Awareness of the patient's environment and of the patient's situation is an integral part of nursing care. Situational awareness in the patient care environment involves knowledge, attention, and responsiveness in relation to patient monitoring; knowing and understanding what's happening around you; and awareness of patient safety (Fore & Sculli, 2013; Fukuta & Iitsuka, 2018; Green et al., 2017; Large & Aldridge, 2018). Situational awareness in nursing includes routine use of a general survey (observation) of the patient, family/caregivers, and environment, using input from all senses (Cohen, 2013). These observations contribute to an understanding of the current situation and support anticipation of potential problems. Identifying and solving problems is essential to effective and safe nursing practice. Integration of situational awareness as part of routine nursing care allows nurses to anticipate patients' needs “by knowing what is going on, why it's happening and what's likely to happen next” (Cohen, 2013, p. 64). Situational awareness promotes a safer patient care environment, reduces risk for falls, and helps the nurse develop care priorities, acting correctly when things go as planned, and reacting appropriately when they don't (Cohen, 2013, p. 64; Fore & Sculli, 2013; Godlock et al., 2016; Large & Aldridge, 2018).

Assessment

A situational assessment is completed during every encounter with the patient and periodically at planned intervals throughout the day. Observations should be modified based on the specific patient care setting (e.g., long-term care, school, home health, etc.) and circumstances.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

• Fall risk
• Injury risk
• Impaired Mobility

Outcome Identification and Planning

The expected outcome to achieve is that a situational assessment is completed, the patient's needs are met, and the patient remains free from injury.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient. Explain the purpose of the assessment to the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors. Explanation helps reduce anxiety and promotes engagement and understanding.
3. Assess for data that suggest a problem with the patient's airway, breathing, or circulation. If a problem is present, identify if it is urgent or nonurgent in nature. Refer to Chapter 3 for specific related assessments.	Problems with the patient's airway, breathing, or circulation may signal a situation requiring immediate action. It is important to determine the importance of information, focus on the most relevant and important data, act on that which is important and develop plans for interventions that can be justified in relation to their likelihood of success (Lasater, 2007).
4. Assess the patient's level of consciousness, orientation, and speech. Observe the patient's behavior and affect (Figure 1). If a problem is present, identify if it is urgent or nonurgent in nature. Refer to Chapter 3 for specific related assessments.	Problems with the patient's level of consciousness, orientation, speech, behavior, or affect may signal a situation requiring immediate action. It is important to determine the importance of information, focus on the most relevant and important data, act on that which is important and develop plans for interventions that can be justified in relation to their likelihood of success (Lasater, 2007).
5. Assess the patency of an oxygen delivery device, if in use. Refer to Chapter 14 for specific related assessments.	Properly functioning equipment is required to maintain delivery of oxygen.
6. Assess other relevant priority body systems as appropriate, based on individual patient circumstances.	Nurses must use clinical judgment to adapt this assessment for each patient, based on the individual circumstances of an individual patient (Henley Haugh, 2015).
7. Survey the patient's environment. Assess the bed position and call bell location. The bed should be in the lowest position, and the call bell (based on specific patient care setting) should be within the patient's reach.	Environmental survey identifies problems that may harm the patient (Cohen, 2013).
8. Assess for clutter and hazards. Remove excess equipment, supplies, furniture, and other objects from rooms and walkways. Pay particular attention to high traffic areas and the route to the bathroom.	All are possible hazards and could cause the patient to fall.
9. Note the presence and location of appropriate emergency equipment, based on individual patient situation.	Emergency equipment must be immediately available if needed.
10. Note the presence and location of appropriate assistive devices and mobility aids, based on individual patient situation. Ensure any devices are within the patient's reach.	Assistive devices should be available for patient use.
11. Assess for the presence of an intravenous (IV) access and/or infusion. Assess patency of the device and the insertion site. If an infusion is present, assess the solution and rate. Refer to Chapter 16 for specific related assessments.	Assessment allows for identification of problems and ensures administration of intravenous fluids as prescribed.
12. Assess for the presence of any tubes, such as gastric tubes, chest tubes, surgical drains, or urinary catheters. Assess patency of the device and insertion site. Refer to Chapter 8 and Chapters 11through14 for specific related assessments.	Assessment allows for identification of problems and ensures patency of devices.
13. Provide a bedside commode and/or urinal/bedpan, if appropriate. Ensure that it is near the bed at all times.	This prevents falls related to incontinence or trying to get to the bathroom.
14. Ensure that the bedside table, telephone, and other personal items are within the patient's reach at all times.	This prevents the patient from having to overreach for a device or items, and/or possibly attempt ambulation or transfer unassisted.
15. Consider what further assessments should be completed and additional interventions that may be indicated. Identify problems that need to be communicated and whom to contact.	Early detection of problems allows for corresponding interventions to prevent adverse occurrences, supporting improved patient outcomes (Large & Aldridge, 2018).
16. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when a situational assessment has been completed, the patient's needs are met, and the patient remains free from injury.