Wednesday, June 8, 2011

Error prone abbreviations

http://www.ismp.org/Tools/errorproneabbreviations.pdf

UNAR's 2011 Diseases and Conditions

DISEASES & CONDITIONS

1.      AIDS
a.      Definition:  Acquired Immune Deficiency Syndrome. The last and most severe stage of the HIV infection. Transmitted through blood, semen, breast milk and vaginal secretions. Inability of body to fight off infections and disease.
b.      S & S: Flu-like symptoms in early period.  Positive HIV antibody formation usually within 3 months. Then become asymptomatic carriers for years.
c.      Care & Tx:  Universal precautions, psychological support, and treat symptoms.

2.      ALZHEIMERS
a.      Definition: Progressive condition that affects the brain. Slowly affects memory, intelligence, judgment, language and behavior.  Most common form is Dementia.
b.      S & S: Progressive, irreversible loss of memory and deterioration of intellect, speech, and gait.  Sun downing can also occur.
c.      Care & Tx: Assist with ADL’s allowing as much independence as possible. Validation therapy. Use a calm, slow voice

3.      ANEMIA
a.      Definition: A reduction in the number of circulating RBC’s.
b.      S & S: Dizzy, fatigue, pallor, weakness, headaches, and GI disturbances.
c.      Care & Tx:  Get up slowly, dangle before ambulating or transferring.

4.      ANXIETY
a.      Definition: A sudden feeling of panic, fear & apprehension.
b.      S & S: SOB, hyperventilation, pounding heart, feeling of losing control or dying.
c.      Care & Tx:  Stay calm and identify/control stressor.

5.      ARTHRITIS (OSTEOARTHRITS)
a.      Definition: Inflammation of the joints. Osteoarthritis is the most common type and mainly affects the hips, knees, hands, and back. Normal consequence of aging.
b.      S & S: Stiffness, pain, swelling, tenderness to joints, decreased mobility and ROM. Everyday movements can hurt.
c.      Care & Tx: Activity/exercise (ROM) with rest periods as needed.  Correct body alignment and supportive devices.

6.      AMPUTATION
a.      Definition: Removal, usually through surgery, of a body part.
b.      S & S: Stump or loss of body part.
c.      Care & Tx: Use of a prosthesis (artificial body part).  ROM and strengthening exercises. 
7.      ANGINA PECTORIS
a.      Definition: Intense pain in the chest due to lack of oxygen to the heart.
b.      S & S:  Pain in chest, SOB and anxiety.
c.      Care & Tx:  Stay with person, call for nurse- this is an emergency life threatening condition.

8.      APHASIA
a.      Definition: Inability to speak, speak clearly, or comprehend speech.  Often follows a stroke.
b.      S & S: Communication barriers with speech.
c.      Care & Tx:  Find and use alternative communication devices.

9.      ASTHMA
a.      Definition:  A chronic condition in the lungs where airways narrow making it difficult to breath.  Can be caused by allergens, stress, or activity/exercise.
b.      S & S:  Wheezing, coughing, SOB, dyspnea and cyanosis.
c.      Care & Tx:  Report to the nurse immediately- this can be life threatening.

10. BED SORE (DECUBITUS ULCER/DQ OR PRESSURE SORE)
a.      Definition:  A serious skin wound from having pressure on one part of the body for too long. Typically over body prominences. This causes death to the tissue from lack of blood supply.
b.      S & S:  Pale skin or reddened area. There are 4 stages beginning with change in color to the skin and progressing to cracks, blisters, underlying tissue exposure, and finally muscle and bone exposure.
c.      Care & Tx:  Prevention through good skin care, repositioning at least every 2 hours, proper positioning, not massaging reddened areas, use of protective devices, good nutrition and hydration, and reporting any signs immediately.

11. BIPOLAR DISORDER (MANIC DEPRESSION)
a.      Definition: A mental health disorder with both manic and depressive episodes.
b.      S & S:  Severe extreme moods, energy and ability to function.
c.      Care & Tx:  Stay calm and supportive.  Report safety issues immediately.

12. BRONCHITIS
a.      Definition:  Inflammation of the bronchi related to an infectious agent or chronic damage to bronchi from smoking or chemical agents.
b.      S & S: Dyspnea and cough.
c.      Care & Tx:  Stop smoking and frequent rest periods as needed.




13. CANCER
a.      Definition: Uncontrolled growth of cells.  Malignant (cancerous) tumors are fast growing, invade surrounding tissue and are life-threatening.  Benign tumors are slow growing, local, and can be treated. 
b.      S & S:  Warning signs are as followed: (CAUTION)
                                                              i.      C  = Change in bowel or bladder habits
                                                            ii.      A  = A sore that does not heal
                                                          iii.      U  = Unusual bleeding or discharge
                                                          iv.      T  = Thickening or lump
                                                            v.       I   = Indigestion or difficulty swallowing
                                                          vi.      O = Obvious change in wart/moles
                                                        vii.      N = Nagging cough or hoarseness
c.      Care & Tx: Chemotherapy, radiation and surgery.  Provide emotional support and physical care as needed. Comfort care and good communication.

14. CATARACT
a.      Definition: Lens of the eye becomes cloudy.
b.      S & S:  Gradual loss of vision.
c.      Care & Tx:  Surgery.

15. CEREBRAL PALSY (CP)
a.      Definition:  Brain damage to cerebrum caused congenitally, at birth or as an infant.
b.      S & S: Partial to full paralysis, lack of muscle coordination and mental disabilities.  Degree of disability varies with each person.
c.      Care & Tx:  Provide assistance as needed and maintain safety.

16. CONGESTIVE HEART FAILURE (CHF)
a.      Definition:  Inability of heart to pump a sufficient amount of blood through the body.
b.      S & S:  Edema, dyspnea. SOB, fatigue and weakness.  Varies on which side of heart is affected.
c.      Care & Tx: Low sodium diet, monitor weight, I & O, O2 therapy, Fowler’s positioning for breathing and anti-embolic stockings.

17. CORONARY ARTERY DISEASE
a.      Definition:  Buildup of plaque in the walls of the arteries causing narrowing and decrease blood supply to the heart muscles.  Can lead to a heart attack where the heart muscle does not receive enough oxygen and parts of the heart muscle die.
b.      S & S:  Angina pectoris, SOB and dyspnea.
c.      Care & Tx:  Control risk factors:  Stop smoking, exercise, healthy diet and decrease stress.

18. CHRONIC ONSTRUCTIVE PULMONARY DISORDER (COPD)
a.      Definition:  A term for a group of respiratory disease that are characterized by airway obstruction/limitation.  Includes: chronic bronchitis, emphysema, and asthma.
b.      S & S:  Dyspnea, wheezing, SOB, chronic cough and fatigue.
c.      Care & Tx: No smoking, O2 therapy, Fowler’s position for breathing and frequent rest periods.

19. CYSTITIS
a.      Definition: Inflammation of the bladder, often called a bladder infection.
b.      S & S:  Burning, difficulty urinating, may be bloody
c.      Care & Tx:  Must see a physician-may become a kidney infection if not treated

20. DEPRESSION
a.       Definition:  A state of sadness that has advanced to a point of disrupting a person’s ability to perform daily functions.  Is common in the elderly population and in the grieving process.
b.      S & S:  Extreme sadness, lack of energy & interest in ADL’s, withdrawal from people and interests, and thoughts of death/suicide.
c.      Care & Tx:  Stay calm and supportive.  Report safety issues immediately.

21. DIABETES MELLITUS
a.      Definition:  A condition where the pancreas does not produce enough insulin.  Insulin is needed for sugar use in the body. 
b.      S & S:  Polyuria, polydipsia, polyphagia, weakness, sweating, headache, dizzy, change in vision, change in respirations, and faintness.
c.      Care & Tx:  Proper diet (ADA/LCS), good foot care (inspect and careful handling), report changes immediately to nurse.

22. DOWN SYNDROME
a.      Definition:  A congenital disorder, caused by the presence of an extra chromosome. Causes moderate to severe mental retardation.
b.      S &S:  Various physical symptoms: flattened face, large tongue and short stature.
c.      Care & Tx:  Assist in ADL’s as needed.  Well balanced diet and exercise.

23. DYSPHAGIA
a.      Definition:  Difficult swallowing.  High risk for aspiration.
b.      S & S: Complaints that food will not go down and frequent coughing or choking with swallowing.
c.      Care & Tx:  Food thickness adjusted to meet person’s needs.  Aspiration precautions and proper positioning.  Follow care plan for feeding.

24. ENLARGED PROSTATE (BPH- Benign prostatic hypertrophy)
a.      Definition:  A condition commonly seen in males over 50.  It is a progressive condition that can lead to obstruction of the urethra. 
b.      S &S:  Change or difficulty in urination and sexual function. 
c.      Care & Tx:  Different medical and surgical treatments can be done to decrease the size of the prostate.  Report any changes in urination pattern to nurse.

25. EPILESPSY
a.      Definition:  A condition of the brain that causes a person to have seizures. 
b.      S & S: Reoccurring seizures (Involuntary muscle contractions / convulsions).
c.      Care & Tx:  Protect person from injury.  Do not restrain movement or place anything in the mouth.  Stay with person throughout seizure.

26. EMPHYSEMA
a.      Definition:  A chronic lung condition where the alveoli become enlarged and less elastic.  Often caused by exposure to toxic chemicals or long term exposure to tobacco smoke. 
b.      S & S:  Cough, SOB at rest, and barrel chest appearance.
c.      Care & Tx:  Stop smoking, O2 therapy, frequent rest periods, and position in Fowler’s position to assist in breathing.

27. FIBROMYALGIA
a.      Definition:  Chronic pain in muscles, soft tissue, and surrounding joints. 
b.      S &S:  Decrease in ability to perform ADL’s related to severity of pain.
c.      Care & Tx:  Use caution and be gentle when assisting.  ROM as ordered.

28. FRACTURE
a.      Definition:  A broken bone.  Hip fractures are commonly related to osteoporosis and the aging process. 
b.      S & S:  Pain, tenderness, swelling, loss of function, a pop or grating sound.  Complications can include: blood clots and permanent deformity and inability to use limb.
c.      Care & Tx:  Do not move person and get nurse right away.  Surgery, traction, casts, and splints may be used.  Follow person’s care plan.

29. GLAUCOMA
a.      Definition:  A condition where pressure in the eye increases and damages the optic nerve.
b.      S & S:  Loss of peripheral vision resulting in tunnel vision, blurred vision, and halos around lights.  May cause blindness.
c.      Care & Tx: Be aware of person’s needs related to vision loss.  Surgery and medication are possible treatments to prevent further damage.

30. HEART ATTACK (MYOCARDIAL INFARCTION)
a.      Definition:  Lack of blood flow to the heart resulting in death to part of the heart muscle.  Typically related to a blockage in the coronary arteries.
b.      S & S:  Sudden severe chest pain that may radiate to the arm, neck or jaw.  Dyspnea, nausea, sweating, cold clammy skin, and a feeling of doom.
c.      Care & Tx:  Immediate treatment required- this is a life threatening condition.

31. HEPATITIS
a.      Definition:  Inflammation of the liver. Hepatitis A is transmitted through the fecal oral route.  Hepatitis B & C are transmitted by blood and body fluid contact.
b.      S & S:  Jaundice (yellow skin and whites of eye coloring), enlarged liver, and flu like symptoms in the acute phase.
c.      Care & Tx:  Universal precautions should prevent transmission. 

32. HYPOTHYROIDISM & HYPERTHYROIDISM
a.      Definition:  A lack of or too much thyroid hormone.  This hormone control the metabolic (energy) functioning of the body.
b.      S & S: Change in metabolic functioning.
c.      Care & Tx:  Plan care according to person’s energy levels.

33. KIDNEY FAILURE
a.      Definition:  Diminished function of the kidney.  May lead to complete loss of kidney function.
b.      S & S:  Oliguria, edema, change in BP & fatigue.
c.      Care & TX; Dialysis: artificial kidney device.  Dietary modifications, I & O, daily weights and anti- embolitic socks.

34. KIDNEY STONES (RENAL CALCULI)
a.      Definition:  Stones that form in the urinary system.
b.      S & S:  Dysuria, hematuria, changes in urinary pattern, nausea, fever and chills.
c.      Care & Tx:  Increase fluid intake, monitor urine output, and stain urine as directed.  Some people may have surgery to assist in removing or breaking up stones.

35. MULTIPLE SCLEROSIS (MS)
a.      Definition:  A chronic disease where the myelin (covering) of the brain and spinal cord are destroyed causing the nerve impulses to not function in the normal manner.  Muscle control, strength, vision, balance, sensation, and mental functions can be affected. 
b.      S & S:  Depend upon the area that is damaged.  A person may have vision problems, muscle weakness, paralysis, tremors, poor coordination, and problems with concentration and behavior.
c.      Care & Tx:  Prevent complications from decreased mobility.  ROM, good skin care and positioning for comfort.  Allow as much self- care as possible.






36. OBSESSIVE COMPULSIVE DISORDER (OCD)
a.      Definition:  An anxiety disorder that causes a person to perform behaviors or mental acts in repetition.
b.      S & S:  Performing a ritual over and over.
c.      Care & Tx:  Monitor safety for person and meet the person’s needs as defined in the care plan.

37. OSTEOPOROSIS   
a.      Definition: A condition where the bones become porous, brittle, and weak. Bones are fragile and can break very easily.  Very common in older people.
b.      S & S:  Back pain, decrease in height, and a stooped posture.
c.      Care & Tx:  Prevention through having a diet rich in calcium and vitamin D, weight- bearing exercise, and avoiding  smoking and alcohol.  Protect people from falls and reposition gently.

38. PANIC DISORDER
a.      Definition:   A condition where an intense and sudden feeling of fear or dread happen suddenly without an obvious reason.  The highest level of anxiety.
b.      S & S:  Fear, anxiety, terror, or dread for no obvious reason.
c.      Care & Tx:  Stay calm and allow person to verbalize needs. Keep safe and report needs or concerns.

39. PARKINSON’S
a.      Definition:  A slow progressive degeneration of the brain that has no cure. 
b.      S & S:  Tremors, rigidity, slow shuffling gait, stooped posture, poor balance, mask-like expression and pill-rolling.
c.      Care & Tx:  Safety measures to prevent injuries. Assist in ADL’s as needed.

40.  PEDICULOSIS
a.      Definition:  a condition of having lice.
b.      S & S:  Itching, scratching, may see small dark spots at end of hair. May fly
c.      Care & Tx:  Medication, washing of all clothing, bedding in hot, hot water.

41. PERIPHERAL VASCULAR DISEASE
a.      Definition:  Inadequate circulation to the extremities.
b.      S & S:  Lower legs and hands cold and cyanotic.  Chronic edema.  Numbness and tingling in extremities. 
c.      Care & Tx:  Provide active ROM.  Perform good skin care and inspect extremities carefully. 

42. PNEUMONIA
a.      Definition:  Infection or inflammation of the lungs. 
b.      S & S:  High fever, chills, pain in chest, cough with sputum.
c.      Care & Tx:  Antibiotics, rest, and fluids.  The very young and old are at high risk for death if not treated quickly with the correct antibiotics.



43. REFLUX DISEASE
a.      Definition:  A condition where gastric contents reflux (backflow) into the esophagus.
b.      S & S:  Heartburn, difficulty swallowing, indigestion, and stomach pain.
c.      Care & Tx:  High-fowlers position for meals. Report symptoms to nurse.

44. RHEUMATOID ARTHRITIS
a.      Definition:  An inflammatory disease that cause joint pain, swelling, and stiffness. 
b.      S & S:  Joints are tender, warm, and swollen.  Limited ROM in affected joint.  Symptoms may come and go.
c.      Care & Tx:  Relieve pain, proper positioning, and the use of self-help devices as needed.

45. SCHIZOPHRENIA
a.      Definition:  A severe chronic brain disorder where severe mental impairment (psychosis) occurs. 
b.      S & S:  Delusions, hallucinations, paranoia, lack of motivation and communication disturbances.
c.       Care & Tx:  Stay calm and allow person to verbalize needs. Keep safe and report needs or concerns.

46. SEIZURE
a.      Definition:  A temporary interference with muscle control, movement, speech, vision or awareness. Also called convulsions.
b.      S & S:  May stare in space, may have jerky movements, eyes may roll back in head, followed by a period of disorientation and possible loss of consciousness
c.      Care & Tx:  Help person to the floor, move furniture out of the way, protect person’s head by placing a pillow or blanket under the head, do not place anything in their mouth, provide warm and quiet environment after seizure.
47.   SHOCK
a.      Definition: A condition when the circulatory system is unable to get enough blood to the vital organs.  This can occur even with a mild injury. Shock is life-threatening.
b.      S & S:  Rapid weak pulse, low BP, rapid respirations, restless, confused and pale cold skin.
c.      Care & Tx:  Have the person lie down and elevate legs (Trendelenburg) unless they have an injury to their back or legs, keep the person warm and comfortable, call for help, stay calm and monitor for changes in signs of life.

48. STROKE (CEREBRAL VASCULAR ACCIDENT or  CVA)
a.      Definition:  A condition when the blood vessels that supply blood to the brain rupture or become blocked and the brain cells in that area of the brain die.  Functions controlled by that area of the brain can be lost or impaired.
b.      S & S: Hemiplegia, dysphagia, slow slurred speech, and aphasia.
c.      Care & Tx: Assist with ADL’s, aspiration precautions at all times, dysphagia diet as ordered, transfer to strong side, dress weak side first, undress strong side first, establish a communication method, and assistive devices as needed for rehabilitation.



49. SUNDOWNING
a.      Definition:  A state of increased agitation, confusion, anxiety and negative behavior that develops during the hours of darkness.  Often seen in a person with Alzheimer’s. 
b.      S & S:   An increase in above behaviors after the sun goes down that may continue through the night.
c.      Care & Tx:  Assure that the person’s basic ADL’s have been met (hunger, hygiene, bowel and bladder care), assess for safety needs, and stay calm and supportive.

50. SEXUALLY TRANSMITTED INFECTIONS (STI)
a.      Definition:  A group of diseases spread through oral, vaginal, and anal sexual transmission. 
b.      S & S:  Vary, related to the organism causing the disease.  Can range from asymptomatic to sores, discharge, pain with urination and intercourse, pain in the genital area, itching, and swelling.  Long term complications and serious health problems may result if left untreated.
c.      Care & Tx:  Maintain standard universal precautions when in contact with blood or body fluids.   Report any unusual appearance or behavior.

51. TRANSIENT ISCHEMIC ATTACK (TIA)
a.      Definition:  Temporary lack of blood flow to the brain.  A warning sign of stoke often called “mini-stokes”.
b.      S & S: Hemiplegia, dysphagia, slow slurred speech, and aphasia that are brief and resolve.
c.      Care & Tx:  Report to nurse any brief symptoms and stay with person to maintain safety.

52. TUBERCULOSIS (TB)
a.      Definition:  A communicable bacterial infection that primarily affects the lungs.  TB is extremely contagious and is spread through airborne droplets from coughing, sneezing, & speaking. 
b.      S & S: Chronic cough, night sweats, fatigue, weight loss and fever.
c.      Care & Tx:  Airborne precautions and isolation are practiced.  Rest and antibiotics are needed with good nutrition and hydration.

53. URINARY INCONTINENCE
a.      Definition:  Loss of bladder control that results in the release of urine. May be temporary or permanent.
b.      S & S:  Inability to hold urine
c.      Care & Tx:  Good skin care, watch patient for falling, incontinence pads, bed protectors, condom catheters, bladder training (exercises), surgery,


54. WHOOPING COUGH (PERTUSSIS)
a.      Definition:  Highly contagious bacterial infection of the upper respiratory system.
b.      S & S:  Begins like a common cold and progresses to a frequent violent cough that is characterized by a whooping sound. 
c.      Care & Tx:  Assist in basic care as needed.  Airborne precautions needed.



June 1, 2011