Nursing Principles
Fall Risks
Delirium Risk Factors
Vital Signs
Is it Medical or Nursing Diagnosis
100

Keeping promises

Fidelity
100

In the home

Clear Clutter, throw rugs

100

S

Problems sleeping

100

Intervention for desaturation

Apply O2, elevate HOB

100

Heart Failure

Medical

200

Avoiding harm

Nonmaleficence 

200

Types of medications

OTC sleep aids, antihistamines, opioids

200

P

Problems eating

200

When to assess apical pulse 

irregular heart rhythm, bradycardia, tachycardia

200

Anemia

Medical 

300

Promotes equity, ethical behavior, non-discriminatory access to healthcare

Social Justice

300

Lighting

Dim lighting or glare

300

I

Incontinence

300

Deep, rapid breathing, followed by periods of apnea

Cheyne-Stokes

300

Impaired Oxygenation

Nursing

400

Concern for welfare and well-being

Altruism

400

Mobility 

Gait or balance issues

Foot problems/shoes

400

C

Confusion

400

Signs of orthostatic hypotension

dizziness, blurred vision, sweating, nausea

400

Impaired Mobility

Nursing

500

Acting according to the code of ethics 

Integrity

500

Highest risk of fall

History of fall

500

ES

Evidence of falls 

Skin integrity

500

Intervention when you cannot obtain a BP reading

Make a fist, elevate arm, then reassess

500

Pneumonia

Medical

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