Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Nursing Care Processes
Lecture:Nursing process including clinical judgment and patient assessment; legal and societal expectations; and roles in improving patient care
Slide content:Five-Step Nursing Process 6.1 Chart: By Vivian Todhunter and CAST, CC-BY 11
Slide notes:All nurses follow a system called the nursing process when they are working with patients. Nurses use clinical judgment skills throughout the nursing process in order to create the best possible outcome for each patient. The nursing process is a holistic system that treats both the problem and the patient. It allows the nurse to evaluate both the immediate health problem and the context of the problem, such as how the health problem affects the patient and the patients family. The nursing process has five steps: assessing the patient, diagnosing the problem, creating a plan of care, implementing the plan, and evaluating how well the plan works. The following slides explain each step of the process. The nurse must document all steps of the nursing process in the plan of care so that other health care providers who care for the patient can then follow the plan. The plan of care can also be used to evaluate how well treatment is working. 11