⚠ Urgent statements (22)
Some statements describe a danger to life or limb. On these entries the first intervention is to call for help or start emergency steps. Treat airway, breathing, and circulation first, then work through other statements in this order: safety, then comfort, then teaching and support.
| Code | Statement | Type | First 3 actions |
|---|---|---|---|
| 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 |
| 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 |
| 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 |
| E9 | Very little urine being made | Actual ⚠ URGENT | Measure output accurately → Check the catheter for kinks → Encourage fluids if allowed |
| 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 |
| S7 | Body temperature too high or too low | Actual ⚠ URGENT | Check temperature → Add or remove layers → Give fluids |
| S10 | Reaction to medicine or allergen | Risk ⚠ URGENT | Check allergies before every drug → Use an allergy band → Observe after new medicines |
| 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 |
| 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 |
| 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 |
| 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 |
| P18 | Sudden confusion | Actual ⚠ URGENT | Look for the cause → Check vital signs and blood sugar → Reorient |
| 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 |
| N10 | Newborn breathing difficulty | Actual ⚠ URGENT | Call for help → Give oxygen → Keep warm |
| K4 | Child cannot express pain | Actual ⚠ URGENT | Use a faces pain scale → Observe behavior → Comfort |
| 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 |
| 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 |
| 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 |
Escalate with SBAR: Situation · Background · Assessment · Recommendation. Use the SBAR handover tool.