1、常用医嘱术语Medical orders（1）医嘱术语medical ordersAdmit/transfer to收入（转入）Resident/attending住院（主诊）医师condition病情critical (Imminence)病危unstable不稳定stable稳定general (fair) 一般emergent急诊Diagnosis诊断Diet饮食full (home) diet普食liquid (semi-liquid) diet流汁（半流汁）饮食soft diet软食low salt and low fat diet低盐低脂饮食salt-free diet无盐饮食lo
2、w purine diet低嘌呤饮食low (non)-residue diet少（无）渣饮食light diet 清淡饮食high caloric diet高热量饮食high protein (protein-rich) diet高蛋白饮食diabetic diet糖尿病饮食nephritic diet肾炎饮食nasal feeding鼻饲fasting (NPO, nothing by mouth)禁食NPO for 5 hours禁食5小时meal standard伙食标准activity活动absolute rest绝对卧床休息stay on the bed (yest in bed)
3、卧床休息Ad lib随意活动In the ward 病房内活动vital signs生命体征Q shift (q.6h)每班（每6小时）一次immoblization制动pressed by sand bag 沙袋压迫I/O (intake and output)记出入量N/A (non-apply)不需要parameter: EKG(Bp,SaO2) monitor 其他：心电图（血压，氧饱和度）监 护allergies过敏NKA (non-known allergies)无已知的过敏反应patient identification 病人身份4th floor,room 5 ,bed 2(4
4、05-2)4楼5号房2床Med. Rec#病历号medical orders医嘱on general routine护理常规on grade I (II, III) nuring careI （I、III）级护理morning (evening) care晨间（夜间）护理bedsore care褥疮护理mouth (oral) care口腔护理CPT( chest physical treatment) 胸部物理治疗O2 inhalation (2-4L/min)吸氧（2-4升/分）alcohol sponge bath酒精擦浴cold (hot) compress冷（热）敷wet (hydr
5、opathic) compress by MgSO4用硫酸镁湿敷change position qh每小时更换一次体位gastric lavage with water用清水洗胃bladder irrigation 膀胱冲洗under water seal drainage of thorax胸腔水封瓶引流GI decompression 胃肠减压keep warm保温医.学 全在.线,提供lower temperature by ice-cap冰帽降温keep bowels open保持大便通畅keep the airway open保持气道通畅retention catheterizati
6、on留置导尿prevent from bedsore预防褥疮on bedside isolation床边隔离P.P sitz bath高锰酸钾液坐浴raising the head (foot) of the bed抬高床头（尾）pencillin (procaine, iodine) skin test青霉素（普鲁卡因，碘）皮试intubate and ventilator support气管插管及呼吸机支持cleaning (retention) enama清洁（保留）灌肠soapsuds (saline) enama肥皂水（盐水）灌肠intradermal injection皮内注射su
7、bcutaneous (hypodermic) injection 皮下注射intramuscular injection( i.m)肌肉注射intravenous injection(i.v)静脉注射intravenous drip(ivgtt)静脉滴入intraarterial injection动脉注射intraarticular injection关节内注射intrapleural injection胸腔内注射intrathecal injection鞘内注射intraspinal injection椎管内注射per os(P.O,by mouth口服inhalation吸入inunc
8、tion涂擦scarification划痕法by rectum直肠灌注quaque die (qd)一天1次bis in die(bid)一天2次ter in die (tid)一天3次quater in die (qid)一天4次quaque hora (qh)每小时1次quaque quarta hora(q4h)每4小时1次quaque nocte (qn)每晚1次quaque mane (qm)每晨1次ante cibum(ac)饭前（给药）post cibum (pc)饭后（给药）hora somni (hs)临睡时pro re nata (prn)必要时si opus sit (s
9、os)必要时只用1次ante meridiem (am)上午post meridiem (pm)下午statim (st)即刻(2)辅助检查术语diagnostic examinationCBC (complete blood count) 全血细胞计数WBC (white blood ount)白细胞数RBC (red blood count) 红细胞数Ret (reticulocyte)网织红细胞数HCT (hematocrit)红细胞比积MCV (mean corpuscular volume) 红细胞平均体积MCH (mean corpuscular hemoglobin)红细胞平均血
10、红蛋白EC (eosinophic count)嗜酸粒细胞计数Plt (platelet count)血小板计数UA (urine analyse)小便常规SRt (stool routine)大便常规stool OB 大便隐血stool ova count大便虫卵计数uric acid 尿酸uric (serum) amylase 尿（血）淀粉酶urine K+ (Na+)尿钾（钠）测定pregnance test妊娠试验urine Bence-Jone protein 尿本-周氏蛋白urinary protein electrophoresis尿蛋白电冰bacterial count of
11、 urine 尿菌落数osmotic pressure assay尿渗透压测定urine (blood, stool) culture 尿（血、大便）培养bone marrow puncture 骨穿iron staining of bone marrow smear 骨髓铁染色serum iron assay 血清铁测定Vit B12 and folic acid assay 维生素B12和叶酸测定BT (bleeding time) 出血时间CT (coagulation time) 凝血时间PT (prothrombin time)凝血酶原时间ACT (activated coagula
12、tion time)活化的凝血时间KPTT(kaolin partial thromboplastin time)部分凝血活酶时间Fb (fibrinogen)纤维蛋白原FDP (fibrinogen degradation product)纤维蛋白原降解产物ABG (arterial blood gas)血气分析renal function and liver function肝肾功能D-dimer fragments assayD-二聚体测定Hcy (homocysteine)同型半胱氨酸Cr and BuN (creatinine and blood urea nitrogen)肌酐和尿
13、素氮blood lipid (TG, TC ,HDL, LDL)血脂（甘油三酯，胆固醇，高密度脂蛋 白，低密度脂蛋白）myocardial enzyme (CK, CK-MB, GOT, LDH)心肌酶谱（肌酸磷酸激酶及 同功酶，谷草转氨酶，乳酶脱氢酶）Mb (myoglobin)肌红蛋白CTn-I 肌钙蛋白-Ithyroid function (T3,T4,TSH,FT3 FT4,TG,TM)甲状腺功能VMA (urine vanillylmandelic acid)尿香草基杏仁酸LH, FSH, ACTH, GH黄体生成素，卵泡刺激素，促肾上腺皮质激素，生 长激素determination of calcitonin降钙素测定17-KS and 17-OHCS尿17-酮和17-羟测定plasma cortisol assay 皮质醇aldosterone assay醛固酮testosterone and estradiol睾酮和雌二醇FBS or blood glucose 空腹血糖或血糖SaO2 monitor 血氧饱和度监测CO2CP (carbon dioxide combining power)二氧化碳结合力Uric ketobody尿酮体serum electrolytes (K+,Na+,Ca2+,Cl-,Mg