Background: Congenital defect gastroschisis manifests as a defect in the sheath in the intestine of the newborn, which is not covered by the hernia sac. In this case, the priority task of the neonatal nurse is to diagnose patient care problems quickly and accurately. Choosing the correct care plan elements has a significant impact on shortening the duration of hospitalization, reducing the number and severity of complications, and preventing their recurrence. The purpose of this study was to formulate a care plan for a newborn with diagnosed congenital defect gastroschisis in the postoperative period, using the International Classification for Nursing Practice (ICNPTM) within the nursing documentation and decision support system, the "ADPIECare Dorothea" software.
Methods: After a review of the relevant literature and nursing documentation, a case study of a newborn with the congenital defect gastroschisis was described. A care plan was prepared using ICNP and the "ADPIECare" software.
Results: It was possible to organize and standardize care plans to provide consistent and comprehensive professional nursing care. The system supporting nursing decisions suggested interventions personalized for the nursing diagnoses and to the patient needs.
Conclusions: Our findings can help to optimize the nurse's work organization to improve health care quality, outcomes, and effectiveness.
Keywords: ICNPTM; IT; care plan; classification; gastroschisis; mapping terminology; nursing care.