What are some important abbreviations I should be familiar with?

[NursingBro]

What are some important abbreviations I should be familiar with as an LVN/LPN?

[amoLucia]

That entry of ST referred to SORE THROAT, like HA = headache. When I would question the writers, they usually become very defensive, like WHY hadn't I ever seen ST or HA???

I always would counter back to 'show me the textbook it's written in' and I would keep repeating it until I make my point. Eventually it would, but there's no convincing the writiers of some of the risks of misinformation.

I keep thinking back to that dx that I careplanned. That dx was even being communicated during report! When I finally saw the admissions nurse, she clarified it when I questioned her. But like 'oh, no big deal...'

I think about abbreviations that I use here on AN. I try to keep them to a minimum, and I realize that there are some that are probably unique to me. I really don't use textspeak because I'm computerily challenged (computerily pathetic per my sister!). But I am careful with official documents, and that's what counts and/or goes to court.

[eatmysoxRN, ASN, RN]

One abbreviation I've refrained from using for the most part is SOB, and that's only because I've experienced wrath of a family member who saw it written on a patients board and they were angry.

Patients are unfamiliar with abbreviations and they shouldn't be used around them. NPO is one I see written on boards all the time. I had no idea what that meant before I took a CNA class. It's confusing sometimes. C/d/I (clean/dry/intact) I see all the time and bsb (bedside bag). HA and CA... Headache I can see but abbreviating cancer to Ca makes me think of calcium.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

[anotherone, BSN, RN]

at work when i see one in notes (typed in emr at least) that i dont know in google it and its context that helps. i see the following very often :

ac(before meals)

hs(bed time)

prn(as needed)

npo(nothing by mouth)

tah (total abdominal hysterectomy)

crrt( continous renal replacement therapy)

hd (hemodialysis)

nc (nasal cannula)

hft (humidified fast tent)

mm (mist mask)

sob (short of breath)

doe (dyspnea on exertion)

hob (head of bed)

cdi (clean dry and intact)

i work in acute care and see the same ones over and over and based on the type of dr and pt i can usually tell what it is. your work place should have a list of approved ones. the other ones, search online or ask someone but i wouldnt use them unless facility approved

[psu_213, BSN, RN]

That entry of ST referred to SORE THROAT, like HA = headache. When I would question the writers, they usually become very defensive, like WHY hadn't I ever seen ST or HA???

At everywhere I worked, ST is the approved abbreviation for sinus tach. I'm not sure if it is approved for sore throat also, but I have never seen it.

[psu_213, BSN, RN]

One abbreviation I've refrained from using for the most part is SOB, and that's only because I've experienced wrath of a family member who saw it written on a patients board and they were angry.

Patients are unfamiliar with abbreviations and they shouldn't be used around them. NPO is one I see written on boards all the time. I had no idea what that meant before I took a CNA class. It's confusing sometimes. C/d/I (clean/dry/intact) I see all the time and bsb (bedside bag). HA and CA... Headache I can see but abbreviating cancer to Ca makes me think of calcium.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

I probably would not use SOB on the pt's white board or on something else (such as discharge instructions) that I am going to give to the pt. However, I use short of breath enough (often "denies SOB") in my charting that SOB becomes useful. I suppose if the pt requests their chart after the fact, they will see "SOB," but it is a very handy approved abbreviation.

As for NPO...patients will ask "can I have something to drink?" Some ER staff will say to the patient "no, you are NPO until you are seen by the doctor." I imagine that most patients have no clue what NPO means.

Also, I have never seen bsb. Is that like a foley bag?

[psu_213, BSN, RN]

One that I see frequently, especially in triage notes, that is not approved is TKR (or THR). I had a doctor ask me what that abbreviation meant (I was not the one who wrote it). It stands for 'total knee replacement' (the latter is 'total hip replacement'). Seems simple enough, but the abbreviation loses its effectiveness (and can become dangerous) when your fellow staff does not know what it stands for.

Also, usually "CSM" intact is the approved abbreviation for "circulation, sensation, movement" intact. This is used, for example, when talking about the fingers (i.e. brisk cap refill, still able to sense, still able to move) after a wrist injury. One triage nurse charted "PSM intact." A resident asked me what that stood for. My best guess was "pulse, sensation, movement" (?). I never did get a chance to ask the triage nurse what she meant with that.

[AngelfireRN, MSN, RN, APRN]

I remember clearly seeing one teenage patient lapse into sobs and ask if she was being punished. She asked if she behaved better, would we give her other things to eat? Poor baby, she was in with some stomach complaint and was on a BRAT diet. The dietary staff left the card on her tray with BRAT on it. She thought it was an assessment of her attitude.

Oddly, she acted better than some of my adult patients.

[amoLucia]

Had an upset daughter approach me, questioning why the staff was calling her Mom a CABG. After my explanation, she was OK, but how easy it is for us all to forget our 'workplace jargon' is NOT common language to all others.

[NursingBro]

COLD SOB.

chronic obstructive lung disease, shortness of breath

[HyperSaurus, RN, BSN]

LOL ( little old lady), FOS (full of ....).

Just kidding. We have a list of approved abbreviations for orders, but we also have abbreviations that we use for report and such.

Others we use include:

STD--spot the dot (our falls risk program--look for the yellow dot on the chart and door and look for the yellow falls risk wrist bands)

SOB--short of breath

HA--headache

ACHS--before meals and at hour of sleep

DWT--daily weight

SCDs--sequential teds

CA--cancer (half our unit is oncology, we get a lot of cancer patients)

NHP--nursing home placement

WA--while awake

Dssg--dressing

Cxr--chest x-ray

Bcx--blood culture

I usually write things out on the boards, "nothing by mouth," "up with assistance", and "falls risk" (could you imagine family reaction to STD on someone's board?)

[jpowell6024]

Get the app "mini nurse lite". When reading charts, I have that pulled up. It has a section that you can type in the letters and it will tell you what they mean. VERY helpful!