• 제목/요약/키워드: Nursing record

검색결과 328건 처리시간 0.022초

간호과정 용어체계를 이용한 간호기록 분석 - 군병원 정형외과 재원환자 기록 대상으로 - (Analysis on Military Hospital Nursing Records by NANDA, NIC, NOC System)

  • 김명자
    • 간호행정학회지
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    • 제16권1호
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    • pp.73-85
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    • 2010
  • Purpose: This study was to construct a useful nursing language system on military nursing field. Method: Military hospital nursing records were analyzed using NANDA(North American Nursing Diagnosis Association), NIC(Nursing Interventions Classification), and NOC(Nursing Outcomes Classification) systems. All kinds of nursing statements from 80 sets of orthopedics inpatient's records were deduced. All nursing statements were mapped to 167 NANDA diagnoses, 433 NIC interventions, and 260 NOC outcomes. Result: 14,744 nursing statements were extracted. Among the extracted nursing statements, 11.75% were linked with NANDA diagnosis, 83.62% were connected with NIC intervention, and 0.96% was tied to NOC outcome. 3.66% of nursing statements were not linked with NANDA-NIC-NOC system. In the nursing statements, 18 diagnoses of NANDA, 63 interventions of NIC, 8 outcomes of NOC were used. Conclusions: The majority of those nursing statements focused on nursing intervention of the nursing process; few nursing plans or goals were found in nursing records. Therefore, it's difficult to make the nursing process network with the nursing statements. Documenting nursing records using a nursing process will contribute to strengthen nursing practice in patient care and to develop nursing as science. Continuous further researches related to nursing records are needed to provide basic data for developing nursing language system and nursing record system.

NCASA(Nursing Child Assessment Sleep/Activity Record)를 이용한 초기 영아의 수면/활동 양상 연구 (A Study on the Sleep/Activity pattern in Normal Early Infants using NCASA (Nursing Child Assessment Sleep/Activity Record))

  • 박혜선;이영은
    • 부모자녀건강학회지
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    • 제3권1호
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    • pp.46-59
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    • 2000
  • The purpose of this study is to determine whether the NCASA (Nursing Child Assessment Sleep/Activity Record) would be suitable to evaluate and to provide the basic resources for a Korean model of sleep/activity patterns during the first 6 months Korean infants' lives and to provide a basis for nursing intervention for mothers of early infants. The subjects of this study were 94 normal infants from birth to 6 months of age who visited the postpartum care center and two general hospitals located in Pusan from February 1 to April 28, 2000. The method of data collection was through convenient sampling. The instrument of this study was the NCASA translated by the Korean parent Child Health Academic Association. The collected data were analysed by mean, standard deviation, frequency percentage and ANOVA, Post Hoc test by use of SPSS/PC. The conclusions obtained from this study are summarized as follows: 1. The mean amount of daytime sleep was 8.06 hours. The mean amount of nighttime sleep was 6.31 hours. The mean amount of total daily sleep was 14.37 hours. The mean of the longest sleep period was 5.20 hours. The mean regularity of daytime sleep was 25.84%. The mean regularity of nighttime sleep was 77.69%. The mean regularity of total daily sleep was 42.60%. The mean frequency of nighttime wakenings was 2.33 times. 2. The mean amount of daytime activity was 8.25 hours. The mean amount of nighttime activity was 1.39 hours. The mean amount of daily total activity was 9.64 hours. The mean of the longest activity period was 3.80 hours The mean frequency of daytime feeding was 5.69 times. The mean frequency of nighttime feeding was 2.08 times. The mean frequency of total daily feeding was 7.74 times. The mean frequency regularity of feeding was 54.62%. The mean frequency of wakenings was 5.14 times. The mean frequency of crying was 1.90 times. 3. According to an analysis of sleep patterns based on an infant's age, there were some significant differences in the following factors: amount of daytime sleep(p<.001), amount of night time sleep(p<.05), amount of total daily sleep (p<.001), longest sleep period(p<.001), regularity of daytime sleep(p<.001), regularity of nighttime sleep(p<.01), regularity of total daily sleep(p<.001), frequency of nighttime wakenings(p<.001). 4. According to an analysis of activity patterns based on an infant's age, there were some significant differences in the following factors: amount of daytime activity(p<.001), amount of nighttime activity(p<.01), amount of total daily activity(p<.001), longest activity period(p<.05), frequency of nighttime feeding(p<.01), frequency of wakenings(p<.001). 5. The mean amount of a mother's day time was 16.30 hours. The mean amount of a mother's night time was 7.70 hours. In conclusion, the initial irregular sleeping and activity patterns of the early infant became regurized as the infant grew older and estabilished firmer patterns of sleeping and of activity.

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모-태아 상호작용 증진 프로그램이 임부 및 영아의 수면-활동 양상에 미치는 효과 (Effects of a Mother-fetus Interaction Promotion Program on Sleep and Activity in Mothers and Infants)

  • 한경자;권미경;방경숙;최미영
    • Child Health Nursing Research
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    • 제16권4호
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    • pp.239-248
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    • 2010
  • Purpose: This study was done to evaluate effects of a mother-fetus interaction promotion program on maternal and infant sleep/activity regulation, and examine the correlation between maternal and infant sleep/activity. Methods: Thirty-four mother-infant dyads were recruited from an OB-GY clinic with postpartum care center, and assigned to the intervention group (17) or control group (17). Data were collected from January 18 to August 5 2005. A programmed education focused on mother-fetus interaction was provided to the intervention group in the 3rd trimester. Maternal sleep/activity record was completed at 32-36 weeks gestation and infant sleep/activity record was completed for one month after birth. Results: During the 3rd trimester, there were no significant differences in maternal sleep/activity between the groups, except for frequency of mothers' night awakening and urination at night. There were no significant differences in infant sleep, but significant difference was found in feeding times between the groups. Correlation of maternal sleep in the 3rd trimester and infant waking times was significant. Conclusion: The results of this study indicate that maternal sleep/activity during pregnancy influences infant sleep/activity at 3-4 weeks, and that nursing interventions to regulate maternal sleep/activity provided to primiparas can be beneficial to the regularity of infant sleep/activity patterns.

간호 대학생의 스트레스와 건강통제위 (The Relationships between Stress and Health Locus of Control in Nursing College Students)

  • 차남현
    • 동서간호학연구지
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    • 제19권2호
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    • pp.177-185
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    • 2013
  • Purpose: This study was to identify the relations between stress and health locus of control in nursing college students. Methods: A total of 243 subjects aged between 17 and 27 were selected through convenient sampling. Data were collected with a self reported questionnaire from March 2 to 25, 2013. Collected data were analyzed with SPSS/PC Win 15.0. Results: Differences in stress and health locus of control according to general characteristics were as follows. Stress were significantly different according to gender (t=-2.51, p<.05), grade (F=5.40, p<.01), school record (F=5.72, p<.01), stress solving methods (F=2.62, p<.05). Internal health locus of control was significantly different according to gender (t=2.30, p<.05), grade (F=14.73, p<.001), religion (F=4.63, p<.01), school record (F=5.29, p<.01), economic state (F=5.50, p<.001) and smoking (F=4.17, p<.05). Chance health locus of control was significantly different according to sibling rank (F=2.86, p<.05). Except chance health locus of control, internal heath locus of control and dependence health locus of control have a negative correlation with stress. 15.6% of variance in stress was explained by dependence health locus of control, chance health locus of control, and grade. Conclusion: The findings of this study may be useful in understanding the stress expression of nursing college students and developing more specific programs on personality and self-control.

보건소 방문 간호 사업의 질보장을 위한 연구 (A study for quality assurance of visiting nurses service of a public health center)

  • 윤순녕;이인숙;현혜진;유인자;김재남;배정희
    • 지역사회간호학회지
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    • 제6권2호
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    • pp.275-285
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    • 1995
  • The purpose of the study is to evaluate the visiting nurses service of a public health center. Data were collectd from the 36 clients who received services from a public health center. In terms of the process evaluation, the tool is composed 4 parts, 27 items such as assessment planning, implementation, and evaluation. It was measured through the health records by 2 peer review. In terms of the outcome evaluation, the level of client satisfaction was measured by self report or interview by 2 supervisor. The result were as follows: 1. 30% of 36 health records showed narsing process was not and out of them, nursing care plann including spectific activities were rarely established or unclear. 2. The lack of systematic data collection' showed and nursing diagnosis was not adressed in health records review. 3. Client satisfaction score was 32, 97, out of maximum score 36. 4. The lack of sufficent objective data, care plan, record of client's health status change, and evaluation was founded therefore quality assurance for visiting nurses service and in-service education are required and the development of standardized record system need.

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인공지능 기반 자연어처리를 적용한 욕창간호기록 분석 (Analysis of Pressure Ulcer Nursing Records with Artificial Intelligence-based Natural Language Processing)

  • 김명수;류정미
    • 한국융합학회논문지
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    • 제12권10호
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    • pp.365-372
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    • 2021
  • 본 연구의 목적은 자연어처리에 의해 생성된 욕창간호진술문의 특성을 파악하고, 욕창 단계판별 예측정확도를 평가하기 위함이다. 욕창관련 간호기록은 서술통계를 이용하여 분석하였고, 워드클라우드 생성기를 활용하여 욕창예방 간호기록에서 단어의 특성을 파악하였다. 딥러닝을 이용하여 욕창단계판별 정확도(accuracy ratio) 를 구하였다. 연구결과, 욕창의 단계에 대한 기록 중 2단계와 심부조직손상의심단계가 각각 23.1% 와 23.0 % 로 가장 많았고, 빈도수가 높은 핵심단어는 홍반, 수포, 가피, 부위, 크기 등으로 나타났다. 예측의 정확도가 높은 단계는 0단계, 심부조직손상의심단계, 2단계 순으로 나타났다. 따라서, 이를 활용하여 임상적 의사결정지지 시스템으로 개발된다면, 임상간호사의 욕창관리역량 향상 전략 개발에 기초가 될 수 있을 것이다.

만성폐쇄성폐질환 환자 사례에 대한 실시간 시뮬레이션 동영상 관찰기록 내용분석-간호술 수행을 중심으로 (Content analysis of real-time simulation video observation records about cases of patients with chronic obstructive pulmonary disease-focusing on nursing skills performance)

  • 홍지연;박진아
    • 융합정보논문지
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    • 제12권5호
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    • pp.40-50
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    • 2022
  • 본 연구는 간호대학생이 시뮬레이션 실습 시 동료 팀의 만성폐쇄성폐질환 환자 시나리오 구현 동영상을 실시간으로 관찰하면서 구조화된 동영상 관찰 기록지에 기록한 간호술 영역의 내용을 분석한 질적 연구이다. 4개의 세부영역으로 구분하여 기록된 내용을 효과적, 비효과적 측면으로 구분한 후 내용분석 방법을 사용하여 분석하였다. 연구결과 절차의 정확성에 있어서 효과적 측면은 필요한 물품준비와 증상완화를 위한 중재, 비효과적인 측면은 원칙 미준수, 부적절한 처방 이행, 이론과 수행의 연계 미흡으로 나타났다. 무균술 준수에 있어 효과적 측면은 내과적 무균술 적용과 외과적 무균술 적용, 비효과적 측면은 내과적 무균술 미수행과 외과적 무균술 미수행이었다. 안전과 안위 고려에 있어 효과적 측면은 심리적 안위 고려과 물리적 안전 고려, 비효과적 측면은 안위에 대한 실재감 부족과 환자안전 인식 미흡으로 나타났다. 설명 및 교육의 효과적 측면은 목적 설명과 방법 교육, 비효과적 측면은 설명 부족과 환자수준 미고려이었다. 본 연구에서 간호대학생은 관찰을 통하여 얻은 시각적 정보를 기록하는 과정을 통해 학습에 집중하고 기억을 강화시킬 수 있었을 것으로 사료된다. 또한 본 연구는 시뮬레이션 기반 실습을 통한 간호술 교육의 효율성을 높일 수 있는 요소들을 제시하였다는 점에서 의의가 있다.

복부수술환자의 간호과정 (Nursing Process of Abdominal Surgery Patients)

  • 유형숙
    • 간호행정학회지
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    • 제8권3호
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    • pp.411-430
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    • 2002
  • Purpose : This study was to develop Nursing Process Model of abdominal surgery patient using nursing diagnoses of NANDA, Nursing Interventions Classification(NIC), and Nursing Outcomes Classification(NOC). Method : The data in database were collected from nursing records in sixty patients with abdominal surgery admitted in a university hospital and open questionnaires of thirteen nurses. Systematic nursing process resulting from each nursing diagnoses, most common, was developed by the statistical analysis through database query from clinical database of abdominal surgery patients. Result : 51 nursing diagnoses were identified in abdominal surgery patients. The most commonly occurred nursing diagnoses were Pain, Risk for Infection, Sleep Pattern Disturbance, Hyperthermia, Altered Nutrition: Less Than Body Requirements in order. The linkage lists of NANDA to NIC and NANDA to NOC, and the nursing activities according to nursing diagnoses of abdominal surgery patients were identified in unit. Conclusion : Nursing Process of abdominal surgery patients was comprised of core nursing diagnoses, core nursing interventions, core nursing outcomes which provides the most reliable data in unit and could make nurses facilitate nursing process easily without full consideration of knowledge about nursing language classification system. Therefore, it could support nurses' decision making and recording of nursing process especially in the computerized patient record system if unit nursing process model using standardized nursing language system which contains of their own core nursing process data was developed.

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간호진단-간호결과-간호중재 연계를 이용한 내외과계 간호단위 간호정보시스템 구축 및 적용 (Construction and Application of Nursing Information System Using NANDA-NOC-NIC Linkage in Medical-Surgical Nursing Units)

  • 고은;소향숙
    • 성인간호학회지
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    • 제25권4호
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    • pp.365-376
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    • 2013
  • Purpose: The purpose of this study was to construct, develop, and apply a nursing information system (NIS) using NANDA-NOC-NIC linkage in medical-surgical nursing units. Methods: This study consisted of three phases which were the construction of the database, development of the NIS, and application of the NIS. To construct the database, a questionnaire and nursing record review by an expert group were used. Collected data were analyzed by the SPSS/WIN 13.0 program. Results: In first phase, the database was made up of 50 nursing diagnoses, 127 nursing outcomes and 300 nursing interventions. In the second phase, NIS was developed according to its flow diagram and then tested. In the third phase, the developed NIS was applied to 130 inpatients. Nursing diagnoses frequently used were acute pain, delayed surgical recovery, and deficient knowledge (specify). Nursing outcomes for a nursing diagnosis of 'acute pain' were identified as pain control, pain level and comfort level. Nursing interventions for the nursing outcome 'pain control' were pain management, patient controlled analgesia assistance and medication management. Conclusion: The results of this study will facilitate the use of the newly proposed NIS in nursing practice and provide a guideline for evidence-based nursing.

외래 및 퇴원환아 부모의 전화상담요구와 간호중재에 대한 조사연구 (An investigational study on telephone calls to the pediatric nursing unit)

  • 강화자;한경자;최명애;박승현;김영미;권원경;김선구;안혜영;허미영
    • Child Health Nursing Research
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    • 제2권1호
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    • pp.112-126
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    • 1996
  • The purpose of this study was to investigate the current status of the need of telephone call and to identify the status of nursing intervention through telephone. Head nurses of the pediatric nursing unit and a nurse of pediatric outpatient clinic wrote down the telephone record of calls by parents of children discharged from hospital from 7 am to 3 pm during the period of March to June, 1995. Content of 120 telephone calls but for 26 calls with incomplete record among 146 calls were analyzed into frequency of general characteristics, needs and nursing intervention. The needs of telephone call were identified and classified into 11 areas and analyzed into frequency of detailed content by 11 areas. Nursing intervention was identified and classified into 10 categories, and analyzed into frequency of detailed content by 10 categories. The findings of this study were as follows ; The need of telephone call was identified with nutritional state, medication, vital signs, language retardation, personal hygiene, vaccination, administration procedure, physical symptoms, follow up care management and others. The most frequent needs were physical symptoms and vaccination. A kind of food among nutrition dose of drugs among medication, fever among vital signs, cough among physical symptoms, and content of vaccination among vaccination was the most frequent needs. Nursing intervention through telephone was identified with instruction, knowledge offer, information offer, judgement, solicitation, referral and instruction, referral, connection, reassurance, reservation, and regulation. Instruction, knowledge offer and information offer was the most frequent nursing intervention by telephone call. Instruction was about a visit to hospital, a visit to nearby clinic, instruction about symptoms,, instruction about nursing care procedure, retelephoning and vaccination. Knowledge offer was about vaccination, knowledge related to medication, and dental care. Information offer and judgement was about vaccination and medication. Referral and instruction delivery was about instruction delivery following consultation to doctor, visit to emergency room and a visit to hospital following consultation to doctor. These results suggest that telephone call intervention program should be established as a field of extended pediatric nursing role in health care delivery system for the children.

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