximum|||"Maximum chloride" "Maximum acetate" n|meal|||"Refusing meals" "Not tolerating meals" "All three meals" "<25% of meals" "< 25% of meals" "50-75% of meals" "25-50% of meals" "pc(after meals)" "ac(bfr meals)" vp|measured|||"Abdominal girth measured" n|measurement|||"Calculate hemodynamic measurements" n|measure|||"Safety measures" adj|mechanic|||"Dyspnea or limited breathing, mechanic airway" adj|mechanical|||"Controlled Mechanical Ventilation " "Assist Mechanical Ventilation " adj|media|media; tonaca media||"Otitus Media" adj|median|mediano; metą; mediale||"Median sternotomy" vp|medicated|||"Medicated as needed" v|meet|||"Does not meet standard" "Does not meet patameter" "Does not meet parameter" "Meets stnadard" "Meets standard" "Meets parameter" "Not Met (Enter note)" adj|mega|||"Mega dose of vitamin/mineral supplements" n|membrane|||"Tympanic Membrane" "decreased skin turgor/dry membranes" adj|mental|||"Mental Status" "Impaired mental status" "Drugs (causing mental changes)" n|metal|metallo||"Metal Worker" adj|metallic|||"metallic taste" adj|metastatic|||"Metastatic Cancer" n|methadone|||"Uses methadone" n|microtia|||"Microtia " adj|midclavicular|||"Midclavicular line" "Left midclavicular" "Left midclavicular line" adv|mildly|||"Mildly underweight" "Mildly depleted protein" n|milk|||"No milk products" "No Milk" "Milk of Magnesia" adj|mineral|minerale|| n|mineral|minerale|| adj|mini|||"Mini trach" n|mist|||"Trach Collar Mist " "Mist Mask" adj|mitral|||"Mitral Stenosis" n|modality|||"Use of external modalities" n|mode|||"Respiratory Mode" vp|monitored|||"I&O Monitored: Positive" "I&O Monitored: Normal" "I&O Monitored: Negative" vp|monitoring|||"Continuous cardiac monitoring" adj|morbid|||"Obese (morbid)" "Morbid obesity" n|morning|||"Yesterday morning" "This morning" adv|mostly|||"Mostly true" "Mostly false" n|motility|||"Motility disfunction" "Motility disfunction of the GI tract" n|motion|||"Range of Motion" "Dec Range of Motion" n|motor|||"Motor Function" "Fine Motor" "Best Motor Response" "Aphasia, motor" v|move|||"Unable to move extremities" "Unable to move extremities voluntarily on command" "Unable to move distal phalanges" "Limited ability to move in bed" "Able to move extremities voluntarily on command" "Able to move distal phalanges" "Able to move 2 extremities on command" "Moves with gravity eliminated (2)" "Moves against gravity, not resistance (3)" "Moves against gravity & resistance, weakly (4)" "Moves with gravity eliminated (2)" "Moves against gravity, not resistance (3)" "Moves against gravity & resistance, weakly (4)" adj|mucolytic|||"Mucolytic tx" "Mucolytic tx not effective" "Mucolytic tx effective" adj|mucous|||"Mucous threads" "Mucous threads present" "Mucous fistula" "Mucous fistula colostomy" n|muscle|||"No muscle contraction (0)" "Muscle Tone" "Muscle Strength" "Muscle Group" "Muscle Atrophy" "MUSCLE TONE" "Flicker of voluntary muscle contraction (1)" "Extraocular Muscle Function" "Uses accessory muscles" "Uses abdominal muscles" "Extraocular Muscles" "Breathing without accessory muscles" "Breathing without abd. muscles" "Accessory Muscles " adj|myocardial|miocardico; muscolo cardiaco; miocardio||"myocardial ischemia" "Myocardial Infarction" n|nailbed|||"Nailbeds pale" "Nailbeds cyanotic" n|name|||"Sent home with S.O. (indicate name & relationship)" "Sent home with (enter name & relationship)" "Inactive Census (by Name)" "Combined Census (by Name)" "Inactive Census (by Name)" "Combined Census (by Name)" n|nare|||"flaring nares" adj|nasal-tracheal|||"Nasal-tracheal tube" adj|natural|naturale||"Natural Gas" adj|neat|||"Clean and Neat" adj|neative|||"L neative Rinne" n|nebulizer|||"Aerosol nebulizer tx" "Aerosol nebulizer treatment" vp|needed|||"floor stock needed" "Sedation Needed" "Reinforcement of previous instruction needed" "Medicated as needed" "Additional instruction needed" v|need|||"Needs to attend formal class" "Needs supervision for adequate intake" "Needs secured" "75% or more of needs" "50-75% of needs" "50 - 75% of needs" "25-50% of needs" "25% or less of needs" "25 - 50% of needs" n|neglect|||"Neglects right side" "Neglects left side" n|neon|neon||"Neon Green" n|nerve|nervo||"Nerve Block" "Cranial Nerves" adj|neuromuscular|||"neuromuscular impairment" "neuromuscular diseases" n|nevus|melanoma benigno; nevo peloso; nevo; nevo pigmentato; nevo melanocitico||"Junctional Nevus" "Junctional Nevus (plural)" "Dermal nevus" "Dermal nevus (plural)" "Compound nevus" "Compound nevus (plural)" adj|new|nuovo||"new experiences" "Original ID temporarily assigned; New ID permanently assigned" "New venipuncture" "New effusion" adj|next|||"next routine delivery" n|night|||"Last night" n|nitrogen|azoto||"NITROGEN BALANCE" n|node|||"R axillary nodes" "No nodes" "L axillary nodes" adj|non-compliant|||"Non-compliant with Activity Restriction" adj|non-occlusive|||"Non-occlusive dressing" adj|non-pitting|non butterante||"Non-Pitting Edema" adj|non-rebreather|||"Non-Rebreather Mask" vp|nonhealing|||"Nonhealing wound" adj|nonoperative|||"Nonoperative or Emergency Postoperative (5)" adj|nonproductive|||"Nonproductive cough" adj|nonspecific|||"Nonspecific changes" adj|nonverbal|||"nonverbal behaviors" adj|non-verbal|||"Monitor verbal/non-verbal responses" n|noon|||"12 noon" n|north|||"2 North" n|note|||"Not Met(Enter note)" vp|noted|||"Uremic Frost noted" "Swelling noted" "Some injury noted" "Redness noted" "Pressure Area noted at:" "Pallor noted" "Odor noted" "Nystagmus noted" "None noted" "No retractions noted" "No pressure areas noted" "No odor noted" "No drainage noted" "No air leak noted" "Mild odor noted" "Foul odor noted" "Foul Odor noted" "Fecal odor noted" "Drainage noted" "Discharge noted" "Blood Clots noted" "Bleeding noted" "Air leaked noted" vp|notified|||"Notified MD re: pulmonary congestion" "Notified MD re: increased HR" "Notified MD re: dysrhythmias" "Notified MD re: UO <30 ml/hr" "Notified MD for increased PCWP" "Notified MD for decreased CI" "MD notified" "M.D. notified" v|notify|||"Notify MD" "Instructed pt. to notify if chest pain" vp|nourished|||"Well nourished" adj|nucchal|||"Nucchal Rigidity Present" "Nucchal Rigidity Absent" n|nutrition|||"Total parenteral nutrition" "Peripheral parenteral nutrition" "Parenteral nutrition provides" "Page nutrition clinician" "Page nutrition clinician " "Nutrition consult" "Home parenteral nutrition" "ENTERAL NUTRITION STATUS" adj|nutritional|||"Poor nutritional habits" "Nutritional supplements" "Nutritional supplements required" "Nutritional status intact" "Nutritional Status" "Nutritional Calculations" "NUTRITIONAL STATUS" n|nystagmus|||"Without nystagmus" "With nystagmus" "Nystagmus noted" "Nystagmus (medial)" "Nystagmus (lateral)" "Nystagmus (Rt. eye)" "Nystagmus (L eye)" "Nystagmus (Both eyes)" v|obey|||"Obeys verbal commands (6)" "Obeys verbal command" "Obeys verbal command (6)" n|object|||"Object Class " adj|oblique|obliquo||"R inferior oblique paresis/paralysis" "Oblique Incisions" "L inferior oblique paresis/paralysis" v|observe|||"Observe diet intake" adj|occlusive|||"Transparent (occlusive)" "Occlusive dressing" "Occlusive Dressing" "Occlusive Bandage" adj|ocular|||"Ocular Globe" "External Ocular Structures" adj|oculomotor|||"III: Oculomotor" adj|offensive|||"Offensive body odor" n|office|||"Office worker" n|officer|||"> 102 Call house officer" "> 101 Call house officer" n|oil|olio||"Mineral Oil" "Glycerine Mineral Oil" "Castor Oil" adj|olfactory|||"I: Olfactory" adj|olympic|||"Olympic trach" n|onset|||"c/o sudden onset" "c/o progressive onset" adj|open|apertura; aperto; pervio||"Open, infected" "Open, clean" "open wound" "Wide Open" "Open wound" "Open to verbal command" "Open to pain" "Open to air" "Open spontaneously" "Open areas" "Open area" n|opening|apertura; aperto; pervio||"Opening snap" "Opening filling pressure" "Opening Pressures" "Eye Opening" v|open|apertura; aperto; pervio||"Opens eyes to command" adj|optic|||"II: Optic" v|order|||"> 102 Order Blood culture stat" "> 101 Order Blood culture stat" n|order|||"Time Order" "Restrictive diet order" "Parameter Order" "Order completed for self medication administration" "Order Set" "Order History" "Diet order" "Other Orders Pending" "Nursing Orders Pending" "Clerical Orders Pending" "Active Orders" vp|ordered|||"Diuretics given as ordered." "BP maintained as ordered." "Urethrogram (ordered)" "Ultrasound (ordered)" "Sigmoidoscopy (ordered)" "Pulse oximetry (ordered)" "Proctoscopy (ordered)" "KUB (ordered)" "IVP (ordered)" "Endoscopy (ordered)" "ERCP (ordered)" "Cystogram (ordered)" "Colonoscopy (ordered)" "Cholangiogram (ordered)" "Cholangiogram (ordered)" "CXR (ordered)" "CT scan (ordered)" "CT Scan (ordered)" "Barium swallow (ordered)" "Barium enema (ordered)" "Abdominal xray (ordered)" "Abdominal tap (ordered)" "Tests Ordered" "As Ordered" n|organ|||"Organ Failure" n|origin|||"Fever of Unknown origin" adj|original|originale||"Original ID temporarily assigned; New ID permanently assigned" "Original ID entered in error" n|oscillation|||"High Frequency Oscillation " n|oscillator|||"High frequency oscillator" n|other|altro||"Other total volume" "Other pertinent history / neuro hx." "Other medication" "Other findings" "Other Tests" "Other Radiant" "Other Orders Pending" "Other Incisions" "Other Findings" "Other Facility" "Other Cl Ac" "Other Cl & Ac" "Other Characteristics" "All other lobes" n|otitus|||"Otitus Media" adj|outer|al di fuori; fuori da; esterno||"Upper outer" "R upper outer" "R lower outer" "Lower outer " "L upper outer" "L lower outer" n|output|||"excessive output" "decreased urinary output" "decreased cardiac output" n|overload|||"volume overload" "sensory overload" n|oximetry|||"Pulse oximetry (ordered)" "Pulse oximetry (completed)" n|pacemaker|||"Wandering Atrial Pacemaker" "Temporary Pacemaker Insertion" "Pacemaker not effective" "Pacemaker effective" "Pacemaker Type" "Pacemaker " "Cardiac Pacemaker" vp|pacing|||"Pacing S.G." n|pack|||"Pack years (# years x packs/day)" "Hot pack" "Cold pack" n|packing|||"Iodoform packing" n|pack|||"Ice packs " n|pad|||"Uvex Pad" "Silicone Pad" "Pressure Pad" vp|padded|||"Up x 4 - Padded" "Up x 2 - Padded" "Side rails padded" n|page|||"Page nutrition clinician" "Page nutrition clinician " n|painful|||"To painful stimuli (2)" v|palpate|||"Difficult to palpate" "Difficult to palpate pulse" n|palpitation|||"C/O palpitations" n|palsy|||"R peripheral palsy" "R central palsy" "L peripheral palsy" "L central palsy" n|pamphlet|||"Handouts/pamphlets provided" n|pansystolic|||"Pansystolic murmur" n|papilledema|||"R Papilledema" "L papilledema" adv|paradoxically|||"Paradoxically split S2" adj|parallel|||"Eye movement is parallel" "Eye movement is not parallel" adj|paralytic|||"restraints/paralytic agents" vp|paralyzed|||"Sedated and paralyzed" "Paralyzed (Med)" "U = unable to assess (ie: paralyzed/anes)" n|paramedian|||"Right Paramedian" "Left Paramedian" n|parameter|||"Parameter Order" "Only selected parameter" "Meets parameter" "Does not meet parameter" "All parameters on this axis" adj|parenteral|||"Total parenteral nutrition" "Peripheral parenteral nutrition" "Parenteral nutrition provides" "Home parenteral nutrition" n|paresis|||"R superior rectus paresis/paralysis" "R paresis/paralysis" "R medial rectus paresis/paralysis" "R inferior rectus paresis/paralysis" "R inferior oblique paresis/paralysis" "L superior rectus paresis/paralysis" "L paresis/paralysis" "L paresis/paralysis " "L medial rectus paresis/paralysis" "L inferior rectus paresis/paralysis" "L inferior oblique paresis/paralysis" adj|parietal|||"Parietal region" adj|paroxysmal|parossistico||"Paroxysmal Junctional Tachycardia" "Paroxysmal Junctional Tach" "Paroxysmal Atrial Tachycardia" adv|partially|||"Pneumothorax partially resolved" "Partially compliant with diet" "Hemothorax partially resolved" "Effusion partially resolved" n|particle|||"With Food Particles " vp|passing|||"Passing flatus" adj|passive|||"Passive acceptance" adv|past|||"Past L mid-clavicular" adj|pathological|patologico||"Pathological Reflexes" n|pathology|||"Disease pathology" n|pause|||"Sinus Pause" vp|peaked|||"Peaked T wave" n|pectus|||"Pigeon chest (pectus carinatum)" "Funnel chest (pectus excavatum)" "Pectus excavatum" "Pectus carinatum" adj|pedal|||"Pedal pulses" "Pedal pulse" "Pedal " adj|pediatric|||"Pediatric Hood or Tent " "Pediatric (Peds)" n|pedis|||"R Dorsalis pedis" "L Dorsalis pedis" "Dorsalis pedis" "Dorsalis pedis pulses" "Dorsalis Pedis " vp|peeling|||"Transparent (peeling)" n|perforator|||"R Perforators" "L Perforators" v|perform|||"inability to perform ADL" "Unable to perform skill(s)" "unable to concentrate/perform tsks" vp|performed|||"Performed by" n|perfusion|||"inadequate ventilation/perfusion" adj|pericardial|||"Pericardial rub" "Pericardial friction rub" adj|perineal|||"Perineal hematoma" "Perineal edema" n|period|||"Periods of apnea" adj|perioperative|||"Perioperative with severe malnutrition" adj|periorbital|||"Periorbital edema" "Periorbital edema (Rt)" "Periorbital edema (L)" adj|periostomal|||"Periostomal skin healthy and intact" "Periostomal skin erythematous" "Periostomal skin denuded" adj|peripheral|periferico||"peripheral edema" "R peripheral palsy" "Peripheral pulses normal" "Peripheral pulses decreased" "Peripheral parenteral nutrition" "Peripheral cyanosis" "Peripheral PN" "L peripheral palsy" "Assess peripheral pulses" adj|peristalsis|||"Visible peristalsis" adj|peristomal|||"Peristomal region" adj|peritoneal|||"Signs of Peritoneal Irritation" "Peritoneal fluid" "Peritoneal Catheter:" "Peritoneal Access" adv|permanently|||"Original ID temporarily assigned; New ID permanently assigned" n|permit|||"Sterilization Permit" n|peroxide|||"Hydrogen Peroxide" adv|persistently|||"Persistently split S2" "Persistently single S2" n|personnel|||"Hospital Personnel" n|perthes|||"Positive R Perthes" "Positive L Perthes" "Negative R Perthes" "Negative L Perthes" adj|pertinent|||"Other pertinent history / neuro hx." n|phalanges|||"Unable to move distal phalanges" "Able to move distal phalanges" adj|pharmacological|farmacologico||"Administer pharmacological agents" n|phenomenon|||"R on T phenomenon" adj|physical|||"physical/chemical restraints" "physical impairment" "Physical assessments" "Drugs (causing physical changes)" adj|physiological|fisiologico||"Monitor physiological params" v|pick|||"unit to pick up" n|pill|||"Uses diet pill" n|pillow|||"Elevated on pillows" n|pin|||"Pin Site Description" vp|pitched|||"Low pitched" "High Pitched" vp|placed|||"Placed with patient" "Placed on Top of Patient" "Placed on Top & Under Patient" "Placed in safe" "Placed Under Patient" n|plane|||"Longitudinal Plane" adj|pleasant|||"Pleasant and cooperative" adj|plural|plurale||"Wheal (plural)" "Vitiligo (plural)" "Ulcer (plural)" "Tumor (plural)" "Thigh (plural)" "Tender (plural)" "Telangiectasia (plural)" "Shoulder (plural)" "Scar (plural)" "Scale (plural)" "Pustule (plural)" "Plaque (plural)" "Patch (plural)" "Papule (plural)" "Non tender (plural)" "Nodule (plural)" "Middle (plural)" "Macule (plural)" "Leg (plural)" "Knee (plural)" "Keloid (plural)" "Junctional Nevus (plural)" "Inguinal (plural)" "Induration (plural)" "Hand (plural)" "Foot (plural)" "Fissure (plural)" "Excoriation (plural)" "Erosion (plural)" "Entire lung fiels (plural)" "Entire lung field (plural)" "Entire lung field (plural) " "Ecchymosis (plural)" "Dermal nevus (plural)" "Cyst (plural)" "Crust (plural)" "Compound nevus (plural)" "Capillary hemangioma (plural)" "Buttock (plural)" "Bulla (plural)" "Breast (plural)" "Base (plural)" "Atrophy (plural)" "Arm (plural)" "Apex (plural)" cj|plus|in aggiunta a; plus; con||"Vivonex Plus" "MVI plus minerals" "Ensure Plus" adj|pneumatic|||"pneumatic tube" n|point|||"Point of Maximal Impulse" "Cane (1 point)" "Cane (3 points)" n|pole|||"Suspended from IV pole" adj|popiteal|||"Popiteal pulses" adj|portable|||"Portable Oxygen" n|posey|||"Chest Posey" adj|post|||"post op" "Post void residual" "Post tibial" "Post tibial pulses" "Post tibial pulse" "Post angioplasty" "Post Procedure" "Post Procedure Instructions" adj|posteromedial|||"R Posteromedial thigh" "L Posteromedial thigh" adj|postoperative|||"Nonoperative or Emergency Postoperative (5)" "Elective Postoperative Patient (2)" adj|postural|posturale||"postural hypotension" "Postural drainage " n|posture|||"Upright Posture" n|power|||"Power of Attorney" "Full power against resistance (5)" ab|pre|||"Pre chemotherapy" adj|preadmission|||"Preadmission testing" n|precaution|||"Precautions Taken" "Maintain safety precautions" "MRSA Precautions" vp|precipitating|||"Precipitating Factors:" n|precipitation|precipitazione||"PRECIPITATION FACTORS" adj|pregnant|||"patient is pregnant" "Pt Pregnant" "Pt Not Pregnant" "Patient is not pregnant" n|presence|||"Presence of Bruit" n|presentation|||"GENERAL PRESENTATION" "Clinical Presentation" vp|presented|||"Verbalized understanding of information presented" vp|pressured|||"Pressured Cycle " adj|previous|precedente||"Reinforcement of previous instruction needed" "Provided reinforcement of previous instruction" "Previous Irradiation" "Previous EEG Results" "Previous Biopsy" adj|primary|primario; principale||"Primary skin lesions" n|printer|||"IBM WS Printer" adj|prior|||"Pre-med prior to procedures" n|privilege|||"Bathroom Privileges" n|probe|probe; sonda||"PH Probe placement" n|problem|problema||"Problem List" "No problems" "No Problems" vp|proceeding|||"Pt. proceeding thru stages" "Pt. not proceeding" n|process|||"disease process" "Tender at mastoid process" "Disease Process" n|proctoscopy|||"Proctoscopy (ordered)" "Proctoscopy (completed)" n|product|||"TUBE FEEDING PRODUCT" "No milk products" "Dressing Products" n|progress|||"Progress Notes" adj|progressive|progressivo||"c/o progressive onset" vp|prolonged|prolungato; allungato; lungo||"prolonged exposure to cold" "Prolonged staring" "Prolonged staring " "Prolonged poor p.o.intake" "Prolonged poor p.o. intake" "Prolonged NPO status" n|prominence|||"Bony Prominence" n|prostate|prostata||"Prostate Cancer" n|protocol|||"surgical protocol" "Per protocol" "Per Protocol" "Betadine allergy protocol" vp|protracted|||"Protracted Right" "Protracted Left" vp|protruded|evaginato; protruso; evaginazione; protrusione||"Tongue protruded" v|provide|||"Provide supportive care" "Provide supplements" "Provide snacks" "Tube feeding provides" "Parenteral nutrition provides" "Provided reinforcement of previous instruction" "Provided instruction related to topic" "Menstrual pads provided" "Handouts/pamphlets provided" v|provider|||"Seen by Physician/Provider" "Ready for Physician/Provider" n|psychosis|psicosi; disturbo psicotico||"ICU psychosis" adj|psychotic|||"psychotic disorder" adj|pulmonary|polmonare; pneumo-; polmone||"Pulmonary stenosis" "Pulmonary rehab" "Pulmonary Embolus" "Pulmonary Contusion" "Pulmonary Artery" "PULMONARY CHARACTERISTICS" "Notified MD re: pulmonary congestion" adj|pulmonic|||"Pulmonic Ejection sound" n|pulsus|||"Pulsus paradoxus" "Pulsus alternans" n|pupil|pupilla||"Argyll Robertson pupils" adj|purposeful|||"lack of purposeful movement" adj|quadruple|quadruplo||"Quadruple lumen" n|question|||"unable to answer questions or follow directions accurately" "frequent repetitive questions" "Unable to answer questions correctly" "Asks many questions" "Able to answer questions correctly" v|quit|||"Just Quit " n|radiant|||"Other Radiant" adj|radical|radicale||"Radical Neck Dissection" n|rail|||"Side rails padded" "Side Rails Up" n|raise|||"Straight Leg Raise" n|ramp|||"Descending Ramp" n|range|||"Range of Motion" "Lab values within expected range" "Dec Range of Motion" adj|rapid|||"Rapid > 100/min" n|rate|||"TUBE FEEDING RATE" "Rate increased" "Rate decreased" "Rate controlled A-Fib" "PN RATE" "Hourly rate" "Heart rate" "Fixed Rate" "AV Sequential (Fixed Rate)" vp|rated|||"Fixed Rated" n|ray|||"Chest X ray" vp|reading|||"Requires glasses for reading only" adj|ready|||"Ready for Physician/Provider" "Ready for Dismissal" n|rebound|||"Rebound tenderness" n|recall|||"Able to recall information/return demonstration" "Able to recall/demonstrate with some verbal cueing" "Able to recall/demonstrate with much verbal cueing" "Able to recall/demonstrate minimal information" "Not able to recall/return demonstration" adj|recent|recente||"recent weight loss" "recent loss" "Recent surgery" "Recent memory intact" "Recent memory impaired" "Recent death in family" "Recent Barium Study" adj|receptive|||"Receptive Aphasia" "Aphasia - Receptive" n|rectus|||"R superior rectus paresis/paralysis" "R medial rectus paresis/paralysis" "R inferior rectus paresis/paralysis" "L superior rectus paresis/paralysis" "L medial rectus paresis/paralysis" "L inferior rectus paresis/paralysis" adj|recumbent|||"Lateral recumbent" adj|recurrent|ricorrente||"Recurrent seizures" adj|reducible|ridotto||"Reducible, easily" "Reducible, difficult" "Non reducible" vp|refeeding|||"REFEEDING SYNDROME RISK" n|refill|||"decreased cap refill" "Capillary refill < 3 secs" "Capillary Refill" "Cap refill > 3 secs" "Cap refill > 3 sec" "Cap refill < 3 sec" "CAPILLARY REFILL" "Assess capillary refill" n|reflex|||"Stretch Reflexes" "Pathological Reflexes" vp|refusing|||"Refusing meals" n|regime|||"Bowel regime" n|regimen|||"Bowel regimen" vp|related|||"gang related incidence" "Provided instruction related to topic" "Attended formal class related to topic" n|relationship|||"Sent home with S.O. (indicate name & relationship)" "Sent home with (enter name & relationship)" n|relaxation|||"Taught comfort measures/relaxation" adj|reliable|||"Reliable historian" vp|relieved|||"Relieved with (type response)" "Relieved by:" "Pain relieved" "Nausea relieved" "Indigestion relieved" "Indigestion not relieved" "Bladder fullness relieved" "Pain relieved-observed" "Pain not relieved-observed" "Pain relieved-stated" "Pain not relieved-stated" vp|relieving|||"RELIEVING FACTORS" adj|reluctant|||"Reluctant to attempt movement" v|remain|||"Remain supine" "Remain prone" "Remain flat" "Airway remains patent" v|remember|||"Don't remember" "Can't remember" adj|remote|remoto||"Remote memory intact" "Remote memory impaired" adj|repetitive|||"frequent repetitive questions" vp|replaced|||"NG/OG (replaced)" "GT (replaced)" n|replacement|||"VITAMIN/MINERAL REPLACEMENT" "ELECTROLYTE REPLACEMENT" vp|reported|||"Assess pt.'s reported pain level" v|require|||"Require O2" "Requires glasses or contacts" "Requires glasses for reading only" "Requires assistance" vp|required|||"Suture required" "Nutritional supplements required" "Dressing required" "Assistance required" n|requirement|||"Calculated fluid requirement" vp|requiring|||"Not requiring supplements" adj|residual|residuo||"Post void residual" n|resistance|||"Moves against gravity & resistance, weakly (4)" "Moves against gravity, not resistance (3)" "Movement thru ROM against resistance (4)" "Irrigates with resistance" "Full power against resistance (5)" vp|resolved|||"SQ emphysema resolved" "Pneumothorax resolved" "Pneumothorax partially resolved" "Hemothorax resolved" "Hemothorax partially resolved" "Effusion resolved" "Effusion partially resolved" "Ectopy resolved" n|respiration|||"No fluctuation with respiration" "shallow respirations" "Spontaneous Respirations " "No spontaneous respirations" "Kussmaul Respirations" "Fluctuates with respirations" "Biot's Respirations" v|respond|||"Responds to voice" "Responds to pain" "Responds to deep pain" "Responds inappropriately" n|restriction|||"Non-compliant with Activity Restriction" "Activity restriction" "activity restrictions" "Fluid restrictions" "Diet restrictions" adj|restrictive|||"Restrictive diet order" n|rest|||"Kidney Rests" n|result|||"Waiting for Results" "Previous EEG Results" vp|retained|||"Enema retained" "Enema not retained" vp|retaped|||"ETT Retaped" n|retention|ritenzione||"fluid retention" "Urinary Retention" v|return|||"Movement returned to functional level" "Not able to recall/return demonstration" "Able to recall information/return demonstration" vp|reviewed|||"Labs Reviewed: Positive" "Labs Reviewed: Negative" n|rhonchi|||"Rhonchi increased" "Rhonchi decreased" "Rhonchi (sonorous wheezes)" "Rales and Rhonchi" "Crackles and rhonchi" n|rigidity|||"Nucchal Rigidity Present" "Nucchal Rigidity Absent" "Flexion-abnormal/decorticate rigidity (3)" "Extension/decerebrate rigidity (2)" "Board rigidity" n|ring|||"Kayser-Fleischer ring" n|risk|||"Risk for malnutrition" "REFEEDING SYNDROME RISK" "No risk for malnutrition" "MALNUTRITION RISK" "High risk screen" n|role|||"role changes" n|roll|||"Shoulder Roll" "Roll off" "Axillary Roll" vp|rolled|||"Log Rolled" n|roll|||"Chest Rolls" n|room|||"deliver to patient room" "Room 2" "Room 1" "Living Will-left in patient's room" "Left in patient's room" adj|rough|||"Rough ****" vp|roving|||"Roving eye movements" n|rub|||"Pleural rub" "Pleural Rub" "Pericardial rub" "Pericardial friction rub" "Friction rub" n|run|||"Runs of V-Tach" adj|rural|||"Isolated Rural" adj|safe|||"Placed in safe" n|safety|||"Safety measures" "Safety issues" "Safety Strap" "Safety Issues" "Maintain safety precautions" adj|saline|||"Sterile Saline" "Saline lavaged with suctioning" n|salt|||"Low Salt (enter amount)" adj|saphenous|||"R Lesser saphenous" "R Greater saphenous" "L Lesser saphenous" "L Greater saphenous" n|satiety|||"Early satiety" n|scan|||"V-Q Scan" "Pet Scan" "CT scan (ordered)" "CT scan (completed)" "CT Scan" "CT Scan (ordered)" "CT Scan (completed)" n|scapula|scapola||"Scapulas Winged" adj|sclerodermal|||"Skin Thickened (sclerodermal)" n|screen|||"High risk screen" adj|scrotal|scroto-; scrotale; scroto||"Scrotal support applied" "Scrotal edema" n|scrub|||"Betadine Scrub" n|seal|||"Water seal" adj|sebaceous|||"Sebaceous cysts" "Sebaceous cyst" adj|secondary|secondario||"Secondary skin lesions" adj|secured|||"Needs secured" n|sedation|||"Sedation Needed" v|see|||"See comment" v|seem|||"Seems anxious" "Seems angry" vp|seen|visto||"Seen by Physician/Provider" "Seen by Nurse" "No fluctuation seen" n|segment|||"ST Segment" vp|selected|||"Only selected parameter" n|sense|||"Decreased vibration sense" "Absent vibration sense" adj|sensory|||"sensory overload" "Sensory Function" "Decreased sensory stimulation" "Aphasia, sensory" vp|sent|||"Sent to Pharmacy" "Sent home with family or S.O." "Sent home with S.O. (indicate name & relationship)" "Sent home with (enter name & relationship)" "Living Will-sent home" n|sentence|||"Unable to speak in sentences" adj|sequential|||"AV Sequential" "AV Sequential (Fixed Rate)" "AV Sequential (Demand)" adj|serial|||"Serial sevens, unable" "Serial sevens, able" n|serum|siero||"decreased serum albumin, total protein" "Horse Serum" n|service|||"Pain Service consult" vp|set|||"Order Set" vp|setting|||"Orientation to Hospital setting" vp|setting|||"Settings Verified" "Change IABP settings" adv|severely|severamente; alto grado; severo; grave||"Severely underweight" "Severely depleted protein" n|shin|||"Heel/Shin slides" n|shift|||"fluid shift" "Weight Shift" "Shift Assessment" vp|shifting|||"Shifting dullness" adj|short|corto||"Short term memory loss" "Short of Breath" "Memory Loss - Short Term " n|shortness|||"Shortness of breath" v|show|||"Show Detail" adj|sick|||"Sick Sinus Syndrome" "C/O feeling sick" adj|sibilant|||"Wheeze (sibilant wheeze)" adj|sigmoid|||"Sigmoid colostomy" "Sigmoid Colostomy" n|sigmoidoscopy|||"Sigmoidoscopy (ordered)" "Sigmoidoscopy (completed)" n|sign|||"Trousseau's sign present" "Trousseau's sign absent" "Trousseau's sign " "Kussmaul's sign" "Homan's sign (R)" "Homan's sign (L)" "HOMAN'S SIGN" "Cullen sign" "Chvostek's sign present" "Chvostek's sign absent" "Chvostek's sign " "Vital Signs" "Vital Signs Trend" "Specific Signs" "Signs of Peritoneal Irritation" "Signs and Symptoms of complications" "Pt. with signs of" "General Signs" "ECG-no signs of ischemia" "Daily Vital Signs" adj|significant|||"Significant other" "Non significant " n|silicone|silicone||"Silicone Pad" adj|simple|semplice||"Simple List " "Simple Face Mask " n|sinus|||"Sinus tract" "Sinus Tachycardia" "Sinus Rhythms" "Sinus Pause" "Sinus Dysrythmia" "Sinus Bradycardia" "Sinus Block" "Sinus Arrhythmia" "Sinus Arrest" "Sick Sinus Syndrome" "Normal Sinus Rhythm" vp|sitting|||"Sitting in Chair" "Sitting in Bed" n|situation|||"crisis situation" n|skill|||"Unable to perform skill(s)" "Unable to demonstrate skill(s)" "Demonstrated skill(s) to be learned" "Able to demonstrate skill(s)" n|slap|||"Foot slap" n|slide|||"Heel/Shin slides" adj|slight|basso grado; minimo; modesto; lieve||"Slight pain" n|smega|||"Smega present" n|smell|||"Smell alterations" vp|smelling|||"Fecal smelling" "Fecal smelling " n|smoke|fumo||"Smoke Inhalation" "Does not smoke" n|snap|||"Opening snap" n|soap|||"Soap and Water" "Soap Suds" adv|socially|||"Drinks socially" n|softener|||"Stool softener" adj|somnolent|||"3 = severe (somnolent; difficult to arouse)" adj|sonorous|||"Rhonchi (sonorous wheezes)" n|soreness|||"c/o soreness" n|source|||"REFERRAL SOURCE" n|south|||"9 South" "4 South" vp|spacing|||"third spacing" n|span|||"Vertical span of liver" "Liver Span" "Limited attention span" v|speak|||"Unable to speak in sentences" "speaks foreign language" vp|speaking|||"Speaking valve" "Speaking trach" "SOB when speaking" n|spell|||"Staring spells" adj|spider|ragno||"Spider angioma" adj|spinal|||"spinal core stimulation" "XI: Spinal Accessory" n|spirometry|||"Incentive spirometry" n|splint|corazza||"Airplane Splint" adj|splinter|||"Splinter hemorrhages" v|split|||"Widely split S2" "Wide split S2" "Split S2" "Split S1" "Persistently split S2" "Paradoxically split S2" "Fixed split S2" adv|spontaneously|||"Voiding spontaneously" "Spontaneously (4)" "Open spontaneously" n|spot|||"White spots" "Blind spot-visual disturbance" n|spouse|||"With Spouse" vp|stablized|||"Mass stablized" n|staff|||"W/4 Staff" "W/3 Staff" "W/2 Staff" "W/1 Staff" n|stage|||"Assessed stage: depression" "Assessed stage: denial" "Assessed stage: anger" "Assessed stage: acceptance" "Stage IV" "Stage III" "Stage II" "Stage I" "End Stage Renal Disease" "End Stage Liver Disease" "Pt. proceeding thru stages" "Assist pt/SO through stages" n|stairs|||"Climbing stairs" v|stare|||"Stares into space" "Stared into space" vp|staring|||"Staring spells" "Prolonged staring" "Prolonged staring " vp|starting|||"Difficulty Starting Stream" "Diff. starting stream" n|state|||"hypermetabolic state" "Severe catabolic state" "Stated aura present" vp|stated|||"Pain relieved-stated" "Pain not relieved-stated" "Pain tolerable-stated" n|stent|marcatore||"Montgomery stent" "External stent" n|step|||"First Step" adj|sterile|||"Sterile Water" "Sterile Saline" "Sterile Gauze" n|sterilization|||"Sterilization Permit" adj|sternal|||"Right sternal margin" "Right Sternal Border" "R sternal border" "Left sternal margin" "Left Sternal Border" "L sternal border" adj|sternocleidomastoid|||"R sternocleidomastoid weakness" "L sternocleidomastoid weakness" n|sternotomy|||"Median sternotomy" n|stick|||"R hockey stick" "L hockey stick" n|stimulation|||"spinal core stimulation" "Decreased sensory stimulation" n|stimulator|||"Neuro Stimulator" n|stimuli|||"To verbal stimuli (3)" "To painful stimuli (2)" "Stimuli removed" "No response to verbal stimuli" n|stock|||"floor stock needed" n|stone|concrezione; calcolo||"Stones present" n|stools|||"liquid stools" "hard stools" "Loose Stools" adj|straight|||"Straight catheterization" "Straight cath completed" "Straight Leg Raise" "Straight Cath Insertion" "A-V shunt, straight" vp|strained|||"Urine strained" n|strap|||"Safety Strap" "Chin Strap" vp|streaked|||"Blood streaked drainage" "Blood Streaked drainage" n|streak|||"Red streaks" "Longitudinal white streaks" n|stream|||"Difficulty Starting Stream" "Diff. starting stream" n|stress|stress||"financial stress" "Stress incontinence" n|stretch|||"Stretch Reflexes" n|striae|smagliature; lineae atrophicae; strie da distensione; linee albicanti; strie della gravidanza; atrofia lineare; strie||"Striae (purple)" "Striae " n|stride|||"Stride Length" n|strike|||"Heel Strike" n|strip|||"Strip & vent" "Rhythm strip" vp|stripped|||"JP drain stripped" n|strip|||"Steri strips intact" adv|strongly|||"Strongly positive" n|structure|||"External Ocular Structures" n|study|||"CSF studies drawn" "Recent Barium Study" "CSF studies drawn" n|style|||"pt prognosis or life style changes" "life style changes" n|stylet|||"Lighted Stylet" adj|subarachnoid|||"Subarachnoid Hemorrhage" adj|subconjunctival|||"Subconjunctival Hemorrhage (Rt)" adj|subcostal|||"R subcostal" "L subcostal" "Bilateral subcostal" adj|subcutaneous|||"Subcutaneous fibrosis" "Subcutaneous emphysema" "Subcutaneous emphysema extends to" "SUBCUTANEOUS EMPHYSEMA" adj|subjective|||"Subjective Complaints" "SUBJECTIVE COMPLAINTS" n|substance|||"substance abuse" "toxic substances" adj|subungual|||"Subungual hematoma" "Subungual Hematoma" vp|suctioning|||"Suctioning not effective" "Suctioning effective" "Saline lavaged with suctioning" adj|sudden|||"c/o sudden onset" adj|suds|||"Soap Suds" n|sugar|||"Excessive sugar intake" adj|suicidal|||"Suicidal Tendencies" "Expresses suicidal intentions" n|summation|||"Summation gallop" "Summation gallop " n|sump|||"Axiom sump" n|supervision|||"Needs supervision for adequate intake" adj|supplementary|||"Administer supplementary O2" n|supply|||"Central Supply" n|support|||"Scrotal support applied" "SIMV with Pressure Support " "Pressure Support " "Emotional support" "Electrolyte support" "CPAP with Pressure Support " "Base of Support" adj|supportive|||"Provide supportive care" n|suppository|||"Suppository not effective" "Suppository ineffective" "Suppository effective" "Rectal suppository" "Rectal suppository " "B/O suppository effective " "B/O suppository administered" n|suppressant|||"Cough suppressant not effective" "Cough suppressant effective" "Cough suppressant administered" "Cough suppressant - expectorant administered" vp|suppressed|soppresso; soppressivo||"Coughing suppressed" adj|supraclavicular|||"Supraclavicular retractions" "R supraclavicular" "R Supraclavicular" "L supraclavicular" adj|suprasternal|||"Suprasternal retractions" adj|supraventricular|||"Supraventricular Tachycardia" n|surface|superficie||"Surface Location of Mass" vp|surrounding|circoscritto; circondante; circolare; circonferenziale||"Color Surrounding Skin" n|survey|||"Venous Survey" "Extremity Survey" "Arterial Survey" vp|suspended|||"Suspended from IV pole" n|swab|||"Alcohol swabs" n|swallow|||"Barium swallow (ordered)" "Barium swallow (completed)" vp|sweating|||"sweating/gooseflesh above level of injury" adj|symmetric|||"Symmetric expansion" n|symptom|sintomo||"Signs and Symptoms of complications" adj|synchronous|||"Ventricular Synchronous" "Synchronous IMV " "Atrial Synchronous" adj|syncopal|||"syncopal episode" n|syndrome|||"Sick Sinus Syndrome" "REFEEDING SYNDROME RISK" "Kwashiorkor syndrome" n|system|||"Unable to use call system" "DRAINAGE SYSTEM" n|T-wave|||"T-wave Triggered" n|table|||"Fracture Table" n|tail|||"Tail of Spence" "R tail of Spence" "L tail of Spence " vp|taken|||"Precautions Taken" n|tap|puntura e aspirazione; paracentesi; taglio chirurgico||"Tap Water" "Abdominal tap (ordered)" "Abdominal tap (completed)" n|tape|||"Elastoplast tape" n|task|||"unable to concentrate/perform tasks" n|taste|||"metallic taste" "Taste alterations" vp|taught|||"Taught comfort measures/relaxation" vp|teaching|||"Pre-op teaching" "Post-op teaching" adv|temporarily|||"Original ID temporarily assigned; New ID permanently assigned" n|tendelenburg|||"Supine with tendelenburg" n|tendency|||"Suicidal Tendencies" n|tent|||"Pediatric Hood or Tent " "Face Tent" adj|tepid|||"Tepid bath" "Tepid ETOH bath" "Bath, Tepid" n|term|||"Short term memory loss" "Memory Loss - Short Term " "Memory Loss - Long Term " "Long term memory loss" adj|terminal|terminale; finale; ultimo stadio; stadio terminale; stadio finale||"Terminal Illness" n|terminology|||"unknown terminology" vp|tested|||"Not tested" "Not Tested (NT)" "Not Tested(NT)" vp|testing|||"Preadmission testing" n|therapy|||"Vaspressive therapy effective" "Vasopressive therapy" "Vasopressive therapy not effective" "Vasopressive therapy effective" "SQ Therapy" "Respiratory Therapy" "PO Therapy" "IV Therapy" "IM Therapy" "Estrogen Therapy" "COMBINATION THERAPY ADEQUACY" "COMB. THERAPY ADEQUACY" n|thickness|||"Partial thickness" "Full thickness" n|thirst|||"increased thirst" n|thoracostomy|||"Tube Thoracostomy" n|thoracot|||"Trans-sternal bilat thoracot" adj|thorough|||"Demonstrates a thorough understanding" n|thought|||"unable to articulate thoughts/words" n|thread|||"Mucous threads" "Mucous threads present" n|tibia|tibia||"Posterior Tibia" adj|tibial|||"R Posterior tibial" "R Anterior tibial" "Posterior tibial" "Post tibial" "Post tibial pulses" "Post tibial pulse" "L Posterior tibial" "L Anterior tibial" n|tilt|||"Lateral tilt right" "Lateral tilt left" vp|timed|||"Timed Cycle " vp|tinged|||"Red Tinged" "Blood tinged" "Blood tinged drainage" "Blood Tinged drainage" "Blood Tinged " n|tip|||"Palpable tip" n|tissue|tessuto corporeo; tessuto||"Granulation tissue present" adj|titrate|||"Titrate vasoactive drugs" "Titrate IV meds" "SBP > 90 titrate to CL 2.5" n|titration|||"Titration of vasopressors" "Titration of vasopressor (s)" adj|tolerable|||"Pain tolerable-stated" v|tolerate|||"Tolerating TF" "Not tolerating" "Not tolerating meals" "Not tolerating feeding" "Not tolerating TF" vp|tolerated|||"Tolerated well" "Not tolerated" "Enema not tolerated" "Diet tolerated" "Diet not tolerated" "Clamping tolerated" n|tone|||"Type of Tone" "Muscle Tone" "MUSCLE TONE" adj|tonic|||"Tonic pupil (Adie)" "Tonic movements" n|top|||"Placed on Top of Patient" "Placed on Top & Under Patient" n|topic|||"Topic (T)" "Provided instruction related to topic" "Misc Topic (M)" "Attended formal class related to topic" "Topics Discussed" adj|topical|area delimitata; topico; localizzato; locale||"Topical antiviral medication applied." "Topical antifungal medication applied." n|torsade|||"Flutter (Torsade)" adj|total|in toto; tutto; totale; completo||"decreased serum albumin, total protein" "Total parenteral nutrition" "Total paralysis (0)" "Total Fluid = ____" "Total Assistance" "Other total volume" adv|totally|||"Totally dependent with ADL" n|touch|||"cool to touch" "Warm to touch" "Touch nose with finger" "No response to touch" "Hot to touch" "Decreased light touch sensation" "Cool to touch" "Cold to touch" "Absent light touch sensation" n|tourniquet|||"Positive R tourniquet" "Positive L tourniquet" "Negative R tourniquet" "Negative L tourniquet" adj|toxic|||"toxic substances" n|tract|||"Sinus tract" "Motility disfunction of the GI tract" "Fistula tract present" adj|trans-sternal|||"Trans-sternal bilat thoracot" n|transducer|||"Transducer Leveled" n|transition|||"Monitor diet transition" adj|transparent|trasparente; non opaco; chiaro||"Transparent dressing" "Transparent (peeling)" "Transparent (occlusive)" n|transplant|trapianto||"Liver Transplant" "Kidney Transplant" "Bone Marrow Transplant" n|transport|||"Pt Transport" "Bring transport equipment" n|transportation|||"No Transportation" n|transrectus|||"Right Transrectus" "Left Transrectus" n|trapezius|||"R trapezius wseakness" "L trapezius weakness" n|tray|||"Central Line Dressing Tray" n|trend|||"Vital Signs Trend" "Monitor Trend" n|trial|||"T-Piece Trial " adj|trifasicular|||"Trifasicular Block" vp|triggered|||"Ventricular Demand (Triggered)" "Atrial Demand (Triggered)" "T-wave Triggered" "T wave Triggered" "QSR Triggered" "QRS Triggered" "Atrial Triggered" "Atrial Triggered (VDD)" adj|triple|triplo||"Triple lumen" "Triple lumen catheter" adj|trochlear|||"IV: Trochlear" adj|true|vero||"Mostly true" "Definitely true" n|tube|tubo||"tube in place" "tube feedings" "pneumatic tube" "Unable to place feeding tube" "Tube removed (by pt.)" "Tube removed (by physician)" "Tube not patent" "Tube feedings" "Tube feeding" "Tube feeding provides" "Tube displaced" "Tube clamped" "Tube Thoracostomy" "Tube Status" "TUBE STATUS" "TUBE FEEDING TYPE" "TUBE FEEDING RATE" "TUBE FEEDING PRODUCT" "T tube" "Rectal tube" "Nephrostomy tube" "Nephrostomy tube to gravity drain" "Nephrostomy tube irrigated" "Nephrostomy tube clamped" "Nasal-tracheal tube" "NG tube" "NG Tube Insertion" "Laryngectomy tube" "Home tube feedings" "Feeding tube removed by pt." "Feeding tube not patent" "Feeding tube displaced" "Feeding tube clamped" "Feeding Tube Insertion" "Enteral tube inserted" "Endotracheal tube" "Endotracheal Tube" "Drainage tube repositioned" "Drainage tube removed" "Drainage tube patent" "Drainage tube inserted" "DRAINAGE TUBE" "Chest tube" "Chest Tube Size" "Chest Tube Insertion" "Check NG Tube" "Check ET Tube Placement" "Biliary tube" n|tuberosity|||"Ischial tuberosity" n|tubing|||"Tubing Changed" "Bag and Tubing Changed" adj|tubular|||"Bronchial (tubular)" n|tunnel|||"C/O tunnel vision" adj|turbid|||"Urine, turbid" "Ascites, turbid" n|turn|||"Turn and position" adj|ulnar|||"Ulnar Deviation" "R ulnar" "R Ulnar" "L ulnar " "L Ulnar" n|ultrafiltration|||"Isolated Ultrafiltration" n|ultrasound|||"Ultrasound (ordered)" "Ultrasound (completed)" vp|wheezing|||"Wheezing absent" "Increased wheezing" "Decreased wheezing" vp|whitened|||"Whitened area" adj|wide|diffuso, esteso; allargato; allargamento||"Wide split S2" "Wide Open" adv|widely|||"Widely split S2" v|wiggle|||"Wiggles toes" "Wiggles hands" "Wiggles fingers" "Wiggles feet" n|will|||"Pt. does not have a living will" "Living Will-given to nurse" "Living Will-left in patient's room" "Living Will-left at home" "Living Will-sent home" n|willingness|||"decreased willingness to learn" adj|winged|||"Scapulas Winged" n|word|||"Incomprehensible words" "Incomprehensible sounds-not words (2)" "Inappropriate words" "Inappropriate words (3)" "unable to articulate thoughts/words" n|worker|||"Office worker" "Metal Worker" "Factory worker" "Worker's Comp" adj|working|||"Working Diagnosis" "Working Copy" adj|worse|||"Somewhat worse" "Much worse" "Chest pain worse" adv|worse|||"Somewhat worse" "Much worse" "Chest pain worse" vp|worsening|||"ECG worsening" adj|worst|||"10 = Worst Imaginable Pain" vp|written|||"Written material" n|xenon|xenon||"Xenon CT"