Situational Assessment in Nursing Quiz

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Questions and Answers

A situational ment is a systematic process to gather, analyze, synthesize, & communicate data to inform planning decisions. Aim promotes a safer patient care environment and helps the nurse develop care priorities and attention to clinical detail. Directions – Enter the patient's room and observe the patient, family, and environment (ABCs, IVs, tubes, oxygen, safety, and environmental safety), including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. Procedural Steps: 1. Use standard protocol. (..going pt’s room..until assuming pt’s position & put on PPE, if indicated) 2. Explain the purpose of the ment to the pt. 3. Assess for data that suggest a problem with the pt’s airway, breathing, or circulation. 4. If a problem is present, identify if it is urgent or non-urgent in nature 5. Assess the pt’s LOC, & orientation. (Observe the pt’s behavior & speech) 6. Note the presence & location of appropriate equipment, based on the individual pt’s situation a. Emergency carriage in pt’s room b. Respirator, oxygen devices. c. Monitor. 7. Note the presence & location of appropriate equipment, based on the individual pt’s situation a. Emergency carriage in pt’s room b. Respirator, oxygen devices. c. Monitor. 8. Assess the patency & function of any device, if in use. a. IV access &/or infusion bag/s (site of insertion, type, amount, patency, rate of infusion,) b.

assess

Explain the purpose of the assessment to the pt. 3. ______ for data that suggest a problem with the pt’s airway, breathing, or circulation.

Assess

If a problem is present, identify if it is urgent or non-urgent in nature 5. ______ the pt’s LOC, & orientation. (Observe the pt’s behavior & speech)

Assess

Note the presence & location of appropriate equipment, based on the individual pt’s situation a. Emergency carriage in pt’s room b. Respirator, oxygen devices. c. Monitor. 7. Note the presence & location of appropriate equipment, based on the individual pt’s situation a. Emergency carriage in pt’s room b. Respirator, oxygen devices. c. ______.

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Assess the patency & function of any device, if in use. a. IV access &/or infusion bag/s (site of insertion, type, amount, patency, rate of infusion,) ______

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The patency & type of drainage tubes (gastric tube, chest tubes, surgical drains, Foley catheter) c.Observe & measure the output (amount, color, odor, & consistency) 9.Survey the whole pt’s environment.a.Bed should be in lowest position (Side rails regarding pt’s condition (turn in bed &/or keep them up) b.Call bell within pt’s reach c.Remove excess equipment supplies and furniture d.Remove other objects from rooms & walkways e.Pay particular attention to high-traffic areas & the route to the bathroom f.Appropriate assistive devices & mobility aids (crutches, wheelchair.) are within pt’s reach g.Provide a bedside commode &/or urinal/bedpan, if appropriate.(Ensure that it is near the bed) h.Ensure that the bedside table, telephone, & other personal items are within the pt’s reach/ all times 10.Complete all assessments & identify what problems need to be reported & whom to contact 11.Complete standard protocol;..(from reassume pt’s position..until documentation) 12.Document significant assessment findings (Hgt, Na+ , K + levels…severe diarrhea, cyanosis..)

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The patency & type of drainage tubes (gastric tube, chest tubes, surgical drains, Foley catheter) c.Observe & measure the output (amount, color, odor, & consistency) 9.Survey the whole pt’s environment.a.Bed should be in lowest position (Side rails regarding pt’s condition (turn in bed &/or keep them up) b.Call bell within pt’s reach c.Remove excess equipment supplies and furniture d.Remove other objects from rooms & walkways e.Pay particular attention to high-traffic areas & the route to the bathroom f.Appropriate assistive devices & mobility aids (crutches, wheelchair.) are within pt’s reach g.Provide a commode &/or urinal/bedpan, if appropriate.(Ensure that it is near the bed) h.Ensure that the table, telephone, & other personal items are within the pt’s reach/ all times 10.Complete all assessments & identify what problems need to be reported & whom to contact 11.Complete standard protocol;..(from reassume pt’s position..until documentation) 12.Document significant assessment findings (Hgt, Na+ , K + levels…severe diarrhea, cyanosis..)

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The patency & type of drainage tubes (gastric tube, chest tubes, surgical drains, Foley catheter) c.Observe & measure the output (amount, color, odor, & consistency) 9.Survey the whole pt’s environment.a.Bed should be in lowest position (Side rails regarding pt’s condition (turn in bed &/or keep them up) b.Call bell within pt’s reach c.Remove excess equipment supplies and furniture d.Remove other objects from rooms & walkways e.Pay particular attention to high-traffic areas & the route to the bathroom f.Appropriate assistive devices & mobility aids (crutches, wheelchair.) are within pt’s reach g.Provide a bedside commode &/or urinal/bedpan, if appropriate.(Ensure that it is near the bed) h.Ensure that the bedside table, telephone, & other personal items are within the pt’s reach/ all times 10.Complete all s & identify what problems need to be reported & whom to contact 11.Complete standard protocol;..(from reassume pt’s position..until documentation) 12.Document significant findings (Hgt, Na+ , K + levels…severe diarrhea, cyanosis..)

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The patency & type of drainage tubes (gastric tube, chest tubes, surgical drains, Foley catheter) c.Observe & measure the output (amount, color, odor, & consistency) 9.Survey the whole pt’s environment.a.Bed should be in lowest position (Side rails regarding pt’s condition (turn in bed &/or keep them up) b.Call bell within pt’s reach c.Remove excess equipment supplies and furniture d.Remove other objects from rooms & walkways e.Pay particular attention to high-traffic areas & the route to the bathroom f.Appropriate assistive devices & mobility aids (crutches, wheelchair.) are within pt’s reach g.Provide a bedside commode &/or urinal/bedpan, if appropriate.(Ensure that it is near the bed) h.Ensure that the bedside table, telephone, & other personal items are within the pt’s reach/ all times 10.Complete all assessments & identify what problems need to be reported & whom to contact 11.Complete standard protocol;..(from reassume pt’s position..until ______) 12.Document significant assessment findings (Hgt, Na+ , K + levels…severe diarrhea, cyanosis..)

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Study Notes

Situational Assessment

A systematic process to gather, analyze, synthesize, and communicate data to inform planning decisions, promoting a safer patient care environment.
Helps the nurse develop care priorities and attention to clinical detail.

Procedural Steps

Enter the patient's room and observe the patient, family, and environment.
Use standard protocol when entering the patient's room.
Explain the purpose of the situational assessment to the patient.

Patient Assessment

Assess for data that suggest a problem with the patient's airway, breathing, or circulation.
Identify if the problem is urgent or non-urgent in nature.
Assess the patient's level of consciousness (LOC) and orientation.
Observe the patient's behavior and speech.

Equipment Assessment

Note the presence and location of appropriate equipment, such as emergency carriages, respirators, oxygen devices, and monitors.
Assess the patency and function of any device in use, including IV access and infusion bags.

Environmental Survey

Survey the whole patient's environment, ensuring the bed is in the lowest position and side rails are adjusted according to the patient's condition.
Ensure the call bell is within the patient's reach.
Remove excess equipment, supplies, and furniture, and other objects from rooms and walkways.
Pay particular attention to high-traffic areas and the route to the bathroom.
Ensure assistive devices and mobility aids, such as crutches and wheelchairs, are within the patient's reach.
Provide a bedside commode or urinal/bedpan, if appropriate.
Ensure the bedside table, telephone, and other personal items are within the patient's reach.

Documentation and Reporting

Complete all assessments and identify what problems need to be reported and whom to contact.
Complete standard protocol.
Document significant assessment findings, such as vital signs, lab results, and observations of abnormal symptoms.

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Description

Test your knowledge about performing situational assessments in nursing, which involves gathering, analyzing, synthesizing, and communicating data to inform planning decisions. This process aims to promote a safer patient care environment and helps nurses develop care priorities and attention to clinical detail.