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A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations,...
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Fundamentals of Nursing Process II01:25

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There are several characteristics related to delivering nursing care. One vital characteristic of the nursing process is that it can be used to protect nurses and justify the provided care. Productive use of the nursing process requires the knowledge and skills of nurses to assess and solve issues. Nurses should develop and strengthen their critical thinking skills and evidence-based nursing interventions to improve their skills in formulating nursing care plans. A well-defined approach to...
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Related Experiment Video

Updated: Feb 8, 2026

The Application of Point-of-Care Ultrasonography (POCUS) in the Management of Acute Respiratory Distress Syndrome (ARDS) in the Intensive Care Unit
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Structuring methodology of the Computerized Nursing Process in Emergency Care Units.

Fernanda Paese1, Grace Teresinha Marcon Dal Sasso1, Gabriela Winter Colla1

  • 1Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil.

Revista Brasileira De Enfermagem
|June 21, 2018
PubMed
Summary
This summary is machine-generated.

This study structured the Computerized Nursing Process using the International Classification for Nursing Practice (ICNP®) in emergency units. The ICNP® supports safe decision-making and improves healthcare quality for emergency care.

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Area of Science:

  • Nursing Informatics
  • Health Information Systems
  • Clinical Informatics

Background:

  • The Computerized Nursing Process (CNP) requires standardized terminology for effective implementation.
  • Emergency care units face unique challenges in documenting and managing patient care.
  • The International Classification for Nursing Practice (ICNP®) offers a standardized language for nursing phenomena.

Purpose of the Study:

  • To structure the Computerized Nursing Process for emergency care units using ICNP® version 2.0.
  • To develop a computerized system for nursing documentation in emergency settings.
  • To enhance the usability of nursing terminologies in critical care environments.

Main Methods:

  • Methodological and technological research approach.
  • Development of a team and resources for system construction.
  • Adaptation of clinical situations, diagnoses, and interventions for emergency care.
  • Association and codification of nursing data based on ICNP®.
  • Implementation of the structured data into a computerized platform.

Main Results:

  • 1,445 clinical evaluation possibilities were established.
  • 961 distinct nursing diagnoses were identified and linked to interventions.
  • The system was tailored to frequent emergency service situations.
  • A comprehensive computerized nursing process was developed.

Conclusions:

  • The ICNP® provides a robust framework for developing a computerized nursing process.
  • This structured approach supports nurses in making safe and informed decisions.
  • The implementation of the ICNP®-based system can improve the quality of healthcare in emergency units.