Inglês de Enfermagem Clínica: Vocabulário e Frases Essenciais

"head-to-toe assessment"

A systematic physical examination that proceeds from the patient's head downward through each body system to ensure no findings are missed

"The admitting nurse completed a head-to-toe assessment on arrival, documenting a 3 cm sacral pressure injury and bilateral ankle oedema not mentioned in the transfer notes."

"AVPU scale"

A rapid neurological assessment tool that classifies a patient's level of consciousness as Alert, responding to Voice, responding to Pain, or Unresponsive

"On re-assessment fifteen minutes after the fall, the patient had deteriorated from Alert to Voice on the AVPU scale, prompting an urgent medical review."

"baseline observations"

The initial set of vital signs and clinical measurements recorded on admission, against which subsequent changes are compared to detect deterioration

"Baseline observations documented a blood pressure of 162/94 mmHg and a heart rate of 102 beats per minute, which were communicated to the admitting physician."

"auscultate breath sounds"

To listen with a stethoscope to airflow through the lungs in order to detect abnormal sounds such as crackles, wheeze, or absent breath sounds indicating pathology

"The nurse auscultated breath sounds bilaterally and identified reduced air entry at the left base consistent with the patient's reported history of pleural effusion."

"capillary refill time"

The time taken for colour to return to a nail bed or fingertip after pressure is applied and released; normally less than two seconds; prolonged refill suggests poor peripheral perfusion

"Capillary refill time was four seconds in both hands, indicating compromised peripheral circulation, and the findings were included in the early warning score calculation."

"pain assessment tool"

A standardised instrument used to quantify and characterise a patient's pain, including numeric rating scales, the FACES scale for non-verbal patients, and the PQRST framework

"Using the PQRST pain assessment tool, the nurse established that the patient's abdominal pain was sharp, rated 8 out of 10, worsened by movement, and unrelieved by the prescribed analgesia."

"intake and output monitoring"

The precise measurement and recording of all fluids taken in by a patient — orally, intravenously, or enterally — and all fluids lost through urine, drainage, vomit, and other routes

"Strict intake and output monitoring over the preceding twelve hours revealed a fluid deficit of 800 mL, prompting an intravenous fluid bolus to support renal perfusion."

"clinical deterioration"

A worsening in a patient's physiological status that is detected through abnormal vital signs, altered consciousness, or declining organ function, requiring timely escalation

"The NEWS2 score of 7 indicated clinical deterioration; the nurse escalated immediately using the SBAR framework and a medical emergency team response was activated."

"five rights of medication administration"

The safety framework requiring nurses to verify the right patient, right drug, right dose, right route, and right time before administering any medication

"Applying the five rights of medication administration, the nurse identified a discrepancy between the prescribed dose of warfarin and the dose labelled on the dispensed blister pack."

"medication reconciliation"

The formal process of comparing a patient's current medication orders with all previously prescribed medications to identify and resolve discrepancies at transitions of care

"Medication reconciliation at admission revealed that the patient had continued taking clopidogrel at home despite its discontinuation prior to the planned surgical procedure."

"adverse drug reaction"

An unintended, harmful response to a medication administered at a standard therapeutic dose, which may range from mild side effects to life-threatening hypersensitivity reactions

"The patient developed an adverse drug reaction to penicillin consisting of urticaria and facial swelling; the drug was stopped and the allergy was prominently documented in all records."

"controlled drug administration"

The process of preparing, signing out, and giving a Schedule II or Schedule IV analgesic or sedative under dual-nurse verification as required by pharmacy regulations

"Controlled drug administration of morphine 5 mg required a second registered nurse to witness the drawn-up dose and co-sign the controlled drug register before administration."

"sliding scale insulin"

A dosing protocol that adjusts rapid-acting insulin doses based on a patient's current blood glucose reading, administered before meals or at set intervals

"Per the sliding scale insulin protocol, a blood glucose of 14 mmol/L required 4 units of actrapid, which was administered subcutaneously thirty minutes before breakfast."

"intravenous push"

The administration of a small volume of medication directly into an IV line over a specified time period, usually between thirty seconds and five minutes, to achieve a rapid therapeutic effect

"The nurse administered furosemide 40 mg as an intravenous push over two minutes and monitored urinary output hourly to assess the diuretic response."

"high-alert medication"

A drug that carries a heightened risk of causing significant patient harm when used in error, including concentrated electrolytes, anticoagulants, insulin, and chemotherapy agents

"Concentrated potassium chloride is classified as a high-alert medication and must never be stored on the ward; it is dispensed pre-diluted from pharmacy on a case-by-case basis."

"prn medication"

A drug prescribed to be given as needed rather than on a fixed schedule, administered by the nurse only when the patient meets the specified clinical criteria

"The nurse assessed the patient's pain as 6 out of 10 and administered the prn medication of oral morphine 5 mg, reassessing pain scores thirty minutes later to evaluate efficacy."

"peripheral intravenous cannula"

A short, flexible plastic tube inserted into a peripheral vein to provide intravenous access for drug administration, fluid replacement, or blood sampling; abbreviated PIVC

"The peripheral intravenous cannula in the right antecubital fossa was no longer patent; a new 18-gauge cannula was inserted in the left forearm and the old site dressed."

"central venous catheter"

A long catheter inserted into a large central vein such as the subclavian, internal jugular, or femoral vein, used for haemodynamic monitoring, vasopressor infusion, or total parenteral nutrition; abbreviated CVC

"Central venous catheter insertion was required for the administration of noradrenaline, as vasopressors must not be given through peripheral access due to the risk of tissue necrosis."

"infiltration"

The inadvertent administration of non-vesicant IV fluid or medication into the surrounding subcutaneous tissue due to catheter displacement, causing localised swelling, pain, and coolness

"The nurse detected infiltration at the cannula site when the patient reported burning pain; the infusion was stopped immediately and the arm elevated to reduce swelling."

"phlebitis"

Inflammation of the vein wall at or near an IV access site, presenting with redness, warmth, tenderness, and a palpable cord along the vessel, caused by chemical, mechanical, or bacterial irritation

"A Maddox score of 3 indicating phlebitis was recorded at the cannula site; the cannula was removed and resited, and a warm compress was applied to the affected vein."

"fluid bolus"

A rapid infusion of a defined volume of crystalloid or colloid fluid — typically 250 to 500 mL — given over fifteen to thirty minutes to restore intravascular volume and improve perfusion

"Following a fluid bolus of 500 mL of normal saline, the patient's mean arterial pressure improved from 58 to 72 mmHg and urine output increased to 0.6 mL/kg/hr."

"infusion pump programming"

The process of correctly setting infusion rate, volume to be infused, drug concentration, and dosing units on an electronic pump to ensure accurate drug delivery

"Infusion pump programming errors were identified in a root cause analysis following the incident; a mandatory drug library with pre-set concentration limits was subsequently implemented."

"catheter-associated bloodstream infection"

A healthcare-associated infection caused by micro-organisms entering the bloodstream through a central or peripheral vascular catheter; abbreviated CABSI or CLABSI

"The patient developed a fever and rigors on day five of CVC use; blood cultures drawn through the line and peripherally confirmed a catheter-associated bloodstream infection with Staphylococcus aureus."

"dressing change protocol"

The standardised procedure for replacing the transparent or gauze dressing at a vascular access site, including aseptic technique, site inspection, and documentation of insertion date

"In accordance with the dressing change protocol, the CVC dressing was replaced every seven days or immediately when soiled, using chlorhexidine skin preparation and a sterile technique."

"wound bed preparation"

A systematic approach to optimising the wound environment to promote healing, encompassing debridement of necrotic tissue, moisture balance management, and infection control

"Wound bed preparation using autolytic debridement with a hydrogel dressing reduced the area of sloughy tissue from 60% to 15% of the wound surface over three weeks."

"pressure injury staging"

The classification of pressure injuries from Stage 1 (non-blanchable erythema of intact skin) through Stage 4 (full-thickness tissue loss exposing bone, tendon, or muscle) plus unstageable and suspected deep tissue categories

"Pressure injury staging confirmed a Stage 3 wound over the right trochanter with visible subcutaneous fat but no exposed fascia; a silicone foam dressing and pressure-redistribution mattress were ordered."

"exudate management"

The assessment and control of wound fluid volume and viscosity through appropriate dressing selection to maintain a moist healing environment without maceration of surrounding skin

"High-volume exudate management required daily dressing changes with a superabsorbent pad and application of a skin barrier cream to protect the periwound area from maceration."

"surgical site infection"

An infection occurring within thirty days of a surgical procedure — or up to one year if an implant is present — classified as superficial incisional, deep incisional, or organ/space; abbreviated SSI

"A surgical site infection was suspected when the laparotomy wound became erythematous, warm, and produced purulent discharge on post-operative day four; wound swabs were sent and antibiotics commenced."

"wound debridement"

The removal of necrotic, devitalised, or infected tissue from a wound bed to promote granulation tissue formation and reduce bioburden, performed by sharp, mechanical, enzymatic, or autolytic methods

"Sharp wound debridement was performed at the bedside by the clinical nurse specialist to remove the dry eschar overlying the heel wound before a negative pressure dressing was applied."

"negative pressure wound therapy"

A wound management system that applies controlled sub-atmospheric pressure to a wound through a sealed foam or gauze dressing connected to a vacuum pump, promoting granulation and reducing oedema; abbreviated NPWT

"Negative pressure wound therapy at -125 mmHg was initiated for the dehisced abdominal wound; the foam insert was changed every 48 to 72 hours under aseptic conditions."

"wound measurement documentation"

The systematic recording of wound length, width, depth, undermining, tunnelling, tissue types, and exudate characteristics at each dressing change to track healing progress

"Wound measurement documentation using a ruler and photographic record showed consistent reduction in wound dimensions from 4.2 × 3.1 cm to 2.8 × 1.9 cm over two weeks of treatment."

"Braden scale"

A validated risk assessment tool used to predict a patient's susceptibility to pressure injury development by scoring six domains: sensory perception, moisture, activity, mobility, nutrition, and friction/shear

"The Braden scale score of 14 on admission identified the patient as at moderate risk of pressure injury; a turning schedule every two hours and a pressure-relieving overlay mattress were implemented."

"mechanical ventilation"

The use of a ventilator to fully or partially support a patient's breathing by delivering controlled volumes or pressures of gas to the lungs via an endotracheal tube or tracheostomy

"Mechanical ventilation was initiated in volume-controlled mode with a tidal volume of 6 mL/kg ideal body weight and a positive end-expiratory pressure of 8 cmH₂O to limit barotrauma."

"Richmond Agitation-Sedation Scale"

A validated ten-point tool used in the ICU to assess and titrate sedation levels from -5 (unarousable) to +4 (combative), aiming for a target score of -2 to 0 in most ventilated patients; abbreviated RASS

"The target Richmond Agitation-Sedation Scale score was set at -1 for this patient; the propofol infusion was increased from 1.5 to 2.5 mg/kg/hr after two consecutive RASS assessments of 0."

"arterial blood gas interpretation"

The analysis of pH, PaCO₂, PaO₂, bicarbonate, and base excess values from a blood sample drawn from an artery to assess acid-base status and respiratory function

"Arterial blood gas interpretation revealed a pH of 7.28, PaCO₂ of 52 mmHg, and bicarbonate of 24 mmol/L, confirming a primary respiratory acidosis consistent with the patient's worsening COPD exacerbation."

"vasopressor therapy"

The intravenous infusion of adrenergic agents such as noradrenaline, vasopressin, or adrenaline to restore adequate mean arterial pressure in patients with distributive or cardiogenic shock

"Vasopressor therapy with noradrenaline was titrated from 0.05 to 0.18 mcg/kg/min to maintain a mean arterial pressure above 65 mmHg following fluid resuscitation of 3 litres."

"ventilator-associated pneumonia bundle"

A set of evidence-based nursing interventions — including head-of-bed elevation, oral care with chlorhexidine, subglottic secretion drainage, and daily sedation breaks — implemented to reduce ventilator-associated pneumonia; abbreviated VAP bundle

"Compliance with all five elements of the ventilator-associated pneumonia bundle was audited daily; a ward-acquired VAP rate of zero was maintained for ninety consecutive days."

"spontaneous breathing trial"

A period during which a mechanically ventilated patient breathes with minimal or no ventilatory support — typically via T-piece or low-pressure support ventilation — to assess readiness for extubation; abbreviated SBT

"The patient passed a thirty-minute spontaneous breathing trial on pressure support of 5 cmH₂O with no tachypnoea, desaturation, or distress, and was extubated successfully one hour later."

"delirium assessment"

Routine screening for intensive care unit delirium using validated tools such as the CAM-ICU or ICDSC, identifying hyperactive, hypoactive, or mixed presentations that worsen outcomes

"Delirium assessment using the CAM-ICU was positive on the third ICU day; non-pharmacological interventions including early mobilisation, sleep hygiene, and reorientation were intensified."

"titration of continuous infusion"

The incremental adjustment of an intravenous drug infusion rate to achieve and maintain a target physiological parameter or clinical response, guided by regular patient reassessment

"Titration of the continuous insulin infusion was performed hourly, targeting a blood glucose range of 6 to 10 mmol/L per the ICU hyperglycaemia protocol."

"SBAR communication"

A structured verbal and written communication framework — Situation, Background, Assessment, Recommendation — used to convey critical patient information clearly and efficiently to other clinicians

"Using SBAR communication, the nurse reported to the on-call doctor: the patient in bed 4 has developed acute shortness of breath (Situation), has a background of heart failure (Background), oxygen saturation is 88% on room air (Assessment), and the nurse recommends urgent review and chest X-ray (Recommendation)."

"nursing handover"

The formal transfer of professional responsibility and accountability for a patient between nursing staff at shift change, encompassing current clinical status, outstanding tasks, and priorities

"Nursing handover was conducted at the bedside using the electronic patient record, allowing the incoming nurse to verify observations, review medication administration records, and ask clarifying questions."

"clinical documentation"

The accurate, timely, and legally defensible recording of all nursing assessments, interventions, patient responses, and communications in the health record

"Clinical documentation of the patient's refusal of the prescribed antibiotic, including the information provided and the patient's stated reason, was entered in the electronic notes within thirty minutes."

"informed consent"

The process by which a competent patient voluntarily agrees to a proposed treatment or procedure after receiving and understanding sufficient information about risks, benefits, and alternatives

"The nurse verified that informed consent for the lumbar puncture had been obtained and documented before preparing the procedure trolley and positioning the patient."

"discharge planning"

The multidisciplinary process of assessing a patient's post-discharge needs and organising community support, follow-up appointments, medication supply, and patient education to enable safe transition home

"Discharge planning commenced on the day of admission; by discharge, the patient had received insulin injection training, a district nurse referral, and written instructions in her preferred language."

"patient education"

The structured provision of health information and self-management skills to patients and their families to improve understanding of their condition and promote adherence to treatment

"Patient education regarding post-operative stoma care included a demonstration, a return demonstration by the patient, and written materials; understanding was confirmed before discharge."

"escalation of concern"

The formal process of communicating clinical deterioration or safety concerns to a more senior clinician or rapid response team when the nurse's assessment indicates the patient's condition is worsening

"When the registrar did not respond to the paged call within ten minutes, the nurse escalated her concern to the senior consultant and activated the medical emergency team, as per hospital policy."

"multidisciplinary team meeting"

A scheduled meeting attended by nursing, medical, allied health, and social work staff to review patient progress, coordinate care plans, and align goals across professional boundaries; abbreviated MDT

"At the multidisciplinary team meeting, the nursing representative reported that the patient's mobility had declined significantly, prompting the physiotherapist to increase sessions from daily to twice-daily."