What is the purpose of nursing terminologies?

Nursing has its own language, including unique terminology and classifications that facilitate the efficient delivery of high-quality health care. It’s important that advanced practice nurses have an acute understanding of the standardized nursing terminology lists and classification systems, as this knowledge can potentially establish the line that separates an efficient health care organization from an inefficient one.

A Look at Terminology and Classification

Building a vocabulary of nursing terminology is important because it establishes a shorthand form of communication that can efficiently communicate key information about patient data and the regulations that govern the nursing profession. This efficiency can make it easier for nurse administrators and other advanced practice nurses to convey detailed care strategies to staff members and providers, ultimately leading to better patient outcomes.

The use of classification systems to effectively track care and administrative activities is also a crucial component of quality care delivery. Systematic categorizations can make it easy for staff members and health care providers to obtain broad yet fundamental metrics on a patient — data that is often essential in establishing and executing health care strategies. As technology and tech-driven data delivery become even more integrated in health care, it is increasingly important for nurses to leverage these systems.

Because nursing terminology and classification systems are so critical to health care delivery, students pursuing advanced nursing degrees, such as a Doctor of Nursing Practice, will often enroll in courses that cover the fundamentals of both topics. Common areas of concentration for DNP students include nurse education, health policy, health informatics, and nursing leadership.

The Purpose of Terminology and Classification

Ideally, nursing terminology lists and classification systems work concurrently to enable nursing professionals to deliver care. Health care professionals can deploy both to dispense various elements of patient data to other providers accurately and efficiently. Such elements can relate to diagnoses, but they can also pertain to a patient’s medical history, current medications, medical coverage, and other key information. These resources can prove to be crucial for nurses as they work with other health care professionals to build comprehensive short-term and long-term care strategies. The standardization of such data can further minimize the chance of misinterpreted information.

The Two Types of Terminology Systems

There are two main standard terminology systems in nursing: enumerative and combinatorial. An enumerative system organizes a strictly controlled list of universal terms and phrases to provide generalized data on a patient. In an enumerative list of diagnoses, for example, each entry would likely include a conceptual label, an informal definition, common associative traits, and risk factors. This could be effective in establishing the building blocks of a health care strategy.

A combinatorial system parses broader terms and phrases, with word-by-word breakdowns. These breakdowns can allow nurses to add unique details to a patient’s data and establish more complex, intricate care strategies.

Benefits of Terminology Lists and Classification Systems

Nurses who are well-versed in these lists and systems can obtain and interpret systematic data from an electronic health record (EHR), for example, without needing clarification from an external source. This efficiency can lead to other benefits, such as improved immediate care delivery and an optimized ability to create effective long-term care strategies.

While there are numerous benefits to this system, there are a few potential drawbacks. For example, the restrictiveness inherent in enumerative systems can make it challenging for nurses and physicians to build detailed strategies tailored to a specific patient. Conversely, the potentially large and widespread data associated with combinatorial systems may make utilizing the process much more time-consuming, which may hinder an organization’s efficiency.

Emerging Systems

Because of the potential challenges that enumerative and combinatorial systems entail, alternatives have emerged to help nurses administer care. A formal terminology system, for example, is a computer-based method that analyzes a patient’s situational metrics and determines if a generalized system or an intricate one should be used. The added flexibility that this process provides could further improve a facility’s caregiving efficiency.

Regardless of what nursing terminology list or classification system is utilized, they all provide fundamental tools that can improve clinical operations significantly. As a result, facilities can more easily reach the ultimate goal of providing their patients with the highest level of care possible. Learn more about how Regis College’s programs for advanced practice nurses can prepare you to utilize nursing terminology and classification systems to their fullest potential.

Recommended Readings:
Top Reasons to Get Your DNP Degree
What Can I Do with a Doctor of Nursing Practice (DNP)
How a Doctor of Nursing Practice Degree Can Lead to Better Patient Outcomes

Sources
HIMSS, “Exemplars for Advancing Standardized Terminology in Nursing to Achieve Sharable, Comparable Quality Data Based Upon Evidence”
NCBI, “Understanding the Use of Standardized Nursing Terminology and Classification Systems in Published Research: A Case Study Using the International Classification for Nursing Practice”
The Office of the National Coordinator for Health Information Technology, Standard Nursing Terminologies: A Landscape Analysis
The Online Journal of Issues in Nursing, “Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes – SURVEY II: Participants’ Education for the Use of Standardized Nursing Terminology “Labels”
The Online Journal of Issues in Nursing, “Nursing Nomenclature and Classification System Development”
The Online Journal of Issues in Nursing, “Standardized Nursing Language: What Does It Mean for Nursing Practice?”
Regis College, Doctor of Nursing Practice: MSN to DNP
Science Direct, “Formal Nursing Terminology Systems: A Means to an End”

You have your sights set on nursing school, but you’re concerned you won’t be able to keep up with all the need-to-know nursing terms. Even years of watching TV medical dramas isn’t making you feel more confident in your knowledge of medical vocabulary. Every career field has its own lingo that can sound like complete nonsense to the uninitiated, and the nursing field is certainly not the exception.

There’s enough to think about before starting your first day of nursing school—even without mysterious jargon to worry about! Keep this cheat sheet of the most common nursing terms handy as you study, and you’ll never again be lost in a blur of meaningless acronyms and confusing medical terms.

62 Common nursing terms you should know

General nursing terms

1. Blood pressure (BP): Blood pressure measures the amount of force placed on a patient’s artery walls with each heartbeat. This is one of the standard vital signs nurses monitor for patients.
2. Charge nurse: A supervisory nurse who oversees other nurses in a particular hospital department.
3. Chart: The medical documentation that follows a patient throughout a healthcare facility. It includes medical history, diagnoses, test results, dosage and timing of medications, and other relevant information.
4. Charting: The process of adding to a patient’s chart to keep it up to date and accurate. Nurses often use medical acronyms and abbreviations in their chartings.
5. Clinicals: The portion of nursing education where student nurses work with patients in a healthcare setting, under supervision from nurses and physicians, to practice their technical skills and gain experiences.
6. Code blue: A medical emergency, often cardiac arrest, that requires immediate attention from a team of healthcare providers. Healthcare workers may shorten code blue to “coding.”
7. Heart rate: The number of heartbeats a patient has per minute.
8. NCLEX: Refers to the nursing exam one must pass to become either a licensed practical nurse (LPN) or a registered nurse (RN).
9. Pain scale: A numeric scale from one to ten that patients use to rate their level of pain. Some healthcare facilities use visual cues like faces to help patients rate their pain levels.
10. Respiratory rate: The number of breaths a patient takes per minute.
11. Specimen: A sample of something from a patient’s body, such as urine, blood, skin or other tissue, that is taken for testing and analysis.
12. Vital signs: Basic indicators of a patient’s health that typically includes heart rate, respiratory rate, body temperature, pain level and blood pressure.

Terms for nursing specialties

1. Cardiac nursing: A nursing specialty centered around the cardiovascular system (the heart and blood circulation system).
2. Dialysis nursing: A nursing specialty that focuses on patients who have kidney disease, are experiencing kidney failure or are undergoing dialysis treatments.
3. Home health nursing: Nurses who visit patients in their own homes to provide care.
4. ICU nurse: Nurses who work in the intensive care unit (ICU), typically caring for just one or two patients with severe injuries or ailments at a time.
5. Nurse anesthetist: Nurse anesthetists who administer anesthesia and pain management medication to patients. This role requires specialized advanced training.
6. Nursing informatics: Nursing informatics who combine practical nursing skills with data analysis and technology to improve patient safety.
7. Oncology nursing:Nurses who care for cancer patients and those being screened for cancer diagnoses.
8. Radiology nursing: Nurses who care for patients who are undergoing diagnostic imaging, such as CT scans, X-rays and ultrasounds.

Nursing acronyms

1. ABC: This is the simple way to remember “airway, breathing, circulation,” which is the order in which nurses assess and prioritize a patient who is unresponsive or unconscious.
2. CAB: Following the CAB acronym helps nurses remember “chest compressions, airway and breathing” as the correct order for performing CPR.
3. CBR: Seeing this on a patient’s chart means “complete bed rest” and refers to a patient who is not allowed out of bed at all, even to use the bathroom.
4. CPR: Cardiopulmonary resuscitation is an emergency procedure commonly used when a patient has stopped breathing.
5. DNR: Do Not Resuscitate is an end-of-life health directive given by patients who do not wish to be revived if they stop breathing or go into cardiac arrest.
6. EHR: Electronic health records (sometimes called electronic medical records, or EMR) are digital medical records that are updated each time a patient visits a healthcare facility.
7. ICU: Intensive care unit.
8. IV: Intravenous therapy.
9. L&D: Labor and delivery.
10. NICU: Neonatal intensive care unit, where critically ill newborns are cared for.
11. OTC: Medication that does not require a prescription (over the counter).
12. PPE: Specialized gear and clothing, such as gloves, masks and face shields, designed to protect both patients and nurses from bacteria and contagious illness (personal protective equipment).
13. Rx: Prescription.
14. SOP: Standard operating procedures, which describe how nursing tasks are to be performed and the outcome that should be achieved.
15. WNL: This charting acronym stands for “within normal limit.” This means a patient’s activity level, test results and so on are considered typical.

Nursing designations and degrees

1. ADN: Associate’s Degree in Nursing.
2. APRN: This stands for “advanced practice registered nurse” and refers to nurses who have completed a specialized graduate degree program. In addition to the usual duties of an RN, they can also diagnose and treat patients and choose to practice certain specialties, such as nurse anesthetist.
3. BSN: Bachelor of Science in Nursing.
4. CNA: Certified nursing assistants are not technically nurses, but they do help patients with basic tasks, like bathing and dressing. They may also take vital signs.
5. LPN: Stands for licensed practical nurses. They have a narrower scope of practice than registered nurses but are tasked with a wide variety of nursing duties, such as changing bandages, administering medication, monitoring vital signs and inserting catheters.
6. MSN: Master of Science in Nursing.
7. RN: This acronym stands for “registered nurse” and refers to a nurse who has passed the NCLEX-RN exam and is fully licensed in their state.

Common medical tests and procedures

1. Basic metabolic panel: Sometimes shortened to BMP, this refers to a routine blood test that measures basic body functions, like kidney effectiveness and sugar levels.
2. CT scan: An imaging procedure that uses X-rays and computer technology to produce highly detailed images.
3. EKG: A test that checks for signs of heart disease (electrocardiogram).
4. IV therapy: An IV is used to deliver fluid, such as medication or rehydration fluids, directly into a patient’s veins.
5. Saline lock: A medical procedure in which an IV catheter is placed in a patient’s vein, then flushed with saline solution and “locked” without additional fluids or medications. Saline locks make it easy for nurses to quickly administer IV medications during a patient’s hospital stay.
6. Spinal tap: Also called a lumbar puncture, this is a procedure that uses a needle to remove fluid from a patient’s spinal column for diagnostic purposes.
7. Ultrasound: An imaging procedure that uses high-frequency sound waves.
8. Urinalysis: A common urine test that can detect and diagnose a variety of illnesses, such as urinary tract infections, or access kidney function.
9. Vaccination: A minor medical procedure that reduces the risk of contracting and spreading contagious illnesses.
10. X-ray: An imaging procedure that uses electromagnetic waves, which is a type of radiation.

Nursing tools

1. Catheter: Any flexible, hollow tube used in medical procedures; most often refers to a tube used to drain urine from the bladder.
2. Pulse oximeter: A small device that clips to a patient’s finger or toe to measure the amount of oxygen in their blood. Nurses can often use a pulse oximeter to determine which patients need to take priority in an emergency department setting.
3. Sharps container: A hard plastic container used as a trash receptacle for any type of biomedical waste—anything that’s been used to puncture human skin—such as needles or IV catheters.
4. Stethoscope: An audio device that allows nurses to hear a patient’s pulse or take their blood pressure.
5. Tourniquet: A tight band used to control bleeding after an injury, surgery or other medical procedure.

Slang

1. Crash cart: A wheeled cart with all the medications and supplies necessary to save someone in cardiac arrest or experiencing other life-threatening emergencies.
2. Peds: Pronounced “peeds,” this term is short for “pediatric,” or anything related to children.
3. STAT: This term, short for the Latin statim, does in fact mean to do something urgently or immediately. However, you won’t hear it quite as often or as dramatically as TV dramas would have you believe.
4. Sundowning: This refers to an observed pattern that often occurs in dementia patients around evening, when the sun is going down. During this time of day, “sundowners” can become especially confused, irritated or delusional.
5. Tachy: Pronounced “tacky,” this term is slang for “tachycardia,” which means a patient has an increased heart rate.

Definitions to use in your nursing career

This handy list of nursing terms will help you stay in the know for nursing school and beyond. Now you have a basic understanding of common nursing vocabulary, but you’ll need more training than that to become a registered nurse! Choose the best education option for you by reading “How to Become an RN Fast: 3 Potential Paths to Pursue.”