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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

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Summary

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.