Computerized nursing process: methodology to establish associations between clinical assessment, diagnosis, interventions, and outcomes

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.