Rock Valley College
Nursing 111
Suggested Charting Terminology
Concerning
Amounts
Appearance,
General
Appetite
Attitude
(mental)
Back (area)
Backrest
Baths
Belch
Factor to be Charted
1. Large amount
2. Moderate Amount
3. Small Amount
1.
2.
3.
1.
2.
3.
4.
5.
6.
1.
Thin and undernourished
Fat, Greatly overweight
Seems very sick
Very fussy about food, refused to
eat many foods
Eats all food served
Eats very little
Loss of appetite
Refuses to eat
Eats small amount
Not interested in surroundings
Suggested Terms to Use
1. Profuse, copious, excessive
2. Moderate, usual
3. Small, scanty, slight
1.
2.
3.
1.
2.
3.
4.
5.
6.
1.
Emaciated
Obese
Acutely ill
Has definite likes and dislikes
concerning food
Appetite good
Appetite poor
Anorexia
Refused food (state reason)
Appetite fair
Indifferent
2. Has dont care attitude
2. Apathetic
3. Doesnt believe anything said to
him/her
3. Distrustful, suspicious
4. Happy, carefree, cheerful
4. Cheerful, optimistic
5. Confused
5. Disorientated (specify to person
place or time)
1. Upper back
1.
2.
3.
4.
5.
6.
7.
2. Small of back
3. End of spine
4. Gluteal area
5. Hump back
6. Sway back
7. Curved spine
1. Backrest raised
1. Given when patient is admitted
2. All-inclusive bath
3. Including face, arms, back, axilla,
genitals
1. Belching
Interscapular region, shoulder area
Lumbar region
Sacral region
Buttocks
Kyphosis
Lordosis
Scoliosis
1. Backrest elevated (indicate degree of
angle)
1. Admission bath
2. Complete bath
3. Partial bath
1. Eructation
Bleeding
1. Spurting of blood
2. Very little
3. Nosebleed
4. Blood in vomitus
5. Blood in urine
6. Spitting of blood
7. Collection of blood
Blister
1. Blister
Breath
1. Unpleasant
2. Foul
3. Smells of alcohol
4. Fruity
Breathing
1. Act of breathing
2. Act of inhaling
3. Act of exhaling
4. Difficult breathing
5. Short period when breathing ceases
6. Inability to breathe while lying down
7. Normal breathing
8. Rapid breathing
9. Increasing dyspnea with periods of apnea
10. Large volume of air inspired
11. Small volume of air inspired
12. Abnormal variations in rhythm
13. Suffocation
14. Snoring sounds of breathing
Care
Color
1. Wash face, hands, brush teeth, bedpan
2. Bath, backrub, care of hair and nails
3. Wash hands, face and back, backrub, bedpan,
mouth
1. Colorless
2. Of normal urine
3. Resembling clay
4. Looks same as tar
5. Tinged with blood
1. In spurts
2. Oozing, minimal
3. Epitaxis
4. Hematemasis
5. Hematuria
6. Hemoptysis
7. Hematoma
1. Vesicle
1. Halitosis
2. Fetid
3. Acetone
4. Acetone
1. Respiration
2. Inspiration
3. Expiration
4. Dyspnea
5. Apnea
6. Othopnea
7. Eupnea
8. Tachypnea, hyperpnea
9. Cheyne-Stokes
10. Deep breathing
11. Shallow breathing
12. Irregular breathing
13. Asphyxia
14. Stertorous respiration
1. Early A.M. care
2. Routine A.M. care
3. P.M. care
1.
2.
3.
4.
5.
Clear
Amber
Clay colored
Tarry
Blood-tinges
Consciousness
Consistency
Convulsion
Cough
Defecation
1. Fully conscious, aware of
surroundings
2. Only partly conscious
3. Unconscious but can be
aroused, responds to some
stimuli
4. Unconscious, cannot be
aroused
1. Retains its shape
2. Watery
3. Thick, sticky or glue-like
4. Containing or resembling
mucus
1. Muscles contract and relax
2. Muscle contraction
maintained for a time
3. Localized muscle
contraction
4. Began without warning
5. Abrupt start and end of
spasm or convulsive seizure
1. Alert, fully conscious
1. Coughs all the time
2. Coughing over long period
of time
3. Coughs up material
4. Cough without producing
material
5. Occurring in spasms
6. Coughs quite often
1. Continuous cough
2. Persistent cough
7. Cough that does not produce
material from lungs
8. With characteristic whoop
9. Occurs in paroxysms or
attacks, sudden
10. Other self-explanatory terms
used to describe a cough
include
7. Nonproductive cough
1. Bowel movement (material),
bowel movement (act of)
2. Excessive defecation
3. Gray colored stool
4. Dark brown liquid stool
5. Formed, yet soft stool
6. Formed with hardened feces
7. Inability to retain, not
1. Feces, stool, defecation
2. Semiconscious, groggy, lethargic
3. Stuporous, responsive to verbal or
tactile stimulus
4. Comatose
1.
2.
3.
4.
Formed
Liquid
Concentrated, tenacious
Mucoid
1. Clonic tremor or convulsion
2. Tonic tremor or convulsion
3. Spasm
4. Sudden onset
5. Paroxysm
3. Productive cough
4. Nonproductive cough
5. Spasmodic cough
6. Frequent cough, intermittent
8. Whooping cough
9. Paroxysmal cough
10. Tight, loose, deep, dry, hacking, harsh,
painful, rasping, explosive, hollow,
crowing, exhaustive
2.
3.
4.
5.
6.
Diarrhea
Clay-colored stool
Highly liquid stool
Soft-formed stool
Hard-formed stool
control over
7. Incontinent
Dizziness
Drainage
Dressings
Ears
Emesis
1. Dizziness
1. Vertigo
1. Water from nose
1. Coryza
2. Containing pus
2. Purulent
3. Bloody
3. Sanguineous
4. Contains both blood and
4. Serosanguineous
serum
5. Consists of feces
5. Fecal
6. Of lymphatic fluid
6. Serous
7. Contains mucus and pus
7. Mucopurulent
8. Tough, sticky
8. Tenacious
9. From vagina after delivery
9. Lochia
10. Sticky
10. Viscous
1. Second dressing added to the
1. Dressing reinforced
first
2. Dressing removed, another
2. Dressing changed
applied
3. Drain tubes cut off
3. Drain tubes shortened (number of cm)
1. Wax in ears
1. Cerumen
2. Ringing in ears
2. Tinnitus aurium
3. Dizziness
3. Vertigo
4. Abnormal in shape
4. Deformed
1. Produced by effort of patient
1. Induced
2. Ejected to few feet distant
3. If blood is only noticeable
2. Projectile
4. Agent given to produce
3. Blood-tinged
emesis
4. Emetic
Enemas
Expectoration
Eyes
1. To induce bowel
2. To supply nourishment
3. To relieve distention
caused by gas
4. To expel worms
5. To be retain for several
hours
1. A great deal, very little
2. Spitting up blood
1.
2.
3.
4.
5.
Sharpness of vision
Yellow in color
Puffy, swollen
Dropping of lids
Motionless, not moving,
staring
6. Unusually sensitive to
light
7. Double vision
8. Abnormal protrusion of
eyeball
9. Inflammation of
conjunctiva
10. Dilation of the pupil
11. Constriction of the pupil
12. Near sightedness
13. Far sightedness
14. Sees objects indistinctly
15. Other characteristic
terms
16. Stye on eye
Face
1.
2.
3.
4.
5.
Without color
Pink
Broken out
black and blue
Characteristic
expression worn
6. Marked with pits and
scars
Faint
1. Fainting
1. Cleansing enema
2. Nutritive enema
3. Carminative enema
4. Anthelminitic enema
5. Retention enema
1. Profuse, scant
2.
1.
2.
3.
4.
5.
Hemoptysis
Visual acuity
Jaundiced
Edematous
Ptosis of lids
Fixed
6. Photophobia
7. Diplopia
8. Exophthalmoses
9. Conjunctivitis
10. Pupil dilated
11. Pupil constriction
12. Myopia
13. Hyperopia
14. Blurred vision
15. Bright clear, dull, inflamed, sunken, crossed,
bloodshot, burning
16. Hordeolum
1. Pale
2. Flushed
3. Presence of rash, acne
4. Bruised, ecchymotic
5. Anxiety, defiance, anger, pain, boredom,
fear, worry, happiness, apathy, sorry,
dissatisfaction
6. Pockmark
1. Syncope
Feet
1. Reddened spots of places caused by
pressure or friction
2. Puffy, enlarged swollen
1. Pressure areas present
Fever
1. Without fever
2. Fever, temperature above normal
3. Temperature greatly above normal
1. Afebrile
2. Pyrexia
3. Hyperpyrexia
Gas
1.
2.
1.
2.
3.
4.
1.
2.
Gas in digestive tract
Distention caused by accumulation of gas
Clean, good appearance
Unclean, coarse
Uncombed neglected
Not normal color
Of hearing
Of sight
1.
2.
1.
2.
3.
4.
1.
2.
Flatus
Flatulence
Clean, glossy
Greasy, coarse
Tangled, neglected
Bleached, dyed
Auditory hallucinations
Delusions
1.
2.
3.
4.
5.
6.
1.
Forehead
region over temple
Back of head
Base of skull
Having a large head
Having a small head
Irregularity of heartbeat
2.
3.
1.
2.
1.
2.
1.
2.
1.
2.
3.
4.
Slowness of heartbeat
Fast heartbeat
Hives
Itching
Thigh to knee
Knee to ankle
Head, body, pubic
Condition of lousiness
Pale, colorless
Blue in color
Presence of tiny cracks
Fever blisters present
1.
2.
3.
4.
5.
6.
1.
2.
3.
Frontal region
Temporal region
Occipital region
Basilar region
Macrocephalous
Microcephalous
Arrhythmia, dysrhythmia
Bradycardia
Tachycardia
Hair
Hallucination
Head
Heartbeat
Hives
Legs
Lice
Lips
Lungs
1. Abnormal sounds in
2. Swollen, edematous
1.
2.
1.
2.
1.
2.
1.
2.
3.
4.
Urticaria
Pruritus
Upper leg (right or left)
Lower leg (right or left)
Pediculi
Pediculosis
Pale
Cyanotic
Fissured, cracked
Presence of herpes
simplex
1. Adventitious
Medicine
administration
Memory
Menstruation
Nails
Nose
Nourishment
1. By mouth
2. By rectum
3. Breathing in
4. Rubbing into skin
5. Under the skin
6. Within the skin
7. Within the muscle
8. Within the spinal canal
9. Within the vein
10. pouring into body
cavity
11. Blowing into body
cavity
12. Shot
1. Loss of memory
1. If present when
admitted
2. Painful
3. Total absence of
4. Profuse or prolonged
flow
5. Occurring between
periods
6. Cessation of
1.
2.
1.
2.
1.
2.
3.
4.
Odor
1.
2.
3.
4.
Pain
1.
2.
3.
4.
5.
6.
7.
Blue in color
Other descriptive terms
Nosebleed
Descriptive terms
Very small amount
how water
Small pieces of ice
Drink of water
Given through tube
into stomach
Not unpleasant
Like fruit
Very unpleasant
Belonging to particular
drub, ect.
Great pain
Little
Comes in seizures
Spreads to distant areas
Hurts worse when
moving
Begins suddenly
Other descriptive terms
1.
2.
3.
4.
5.
6.
7.
8.
Orally
Rectally
Inhalation
Inunction
Subcutaneous, hypodermic
Intradermal
Intramuscular
Intraspinal
9. Intraveinous
10. Instillation
11. Insufflation
12. A lay term for injection
1. Amnesia
1. Menses present
2. Dysmenorrhea
3. Amenorrhea
4. Menorrhea
5. Metrorrhagia
6. Menopause
1.
2.
1.
2.
1.
Cyanotic
Brittle, clean, torn, manicure, clubbed
Epistaxis
Red. Enlarged, deformed
Sips hot water
2. Ice chips
3. Water (amount of ccs)
4. Gavage
1.
2.
3.
4.
Aromatic
Fruity
Offensive, foul
Characteristic
1.
2.
3.
4.
Severe (rate on scale 1-10)
Slight (rate on scale 1-10)
Paroxysmal, spasmodic
Radiating
5. Increased by movement
6. Sudden onset
7. Sharp, sudden, darting, gnawing, burning,
Paralysis
Perspiration
Positions
Pulse
1. Of the muscles of the
face
2. Of one the legs
3. One side of the body
4. Single limb
5. All four limbs
1. Large amount
2. Small amount
1. Flat on back, arms
straight at sides
2. On side, knees flexed
3. On left side, left arm
behing back, right leg
flexed
4. Head elevated 45
degrees, knees may or
many not be flexed
5. Head elevated 30
degrees
6. Head elevated 90
degrees
7. On back, buttocks near
edge of table, knees
well flexed and
separated,
8. On back, knees flexed
and apart, feet on table
9. Resting on knees and
chest
10. On back. Pelvis higher
than head
11. On abdomen, face
turned to one side
12. Prone with hips over
break in table and feet
below level of head
1. Number of beats per
minute
2. Rhythm
3. Beats missed at
intervals
4. Over 100 beats per
minute
5. Very rapid, beats
indistinct
staffing, cramping, shooting, colicky,
persistent, transient, constant, shifting,
localized, deep, superficial, agonizing,
piercing, aching, generalized, excruciating,
unyielding, darting, intense
1. Facial
2.
3.
4.
5.
1.
2.
1.
Paraplegia
Hemiplegia
Monoplegia
Quadraplegia
Profuse, excessive
Scanty
Horizontal, supine
2. Lateral
3. Sims
4. Fowlers
5. Semi-Fowlers
6. High Fowlers
7. Lithotomy
8. Dorsal recumbent
9. Knee-chest
10. Trendelenburg
11. Prone
12. Jackknife
1. Rate
2. Regular or irregular
3. Intermittent
4. Tachycardia
5. Running
6. Diminished rate
7. Below 60 beats per
minute
8. One scarcely
perceptible
9. Small, rapid and tense
10. With excessive recoil
wave
11. According to strength
12. Readily perceived
(felt)
13. Cannot be felt
14. Rapid, quite distinct
beats
15. Normal in Rate and
rhythm
Reproductive
organs
Respirations
Skin
1. External reproductive
organs
1. Act of breathing
2. Above 25 respirations
per minute
3. Induced by artificial
means
4. Snoring
5. Difficult
6. Alternated periods of
apnea and increasingly
deep respiration
7. Other descriptive terms
1. Normal
2. Pink, hot
3. Blue in color
4. Very white
5. Shines
6. Raw surface
7. Yellow in color
8. Torn
9. Cold and moist
10. Birthmark
11. Wart
12. Boil
13. Other descriptive terms
6. Infrequent
7. Bradycardia
8. Thready
9. Wirey
10. Water hammer
11. weak, strong
12. Perceptible
13. Imperceptible
14. Pounding, bounding
15. Normal
1. Genitals (external)
1. Respiration
2. Tachypnea
3. Artificial
4. Stertorous
5. Labored, dyspneic
6. Cheyne-Stokes
7. Quiet, sighing, gasping, rapid, shallow,
deep, costal, audible, noisy
1. Healthy
2. Flushed
3. Cyanotic
4. Extreme pallor, pale
5. Glossy
6. Excoriated
7. Jaundiced
8. Lacerated
9. Clammy
10. Nevus
11. Verruca
12. Furuncle, abscess
13. Mottled, discolored, moist, dry, hot, cold,
warm, oily, broken, calloused, wrinkled,
tight, coarse, fine texture, tanned, scaly,
bruised, painful, scarred, black, brown,
white, clammy, rash, wrinkled, smooth
14. Indicate presence of
14. Rash, abrasion, laceration, insect bites,
tumors, scare, eruptions, acne crusts, ulcers,
moles, fissures, abscesses
15. A discolored spot
16. Pimple
17. A blister
18. A pimple filled with
pus
19. Containing colored
areas
20. Wet
21. Small purplish spots on
skin
22. Area where skin is
rubbed
23. Redness of
15. Macule
16. Papule
17. Vesicle
18. Pustule
19. Pigmented
20. Moist
21. Petechiae
22. Abrasion
23. Erythema
Sleep
1.
2.
3.
4.
Slept very little
Tired when wakens
Moans while sleeping
Inability to sleep
Speech
1. Speaks normally
2. Not understandable
3. meaningless,
wandering
4. Words run together
5. Stammering, stuttering
6. Not heard distinctly
7. Speaks long and well
8. Difficulty in speaking
9. Unable to speak
10. Other terms
1. Slept very little, slept at short intervals
2. Wakens fatigued
3. Sleep disturbed, moaning
4. insomnia
1. Normal speech
2. Incoherent
3. Rambling
4. Slurring
5. Stammering, stuttering
6. Inarticulate
7. Fluent
8. Dysphasia
9. Aphasia
10. Hoarse, feeble, fluent, clear
Throat
Tongue
1. Difficulty in swallowing
2. Inability to swallow
3. Other descriptive terms
1. Descriptive terms
1. Dysphagia
2. Aphagia
3. Red, swollen, inflamed,
irritated
1. Pink, moist, dry, cracked,
coated, raw, swollen, scarred,
inflamed, ulcerated
Unconsciousness
1. Complete unconsciousness
2. Partial unconsciousness
1. Comatose
2. Stuporous
Urination
1. To urinate
2. No control over urination
1. Void, micturate
2. Incontinent
3. Burning when urinates
3. Burning sensation with
voiding or on micturition
4. Diuresis
Vomit
Weight
Wounds
4. Large amount of urine
voided
5. Total suppression of urine
6. Frequent voiding at night
7. Increased amount voided
8. Painful urination
9. Pus in urine
10. Blood in urine
11. Hemoglobin in urine
12. Glucose in urine
13. Albumin in urine
14. Acetone in urine
15. Bile in urine
16. Scantiness of urine
17. Sugar in urine
18. Bedwetting
19. Stones in urine
1. Desire to do so (for various
types, see emesis)
1. Overweight
2. Thin, underweight
1. Deep
2. Slight, surface only
3. Not infected
4. Discharging pus
5. Infected
6. Torn
5. Anuria
6. Nocturia
7. Polyuria
8. Dysuria
9. Pyuria
10. Hematuria
11. Hemoglobinuria
12. Glucosuria
13. Albuminuria
14. Acetonuria
15. Choluria
16. Oliguria
17. Glycosuria
18. Enurese
19. Calculi
1. Nausea
1.
2.
1.
2.
3.
4.
5.
6.
Obese
Emaciated
Deep
Superficial
Clean
Suppurating
Infected
Lacerated
