ATI Ch. 7 Flashcards
This is collected during the nursing history. It includes client’s feelings, perceptions and descriptions of health status. Clients are the only ones who can describe their own symptoms.
Subjective data (symptoms).
This is collected during the physical exam. The nurse sees, hears, feels and smells this data through observation and physical assessment of the client.
Objective data (signs).
What the client tells the nurse.
Primary source.
What others tell the nurse based on what the client has told them.
Secondary source.
The three types of planning nurses do:
- Initial Comprehensive Plan. 2. Ongoing planning. 3. Discharge planning.
Identifies optimal status.
Goals.
Identify observable criterion that will determine success or failure of the goal.
Outcomes.
Use evidence and scientific rationale to take autonomous actions to benefit clients. These are based on identified problems and are within the scope of their practice.
Nurse-initiated/independent interventions.
Interventions nurses initiate based as a result of the provider’s prescription or facility protocol.
Provider-initiated/dependent interventions.
Interventions nurses carry out in collaboration with other health care team professionals.
Collaborative interventions.
The end product of the planning step.
The NCP -Nursing Care Plan.
