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[Computerized nursing process: methodology to establish associations between clinical assessment, diagnosis,
Grace Teresinha Marcon Dal Sasso1, Daniela Couto Carvalho Barra, Fernanda Paese
1Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil. grace@ccs.ufsc.br
Abstract:
The Nursing Process is a care technology that guides the sequence of clinical reasoning and improves the quality of care. This article reports the development of a Computerized Nursing Process (CNP) for the Intensive Care Unit. The study was conducted in three main steps: discussion and understanding of the International Organization for Standard 18104; theoretical expertise regarding the ICNP® 1.0; and the association of information with nursing diagnoses and interventions. The knowledge base was organized according to the ICNP® Version 1.0. The result was a restructuring of the CNP from the association of clinical evaluations to diagnosis and interventions that allow documentation of the clinical practice of nursing and provide support for decision-making. The methodological steps employed permitted the creation of an association between the clinical evaluation, diagnoses, interventions and results of the ICNP ® 1.0 with ISO 18104.
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