A client arrives in the emergency department.He is pale and breathing rapidly.He immediately becomes unconscious and collapses to the floor.The nurse rapidly assesses the patient and decides the first series of actions that are needed.This scenario demonstrates:

Question

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Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind.The end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths; this nurse has no time to create a holistic plan of care.Ongoing planning refers to changes made in the plan as the nurse evaluates the patient's responses to care; no care has been given at this point.Initial planning does indeed begin with the first patient contact.However,it refers to the development of the initial comprehensive plan of care; this nurse does not have enough data for a comprehensive plan,nor does she have time to make such a plan at the moment.

A Client Arrives in the Emergency Department