⚡ Cheat sheet

A Actual · R Risk · ⚠ URGENT = escalate per policy · → first 3 nursing actions

Priority: ABC first (Airway → Breathing → Circulation) → Safety → Comfort → Teaching & support.
Format: Problem related to cause as evidenced by signs (risk: risk factors only).
Escalate: SBAR · ABCDE · Goals: SMART.

⬇ PDF

🫁 B Breathing and circulation

Assess: CP-BREATH · NEWS2, SpO₂, ECG

Code	Diagnosis	Type	First 3 actions
B1	Struggling to breathe comfortably	Actual	→ Sit him upright · Check breathing rate and oxygen level · Give oxygen or medicine as ordered
B2	Poor oxygen exchange in the lungs	Actual	→ Raise the head of the bed · Give oxygen as ordered · Check oxygen and breathing often
B3	Airway blocked by secretions	Actual	→ Position upright · Teach deep breathing and supported coughing · Give fluids and humidified air if ordered
B4	Weak heart pumping	Actual	→ Check pulse, blood pressure, and weight daily · Give heart medicines as ordered · Limit fluid and salt if ordered
B5	Poor blood flow to hands or feet	Actual	→ Check pulses, color, and warmth · Keep limbs warm but avoid heat pads · Avoid tight clothing
B6	Unstable blood pressure	Risk	→ Check blood pressure at ordered times with the right cuff size, lying and standing · Give medicines as ordered and note the time of each dose · Encourage fluids as allowed and record intake
B7	Fluid in the lungs	Actual ⚠ URGENT	→ Sit upright · Give oxygen and diuretics as ordered · Monitor fluid balance and weight
B8	Low blood oxygen needing support	Actual ⚠ URGENT	→ Give oxygen at the ordered flow · Check equipment and tubing · Position upright
B9	Needs breathing machine support	Actual	→ Check tube position and ventilator settings · Suction as needed · Give mouth care
B10	Swollen legs or feet	Actual	→ Raise legs when sitting · Weigh daily · Follow salt and fluid advice
B11	Irregular heartbeat	Actual	→ Check pulse and blood pressure · Connect to monitor if ordered · Report symptoms
B12	Dizzy when standing up	Risk	→ Check lying and standing blood pressure · Have him sit on the bed edge before standing · Rise slowly
B13	Poor blood flow to the brain	Risk ⚠ URGENT	→ Check blood pressure and pulse, and do a quick brain check (face, arm, speech) each shift · Give the blood thinner as ordered and explain why every dose matters · Teach the signs of stroke: face drooping, arm weakness, slurred speech
B14	Very low blood circulation (shock)	Risk ⚠ URGENT	→ Check pulse, blood pressure, breathing, skin and mental state every 15 minutes · Control any bleeding and keep the patient warm · Give oxygen and fluids or blood as ordered

🥤 F Food and fluids

Assess: CP-FLUID · MUST, fluid chart, glucose

Code	Diagnosis	Type	First 3 actions
F1	Not eating enough to meet body needs	Actual	→ Weigh weekly · Offer small frequent meals · Involve a dietitian
F2	Eating more than the body needs	Actual	→ Assess eating habits · Set small realistic goals · Teach portion control and activity
F3	Dehydration	Actual	→ Measure intake and output · Give oral rehydration or intravenous fluids as ordered · Weigh
F4	Fluid build-up in the body	Actual	→ Measure fluids in and out · Weigh daily · Limit fluids and salt as ordered
F5	Unsteady blood sugar	Risk ⚠ URGENT	→ Check blood sugar before meals and if symptoms appear · Call the kitchen and give a snack if the meal is late · Treat blood sugar below 4 mmol/L at once per protocol and recheck in 15 minutes
F6	Trouble chewing or swallowing	Actual	→ Screen swallowing · Sit upright for meals · Follow texture advice from the speech therapist
F7	Vomiting	Actual	→ Give anti-sickness medicine as ordered · Keep upright · Offer small sips
F8	Needs tube feeding	Actual	→ Check tube position before each feed · Keep head raised at least 30 degrees · Flush as ordered
F9	Breastfeeding difficulty	Actual	→ Teach positions and latch · Encourage skin-to-skin contact · Treat soreness
F10	Body salts out of balance	Risk	→ Check blood results · Give replacements as ordered · Monitor heart rhythm
F11	Poor appetite	Actual	→ Find the cause · Offer favorite foods and small meals · Make meals pleasant
F12	Sore or damaged mouth	Actual	→ Give mouth care with a soft brush · Use rinses as ordered · Avoid spicy or hot food
F13	Unplanned weight loss	Actual	→ Weigh regularly · Look for causes · Give high-energy foods and supplements

🚽 E Elimination

Assess: CP-ELIM · Bristol Stool Chart, bladder scan

Code	Diagnosis	Type	First 3 actions
E1	Hard or infrequent bowel movements	Actual	→ Encourage fluids, fiber, and movement · Offer toilet privacy · Give laxatives as ordered
E2	Frequent loose stools	Actual	→ Replace fluids · Protect skin with barrier cream · Use infection precautions
E3	Unable to empty the bladder	Actual	→ Check with a bladder scan or palpation as ordered · Offer privacy and a normal position · Try running water or warm water
E4	Leaking urine	Actual	→ Teach pelvic floor exercises · Set a toileting schedule · Use pads
E5	Unable to reach the toilet in time	Actual	→ Place the bed near the toilet · Use a commode · Set regular toilet times
E6	Bowel leakage	Actual	→ Set a bowel routine · Clean skin gently and use barrier cream · Use pads
E7	Burning or pain passing urine	Actual	→ Encourage fluids · Give antibiotics as ordered · Send a urine sample
E8	Likely to get urine infection from a catheter	Risk	→ Use clean technique · Keep the bag below the bladder · Give catheter care
E9	Very little urine being made	Actual ⚠ URGENT	→ Measure output accurately · Check the catheter for kinks · Encourage fluids if allowed

😌 C Comfort and rest

Assess: CP-PAIN · NRS 0–10, FLACC, PAINAD

Code	Diagnosis	Type	First 3 actions
C1	Short-term pain	Actual	→ Assess pain with a scale · Give pain relief on time · Reposition
C2	Long-lasting pain	Actual	→ Assess pain and its effect on life · Give regular medicines as ordered · Teach pacing, gentle exercise, and relaxation
C3	Feeling sick to the stomach	Actual	→ Give anti-sickness drugs as ordered · Keep the air fresh · Offer small sips
C4	Unable to sleep well	Actual	→ Group care to allow rest · Reduce noise and light · Avoid caffeine late in the day
C5	Constant tiredness	Actual	→ Plan rest periods · Space out activities · Treat causes
C6	Itching or skin discomfort	Actual	→ Keep skin moist · Trim nails · Use cool compresses
C7	Side effects of pain medicine	Actual ⚠ URGENT	→ Check sedation level and breathing rate before and after each dose; if drowsy or breathing slowly (under 10/min), hold the dose and call for help at once · Give oxygen and prepare an opioid antagonist (for example naloxone) as ordered · Give laxatives and anti-sickness medicine as ordered
C8	Pain near end of life	Actual	→ Assess often, including by behavior · Give pain relief regularly as ordered · Reposition gently
C9	Muscle cramps or spasms	Actual	→ Stretch and massage gently · Give fluids · Check salt levels
C10	Headache	Actual	→ Assess pain and warning signs · Rest in a quiet dark room · Give pain relief as ordered
C11	Dry mouth or thirst	Actual	→ Give frequent mouth care · Offer ice chips or sips if allowed · Use lip balm
C12	Noise or light disturbing rest	Actual	→ Close doors · Lower voices and alarms · Dim lights at night

🛡️ S Safety and protection

Assess: CP-SAFE · Morse Fall Scale

Code	Diagnosis	Type	First 3 actions
S1	Likely to fall	Risk	→ Assess fall risk · Keep the bed low with the call bell in reach · Non-slip shoes
S2	Likely to catch an infection	Risk	→ Wash hands · Use clean technique for dressings and lines · Monitor temperature
S3	Likely to get hurt	Risk	→ Remove hazards · Supervise · Meet needs early
S4	Broken or damaged skin	Actual	→ Assess skin daily · Clean and dress as ordered · Protect from friction and moisture
S5	Likely to develop pressure sores	Risk	→ Turn every 2 hours or per plan · Check skin · Use a pressure-relieving mattress
S6	Likely to bleed easily	Risk	→ Check blood tests (INR) as ordered and report values above target · Check with the prescriber before each warfarin dose while the INR is above target; give at the same time each day as ordered · Use a soft toothbrush and electric razor
S7	Body temperature too high or too low	Actual ⚠ URGENT	→ Check temperature · Add or remove layers · Give fluids
S8	Likely to inhale food or fluid	Risk	→ Sit fully upright to eat · Supervise meals · Follow swallow advice
S9	Slow wound or surgical healing	Risk	→ Check the wound every shift · Support nutrition · Control blood sugar
S10	Reaction to medicine or allergen	Risk ⚠ URGENT	→ Check allergies before every drug · Use an allergy band · Observe after new medicines
S11	Likely to develop blood clots	Risk	→ Give clot prevention as ordered · Encourage early movement and fluids as allowed · Check both legs each shift for swelling, pain, redness or warmth
S12	Likely to bleed heavily after surgery	Risk ⚠ URGENT	→ Check dressings, drain output and vital signs at ordered times · Keep dressings intact and mark any leaking area · Report quickly rising drain output, bright blood, rising pulse, falling blood pressure or paleness at once
S13	Wrong medicine or dose	Risk	→ Check the patient's name band and ask the patient to state their name before every medicine · Check drug, dose, time, route and allergies against the order · Mark similar-name patients with an alert
S14	Harm from restraints	Risk	→ Use the least restrictive option · Follow policy · Check restraints often
S15	Likely to wander or get lost	Risk	→ Use an ID band · Place near the nursing station · Distract and redirect
S16	Burn or scald risk	Risk	→ Test water temperature · Avoid heat packs on numb skin · Supervise baths
S17	Choking	Risk ⚠ URGENT	→ Cut food small and serve soft foods if needed · Sit upright and supervise every meal · Remind to eat slowly without talking
S18	Poisoning risk	Risk ⚠ URGENT	→ Teach parents to lock medicines and chemicals away, out of sight and reach · Use child-safe lids and keep medicines in original labelled containers · Give the poison-control number and put it near the phone
S19	Unsafe home	Risk	→ Do a home safety check · Improve lighting · Clear clutter and secure loose items
S20	Abuse or violence exposure	Risk	→ Ask privately and kindly · Ensure safety · Document facts
S21	Likely to harm others	Risk	→ Stay calm · Keep a safe distance · Give space
S22	Staff exposure to needles or body fluids (workplace safety)	Risk	→ Use safety devices · Keep a sharps bin at the point of use · Never recap
S23	Nerve or limb damage from positioning	Risk	→ Pad and support limbs · Avoid pressure · Reposition
S24	Likely to spread infection to others	Risk	→ Use isolation as needed · Do hand hygiene · Wear masks and gloves
S25	Eye damage in unconscious patients	Risk	→ Clean eyes · Use lubricant · Close eyes gently or cover as ordered
S26	Injury during seizure	Risk ⚠ URGENT	→ Give anti-seizure medicine on time and as ordered · Keep the bed low and padded; clear the area · Teach the patient and family seizure first aid

🦽 M Movement and self-care

Assess: CP-MOVE · Barthel Index, Katz ADL

Code	Diagnosis	Type	First 3 actions
M1	Limited ability to move	Actual	→ Give pain relief before activity · Assist with exercises · Encourage safe movement
M2	Tires quickly during activity	Actual	→ Pace activity · Allow rest · Check pulse and breathing
M3	Cannot turn or change position in bed	Actual	→ Use turning aids · Assist safely · Reposition regularly
M4	Difficulty walking	Actual	→ Assess walking · Use a walking aid · Physiotherapy
M5	Needs help to wash	Actual	→ Assist as needed · Let him do what he can · Ensure privacy
M6	Needs help to dress	Actual	→ Offer easy-fit clothing · Dress the affected side first · Allow time
M7	Needs help to eat	Actual	→ Set up the meal · Use adaptive cutlery · Give time
M8	Needs help to use the toilet	Actual	→ Provide a raised seat and rails · Assist and give privacy · Schedule toileting
M9	Too little physical activity	Actual	→ Set small goals · Teach benefits · Start gently
M10	Difficulty using a walking aid	Actual	→ Check the fit · Teach technique · Practice with supervision
M11	Muscle weakness	Actual	→ Encourage exercise · Physiotherapy · Give protein-rich nutrition
M12	Stiff joints or shortened muscles	Actual	→ Do range-of-motion exercises · Position correctly · Use splints as ordered
M13	Cannot groom or care for appearance	Actual	→ Assist with grooming · Encourage independence · Offer choices
M14	Unsafe wheelchair or transfer	Actual	→ Use hoists or slide sheets · Use two staff when needed · Lock wheels
M15	Cannot do household tasks	Actual	→ Assess abilities · Arrange home help · Teach safe methods
M16	Poor balance	Actual	→ Assess balance · Use an aid · Non-slip shoes
M17	Loss of limb movement	Actual	→ Position correctly · Do passive exercises · Protect from injury
M18	Muscle wasting from bed rest	Risk	→ Mobilize early · Exercise · Give protein nutrition
M19	Poor body positioning	Actual	→ Align the body · Support with pillows · Reposition often

🧠 P Emotions and mind

Assess: CP-MIND · PHQ-9, GAD-7, C-SSRS

Code	Diagnosis	Type	First 3 actions
P1	Worry or nervousness	Actual	→ Stay calm · Listen · Explain the next steps simply
P2	Fear of a specific thing	Actual	→ Explain in simple words · Let the child hold a toy · Show the equipment
P3	Difficulty handling stress	Actual	→ Listen · Explore how he copes · Teach relaxation
P4	Loss of hope	Actual	→ Show interest · Set tiny goals · Encourage hope
P5	Feeling no control over one's situation	Actual	→ Give information · Offer choices · Involve him in the care plan
P6	Low self-worth	Actual	→ Reflect strengths · Praise efforts · Give him a role in his care
P7	Unhappy with body appearance	Actual	→ Allow her to express feelings · Support her at her own pace · Involve her partner
P8	Sadness after a loss	Actual	→ Listen · Allow tears · Do not rush
P9	Risk of self-harm (needs urgent response)	Risk ⚠ URGENT	→ Take every statement seriously and stay with the patient · Ask directly and kindly about thoughts of suicide and use the structured risk tool required by local policy · Remove hazards and keep the patient under the observation level ordered
P10	Distress after a frightening event	Actual	→ Create a safe place · Listen without pushing · Teach grounding
P11	Confusion or memory problems	Actual	→ Reorient gently · Use clocks and calendars · Keep routines
P12	Low mood	Actual	→ Listen · Encourage activity · Support routine
P13	Anger or aggression	Actual	→ Stay calm · Give space · Listen
P14	Extreme mood swings	Actual	→ Stay calm and consistent · Keep stimulation low · Teach coping
P15	Hearing or seeing things others do not	Actual	→ Do not argue · Reassure · Ask about the voices and any commands
P16	Suspicious or distorted thinking	Actual	→ Stay calm and honest · Do not argue · Keep routines
P17	Poor concentration	Actual	→ Give short clear instructions · Reduce distractions · Repeat
P18	Sudden confusion	Actual ⚠ URGENT	→ Look for the cause · Check vital signs and blood sugar · Reorient
P19	Difficulty making decisions	Actual	→ Give balanced information · Explore her values · Allow time
P20	Trouble controlling impulses	Actual	→ Set clear limits · Teach coping · Reward self-control
P21	Dependence on alcohol or drugs	Actual	→ Assess without judging · Monitor for withdrawal · Motivate
P22	Withdrawal symptoms	Actual	→ Use a withdrawal scale · Give medicines as ordered · Monitor vital signs
P23	Harmful eating behaviors	Actual	→ Build trust · Supervise meals as planned · Avoid blame
P24	Self-injury	Actual	→ Treat wounds calmly · Do not judge · Assess safety and suicide risk
P25	Guilt or shame	Actual	→ Listen · Correct unfair self-blame gently · Encourage forgiveness
P26	Long-lasting grief	Actual	→ Acknowledge the pain · Offer grief counseling · Encourage support groups
P27	Stress from illness or hospital stay	Actual	→ Explain the surroundings and routines · Encourage questions · Allow personal items
P28	Loss of sense of identity	Actual	→ Explore values and strengths · Encourage meaningful activity · Link to peer support
P29	Ready for better coping	Actual	→ Praise readiness · Teach skills · Set goals

💬 R Communication and relationships

Assess: CP-TALK · Communication barrier checklist

Code	Diagnosis	Type	First 3 actions
R1	Difficulty speaking or being understood	Actual	→ Speak slowly · Use yes or no questions · Use picture boards
R2	Difficulty hearing or seeing	Actual	→ Check hearing and vision aids · Reduce noise · Face the patient
R3	Feeling alone or cut off from others	Actual	→ Encourage contact · Arrange visits · Link to community groups
R4	Struggling with family or work roles	Actual	→ Explore feelings · Help redefine roles · Involve family
R5	Family caregiver overwhelmed	Actual	→ Acknowledge her effort · Teach skills · Encourage breaks
R6	Conflict or breakdown in family support	Actual	→ Hold a family meeting · Give facts · Mediate
R7	Difficulty trusting or cooperating with care	Actual	→ Build trust · Listen · Explain reasons
R8	Not enough help at home	Actual	→ Assess needs · Arrange home care · Involve family and a social worker
R9	Language barrier	Actual	→ Use a qualified interpreter · Use simple words and pictures · Give translated leaflets
R10	Trouble understanding health information	Actual	→ Use plain words · Short steps · Teach-back
R11	Relationship or intimacy difficulty	Actual	→ Create a private safe space · Give information · Include the partner
R12	Abuse or neglect in the family	Actual	→ Observe and document · Speak privately · Ensure safety
R13	Parenting difficulty	Actual	→ Teach skills · Praise efforts · Arrange support
R14	Weak bond between parent and baby	Risk	→ Encourage touch and skin-to-skin care · Involve her in care · Explain baby's cues
R15	Loss of privacy or dignity	Risk	→ Use curtains and screens · Knock before entering · Keep covered
R16	Care conflicts with culture	Actual	→ Ask respectfully · Adapt where safe · Involve family and chaplain

📘 L Learning and self-management

Assess: CP-LEARN · Teach-back

Code	Diagnosis	Type	First 3 actions
L1	Not enough knowledge about the condition	Actual	→ Assess what they know · Teach simply · Use pictures
L2	Not following the treatment plan	Actual	→ Ask kindly why · Explain benefits · Simplify the plan
L3	Difficulty managing medicines	Actual	→ Review medicines · Use a pill box · Give a simple schedule
L4	Difficulty managing the illness at home	Actual	→ Assess needs · Teach self-care · Set a routine
L5	Ready to learn and improve health	Actual	→ Reinforce readiness · Give tailored teaching · Set goals
L6	Unsure how to use equipment or devices	Actual	→ Demonstrate · Ask for a return demonstration · Give written steps
L7	Unsafe medicine use at home	Actual	→ Review all medicines · Teach safe use · Remove expired drugs
L8	Struggling to manage long-term illness	Actual	→ Set small goals · Teach self-monitoring · Suggest support groups
L9	Unhealthy habits (smoking, inactivity)	Actual	→ Give nonjudgmental advice · Use motivational talk · Set goals
L10	Cannot reach health services	Actual	→ Identify barriers · Arrange transport · Use telehealth
L11	Cannot afford care or medicines	Actual	→ Refer to a social worker · Explore assistance programs · Consider generic options
L12	Not ready for discharge	Actual	→ Assess readiness · Teach · Arrange equipment and home support
L13	Believes wrong health information	Actual	→ Listen · Correct kindly with facts · Use trusted sources

🕊️ V Spiritual and values

Assess: CP-SPIRIT · FICA spiritual screen

Code	Diagnosis	Type	First 3 actions
V1	Struggling with meaning, faith, or purpose	Actual	→ Listen without judging · Offer presence · Offer a chaplain
V2	Conflict between care and personal beliefs	Actual	→ Respect values · Explain options and risks · Involve the ethics team
V3	Ready to grow spiritually	Actual	→ Support practices · Arrange a quiet space · Offer a chaplain
V4	Wishes about end of life unclear	Actual	→ Open the conversation gently · Explain options · Document wishes
V5	Fear of dying	Actual	→ Listen · Stay with the patient · Control symptoms
V6	Cannot practice faith or rituals	Actual	→ Ask about needs · Provide a clean space · Adjust schedules

🤱 N Maternal and newborn

Assess: CP-MOTHER · MEOWS, APGAR

Code	Diagnosis	Type	First 3 actions
N1	Pregnancy discomfort	Actual	→ Reassure · Teach comfortable positions · Suggest small meals
N2	High-risk pregnancy	Risk	→ Arrange regular visits · Monitor vital signs and baby movement · Teach warning signs
N3	Fear of labor	Actual	→ Explain the stages · Teach breathing and comfort methods · Tour the labor ward
N4	Labor pain	Actual	→ Offer comfort · Massage · Position changes
N5	Risk of heavy bleeding after birth	Risk ⚠ URGENT	→ Check bleeding, uterus firmness and vital signs at ordered times · Massage the uterus if it feels soft · Check pads and weigh them if bleeding seems heavy
N6	Slow recovery after birth	Actual	→ Give pain relief · Encourage rest and mobility · Wound care
N7	Baby feeding poorly	Actual	→ Check the latch · Wake the baby · Set a feeding plan
N8	Baby's temperature unstable	Actual	→ Do skin-to-skin contact · Warm the room · Use a hat
N9	Newborn jaundice	Actual	→ Check bilirubin · Feed often · Give phototherapy as ordered
N10	Newborn breathing difficulty	Actual ⚠ URGENT	→ Call for help · Give oxygen · Keep warm
N11	Difficulty adjusting to new parenthood	Risk	→ Teach baby care · Encourage rest · Involve the partner
N12	Sadness after childbirth	Actual	→ Listen · Screen mood · Encourage support and rest
N13	Grief after pregnancy loss	Actual	→ Show compassion · Allow time with the baby · Offer keepsakes
N14	Family planning questions	Actual	→ Give balanced information · Respect choices · Explain options

🧒 K Child and teen

Assess: CP-CHILD · PEWS, FLACC

Code	Diagnosis	Type	First 3 actions
K1	Slow growth	Actual	→ Measure growth · Make a feeding plan · Involve a dietitian
K2	Delayed development	Actual	→ Screen development · Encourage stimulation · Refer for therapy
K3	Fear of hospital or procedures	Actual	→ Explain simply · Allow play · Let a parent stay
K4	Child cannot express pain	Actual ⚠ URGENT	→ Use a faces pain scale · Observe behavior · Comfort
K5	Accident risk at home	Risk	→ Child-proof the home · Teach parents · Supervise
K6	Distress when separated from parents	Actual	→ Encourage a parent to stay · Keep routines · Offer a comfort object
K7	Behavior problems	Actual	→ Set limits · Praise good behavior · Distract
K8	Missing school due to illness	Actual	→ Liaise with the school · Arrange hospital teaching · Plan catch-up
K9	Risk-taking behavior in teens	Actual	→ Talk without judging · Teach the risks · Encourage support
K10	Infant dehydration risk	Risk	→ Give oral rehydration · Breastfeed · Monitor diapers
K11	Unsafe infant sleep	Risk	→ Turn the baby onto his back and remove the pillow and loose bedding now · Teach safe sleep: on the back, firm flat mattress, nothing soft in the cot · Keep the baby cool and avoid heavy blankets
K12	Missed vaccinations	Actual	→ Check records · Explain benefits · Address fears

👵 A Older adult

Assess: CP-OLDER · 4AT / CAM, Mini-Cog

Code	Diagnosis	Type	First 3 actions
A1	Frailty	Actual	→ Assess strength and nutrition · Start an exercise program · Prevent falls
A2	Memory loss	Actual	→ Assess · Use reminders · Keep routines
A3	Too many medicines	Risk	→ Review the list · Involve a pharmacist · Ask the prescriber or pharmacist to remove duplicate medicines
A4	Loneliness at home	Risk	→ Encourage visits · Link to community groups · Arrange phone calls
A5	Neglect or money exploitation risk	Risk	→ Ask privately · Document · Report per policy
A6	Unsafe to live alone	Actual	→ Assess abilities · Make the home safe · Arrange services
A7	Difficulty adjusting to a care home	Actual	→ Orient her · Allow personal belongings · Involve family
A8	Loss of independence	Actual	→ Respect choices · Encourage independence · Use adaptive aids

🩹 W Wounds and skin

Assess: CP-SKIN · Braden Scale, TIME wound chart

Code	Diagnosis	Type	First 3 actions
W1	Wound not healing	Actual	→ Assess the wound · Treat the cause · Dress as ordered
W2	Heavy wound drainage	Actual	→ Use absorbent dressings · Protect surrounding skin · Measure drainage
W3	Pressure sore present	Actual	→ Relieve pressure · Dress as ordered · Turn regularly
W4	Difficulty caring for a stoma	Actual	→ Teach and practice · Check skin · Use a skin barrier
W5	Fragile skin or skin tears	Risk	→ Handle gently · Keep skin moist · Protect limbs
W6	Skin reaction to cancer treatment	Actual	→ Clean gently · Apply moisturizer as ordered · Advise loose cotton clothes
W7	Rash or skin infection	Actual	→ Wash hands · Clean skin · Give medicine as ordered

🏥 O Surgery and intensive care

Assess: CP-SURG · RASS, CPOT, Aldrete

Code	Diagnosis	Type	First 3 actions
O1	Fear before surgery	Actual	→ Explain the steps · Allow questions · Teach breathing
O2	Breathing problems after anaesthesia	Actual ⚠ URGENT	→ Open the airway · Give oxygen · Stimulate
O3	Risk of internal bleeding after surgery	Risk ⚠ URGENT	→ Check vital signs, abdomen and dressings at ordered times · Report a rising pulse, falling blood pressure, pallor, abdominal swelling or new pain at once · Call the surgeon if bleeding is suspected
O4	Drain, tube, or line problems	Risk	→ Secure tubes · Check they are open · Teach the patient not to pull
O5	Infection from lines	Risk	→ Use aseptic technique · Clean hubs · Check the site
O6	Slow gut recovery after surgery	Actual	→ Encourage walking · Limit opioids · Give intravenous fluids as ordered, and keep nothing by mouth if instructed
O7	Needs of sedated or unconscious patient	Risk	→ Turn regularly · Give eye and mouth care · Suction
O8	Discomfort from tubes	Actual	→ Give comfort · Secure the tube · Give sedation as ordered
O9	Sleep loss in ICU	Actual	→ Group care · Dim lights · Reduce noise
O10	Family distress in ICU	Actual	→ Give updates · Explain equipment · Allow visits

👁️ Z Brain and senses

Assess: CP-NEURO · GCS, pupils, NIHSS

Code	Diagnosis	Type	First 3 actions
Z1	Difficulty understanding speech	Actual	→ Use short sentences · Use gestures and pictures · Repeat
Z2	Ignoring one side of the body	Actual	→ Approach from the affected side · Cue him to scan · Arrange items
Z3	Risk of seizures	Risk ⚠ URGENT	→ Give anti-seizure medicine on time, and tell the doctor at once if vomiting stops tablets staying down · Keep the bed low, padded, and the area clear · Teach seizure precautions to the patient and family
Z4	Adjusting to vision loss	Actual	→ Orient him to the space · Label items · Teach safe mobility
Z5	Adjusting to hearing loss	Actual	→ Face the patient · Reduce noise · Speak clearly
Z6	Risk of injury from numbness	Risk	→ Check both feet daily for cuts, blisters and color change · Protect from heat and cold; test bath water with the elbow · Teach to wear shoes and socks at all times and check shoes before wearing
Z7	Raised pressure in the brain	Actual ⚠ URGENT	→ Call for help urgently · Raise the head to 30 degrees and keep the neck straight · Do neurological checks (alertness, pupils, limb movement) as ordered

🦠 H Infection and community health

Assess: CP-INFECT · qSOFA / sepsis screen

Code	Diagnosis	Type	First 3 actions
H1	Exposed to an infectious disease	Risk	→ Do hand hygiene · Wear masks · Isolate the source patient
H2	Distress from isolation	Actual	→ Explain the reasons · Allow calls · Keep routines
H3	Outbreak risk in community	Risk	→ Report · Isolate · Trace contacts
H4	Unsafe water or sanitation	Risk	→ Teach boiling and treatment of water · Improve sanitation · Report
H5	Crowded living conditions	Risk	→ Teach hygiene · Improve ventilation · Screen
H6	Poor hygiene practices	Actual	→ Teach handwashing · Provide soap · Model good habits

🕯️ D End of life

Assess: CP-END · ESAS

Code	Diagnosis	Type	First 3 actions
D1	Needs comfort near death	Actual	→ Control symptoms · Give mouth care · Reposition gently
D2	Family grief before death	Actual	→ Listen · Encourage goodbyes · Explain changes
D3	Unfinished affairs or wishes	Actual	→ Listen · Help plan visits · Involve a social worker and chaplain
D4	Distressing symptoms near death	Actual	→ Give comfort medicines as ordered · Reposition · Give mouth care
D5	Needs bereavement support	Actual	→ Offer condolences · Give information on grief · Refer to counseling

⏳ T Long-term illness

Assess: CP-LONG · Self-management review

Code	Diagnosis	Type	First 3 actions
T1	Uncontrolled high blood pressure	Actual	→ Check technique · Encourage taking medicine · Reduce salt
T2	Foot problems in diabetes	Risk	→ Check feet daily · Use proper shoes · Keep feet clean and dry
T3	Lung disease flare-ups	Actual	→ Give medications as ordered · Give oxygen · Position
T4	Difficulty following fluid limits	Actual	→ Teach limits · Offer ice chips or sugar-free candy · Measure intake
T5	Dialysis access care	Risk	→ Protect the arm · No blood pressure or needles on that arm · Check the thrill
T6	Cancer treatment side effects	Actual	→ Give anti-sickness medicine · Mouth care · Rest
T7	Difficulty accepting long-term illness	Actual	→ Listen · Give information · Suggest support groups
T8	Weak immune system	Risk	→ Protect from infection · Hygiene · Vaccines as advised

⚕️ X Sexual and reproductive health

Assess: CP-SEX · PLISSIT

Code	Diagnosis	Type	First 3 actions
X1	Concern about sexual function	Actual	→ Provide privacy · Give information · Include the partner
X2	Concern about fertility	Actual	→ Listen · Give information · Refer for testing
X3	Needs safe-sex knowledge	Actual	→ Give clear information · Discuss protection and testing · Keep confidentiality
X4	Menopause symptoms	Actual	→ Reassure · Give lifestyle advice · Suggest layered clothes