Say What? 10 Nurse Acronyms Every New Grad Nurse Should Know

12/03/2018

nurse acronyms new grad nurses should know

By Alana Luna, Contributor

In the hectic environment of a busy hospital, nurse acronyms save time while ensuring every patient still gets proper care. Learning how to communicate on the fly is a fundamental part of being a nurse. Here are 10 important acronyms every new nurse should know.

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10 essential nurse acronyms all new nurses should use

1. Altered level of consciousness (ALOC)

When a doctor or nurse judges a patient’s level of consciousness or awareness as anything other than normal, that patient is said to be “altered.” ALOC isn’t a final diagnosis but rather a fluid state. A patient may be simply confused one moment and subsequently devolve into a lower level of consciousness or, hopefully, improve to become more alert. Rechecks are crucial, with caregivers assessing at-risk patients for the different levels of ALOC:

  • Lethargic
  • Somnolent
  • Stupor
  • Coma
  • Confusion
  • Delirium

2. Medication administration record (MAR)

MAR and its sister term TAR (treatment administration record) are commonly used when recording or referring to documentation. Medical administration records are comprehensive files that may include everything from treatments and labs to advanced directives. Though the exact format may differ from facility to facility, all MARs include the patient's name plus the name, dosage, frequency and method of medication.

3. At liberty (ad lib)

At liberty and ad lib come from the Latin phrase “ad libitum” meaning “at one’s please” or “as desired.” In the healthcare industry, ad lib is used to signify that a patient can eat, exercise or drink water as much as they want. While this abbreviation is often a simple indication that there’s no reason for a restriction, it also gives patients a modicum of control in an otherwise strict setting —something one study suggests could lead to increased health.

4. Temperature, pulse, respiration (TPR)

Vital signs are the foundation of a thorough medical examination, but in a professional setting, you’re more likely to see temperature, pulse and respiration rates documented as TPR. Think of TPR as a snapshot of a patient’s health; if the numbers are good, the patient is almost guaranteed to be stable, but if the numbers are off, that’s an indication that further assessment is needed ASAP.

5. Subjective, objective, assessment, plan (SOAP)

Standardized documentation benefits patients and makes life easier for nurses who can’t afford to miss a single detail. SOAP notes are another nurse acronym that saves times and prevents mistakes by organizing information using a widely agreed-upon framework. Every SOAP note includes four main headers: Subjective, Objective, Assessment and Plan. Nurses who understand how to write and read SOAPs are in a better position to advocate for patients and effectively perform their jobs.

6. Nothing by mouth (NPO)

Patients with certain medical conditions or who need to fast before testing or surgery may be designated as NPO, meaning they are to get nothing by mouth. While the “no food or water after midnight” rule is not as black and white as it used to be, most healthcare institutions still use NPO and expect nurses to closely follow and enforce the restriction.

7. Health Insurance Portability and Accountability Act (HIPAA)

Anyone who has seen a medical drama on TV has heard the nurse acronym HIPAA thrown around more than once, but not everyone realizes what the Health Insurance Portability and Accountability Act does for patients. In addition to confidentiality, HIPAA protects Americans from healthcare fraud and abuse, ensures workers can transfer or continue their insurance coverage if they lose or change their job and outlines expectations for the use and safeguarding of personal healthcare information.

8. Activities of daily living (ADL)

Activities of daily living are those basic functions like using the bathroom, getting dressed and eating that every patient needs to do. Patients who can’t perform those activities independently may require ongoing assistance. These tasks seem simple, but knowing whether an aging patient can still care for themselves could mean the difference between self-directed long-term home care and placement in an assisted living facility or nursing home.

9. Pupils equal, round, and reactive to light and accommodation (PERRLA)

Every second counts in healthcare. A few minutes may not seem like a lot of time, but every moment wasted on overly long explanations could lead to overcrowding and needlessly taxed resources. Acronyms like PERRLA are a fast, effective way for physicians to remember how to assess for conditions such as glaucoma and neurological disease and then convey satisfactory findings to their colleagues.

10. Advanced healthcare directive (AHCD)

Nearly one-fourth of all deaths in the United States happen in a long-term care setting, and that figure is on the rise. People are living longer, and many reach old age despite suffering from chronic illness. For all those reasons and more, advanced healthcare directives are becoming more important, not just for the elderly or infirm but for anyone who wants to know their wishes will be understood and respected. AHCDs basically serve as an instruction manual, outlining who has power of attorney, whether or not artificially provided fluids and nutrition are permissible, what happens in the case of brain death or coma, what comfort care measures are allowed and whether the individual assents to cardiopulmonary resuscitation (CPR) or life support measures.

Finding the right nursing job is important, but once you’re hired, all that matters is your on-the-job performance. Knowing the top nurse acronyms helps you show competency in front of colleagues, facilitates quick and professional communication and allows you to capably document your patient’s status so they’re always receiving the very highest standard of care.

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