• Journal of Korean Academy of Fundamentals of Nursing
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• v.4 no.1
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• pp.119-131
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• 1997

This study was conducted to analyze the nursing diagnoses applied for case studies of nursing students through their clinical practices, and to provide the educational basis of nursing diagnoses with its results. The data were collected for two years(1995 and 1996) from 70 case studies reported by the 2nd and 3rd year nursing junior college students. The students made 259 nursing diagnoses among which 230 diagnoses qualified NANDA classification and were taken for analysis. The results of the analysis were as follows : 1. The number of diagnoses indicating response patterns was 35(35.7%), whereas 98 diagnoses in NANDA table. Among the 35 diagnoses, the pattern of exchange was most frequent, then feeling, moving, knowing in rank. 2. The diagnoses were analyzed in the categories of response patterns. For Instance, 'Altered in Nutrition' was most frequent in exhange, then Risk for Infection', 'Ineffective Airway Clearance', in rank. 3. Among 230 diagnoses, 'Knowle Deficit' was most frequently mentioned, then 'Activity Intolerance' 'Anxiety', 'Pain', 'Altered in Nutrition', 'Risk for Infection', 'Ineffective airway clearance', in rank. 4. The types of word expression of each diagnoses were various. 'Activity Intolerance' was expressed in 6 types. 5. The relating factors applied to each diagnosis were analyzed. For Instance, the relating factor of 'Knowledge Deficit' were illness, and therapeutic process, lack of motivation, occurrance of complication, short experience, operation, and so on. From the above study, the researcher would like to recommend as follows : 1) The current diagnoses need to be verified its content validity, when they are applied to our culture. 2) The most effective educational method for applying nursing diagnoses should be explored. 3) Further study could be focused on not only 'relating factors' but also 'sign and symptoms'.

• Journal of Korean Academic Society of Home Health Care Nursing
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• v.2
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• pp.35-51
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• 1995

This study was done to define nursing diagnose and to test the validity of the characteristics for patients with cerebrovascular accidents being seen at home by home health care nurses. This study was a descriptive study. The sample consisted of 10 experts(professors and home health care nurses) who had had a variety of experience using nursing diagnoses in clinical practice, and 336 nurse progress notes for 18 patients with cerebrovascular accidents. First, 32 nursing diagnoses were defined by the analysis of 336 nurse progress notes, and ten nursing diagnoses were selected according to a criteria of frequency and four nursing diagnoses from home health care clinical practice. Second, content validity was examined by an expert group which considered the sign / symtoms of the fourteen nursing diagnoses. The instrument used for this was a checklist for sign / symtoms based on the nurse progress notes and literature : Carpenito(1993), Kim Cho Ja et al (1994), Lee Sun Ok et al.(1994), Kim Mae Ja et al. (1992), Seoul University Hospital (1993) , Kim Mi Ja et al. (1991). The data were collected from March 1995 to April 1995. Data were analyzed using Content Validity Incidence where if 80% or more of the expert group agreed, characteristics were defined as a major sign/symtoms, if between 50% and 79% of the expert group agreed with the characteristic it was defined as a minor sign / symtoms. The results of this study are summarized as follows : 1. Thirty-two nursing diagnoses related to patients with cerebrovascular accidents were defined. There was a high frequency for the following : 'Potential for disuse syndrome (61%)', 'Impaired physical mobility(50%)', 'Impaired skin integrity (44.4%)', Potential for aspiration(33.3%)', 'Potential for infection: respiration(33.3%)', 'Self-care deficit : bathing /hygine(27.8%)', 'Ineffective family coping(22.2%)', 'Potential for trauma(22.2%)', 'Alteration in nutrition: less than body requirements(22.2%)'. The following diagnoses were also used in home health care clinical practice : 'Anxiety in family (50%)', 'Caregiver fatigue(27.8%)', 'Ineffective treatment behavior (22.2%)', 'Ineffective Levin tube management and Levin tube feeding(22.2%)'. Fourteen nursing diagnoses were selected. 2. Ten of the nursing diagnoses for patients with cerebrovascular accident were listed as nursing diagnoses by NANDA but four nursing diagnoses were new nursing diagnoses used in home health care clinical practice. 3. Characteristics of the ten Nursing Diagnoses from NANDA were developed from the sign /symtoms in the literature and in the nurse progress notes. These characteristics was verified as major or minor sign / symtoms by the expert group. 4. Characteristics of the four nursing diagnoses used in home health care were not defined by the literature but only by the nurse progress notes and verified as major or minor signs /symtoms by the expert group. On the basis of the findings of this study, the following recommendations are made : 1. Continual study is necessary to identify other signs /symtoms not verified in this study. 2. It is necessary to use verified signs /symtoms in home health care clinical practice. 3. It is necessary to define related factors which define each diagnoses in this study. 4. It is necessary to develop of standardized nursing are plans which include defined signs and symtoms. 5. It is necessary to study the outcomes of the standardized nursing care plans.

• Journal of Korean Academy of Nursing
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• v.25 no.3
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• pp.457-471
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• 1995

This research was done to promote improvement of practical application of nursing diagnoses and to improve the quality of nursing. The subjects of this research were 156 second year students of C junior nursing college who were giving adult patient care. The nursing diagnoses of 312 reports were analyzed using NANDA. In these case reports only nursing diagnoses were considered, of which there were a total of 982. In the data analysis the 9H of the nursing students' nursing diagnoses matched with 105 NANDA nursing diagnoses, Of these, the most frequent diagnoses were pain(165, 17.48%), anxiety(101, 10.70%), alteration in nutrition(83, 8.79%) , sleep disturbance (67, 7.10%), in activity intolerance (67, 7.10%), ineffective breathing pattern(51,5.40%). The etiology for the students' nursing diagnoses were compared with NANDA's nursing diagnoses by frequency. The most frequent etiology for the nursing diagnoses of pain was a biological etiology(50, 31%), for anxiety, situation crisis(58, 57.43%), for alteration in nutrition, indigesion(23, 27.71%), for sleep disturbance, external etiology(25, 37.32%), for activity intolerance, immobile position(22, 32.84%), for ineffective breathing pattern, pain(35, 68.63%), and for ,impaired physical mobility, pain(31, 65.96%). The most frequent etiology for constipation was inadquate digestion of water and cellulose (16, 34.78%), for fluid volume felicity, loss of body fluid (21, 52.50%), for impaired skin integrity, external etilogy(16, 43.24%), for impaired physical mobility, pain(22, 62.86%) , for knowledge deficits, cognition disturbance(9, 27.27％), for ineffective air way clearance, secretion obstruction(14, 48.27%) , for impaired gas exchange, loss of transport ability of blood oxygen(9, 37.50%) , and for powerlessness, therapy environment (5, 22.73%). The number of nursing diagnoses by pattern was exchange(16), moving(6), feeling(4), choosing(4), relating(3), communication(1), perceiving(1), knowing(1), valuing(1).

• Journal of Korean Academy of Nursing
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• v.26 no.4
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• pp.930-945
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• 1996

The purpose of this study was to identify the degree to which nursing diagnoses accepted by NANDA are used and to identify problems in application of nursing diagnoses in clinical practice. With the expanding potential for computerization of nursing diagnosis, the survey also included data on the present status of hospital computerization and willingness to use computerized nursing diagnoses. The data collection was done from July 1 to August 3, 1996 using structured questionnaires. The questionnaires were mailed to 1,126 head nurses working in 44 hospitals with on occupacy of over 500 beds located in Korea, of these, 883 were returned from 40 hospitals. Among the 883 questionnaires, 867 were used for the analysis. The results of the analysis are as follows 1. Among 109 nursing diagnoses, pain, constipation, diarrhea, hyperthermia, high risk for infection, sleep pattern disturbance, and anxiety, chronic pain, altered urinary elimination, and altered nutrition : less than body requirements were the ten most frequently used diagnoses. 2. The primary problem in the use of nursing diagnoses was lack of time and personnel. Others were lack of knowledge and motivation, absence of protocols and absence of the appropriate methods to apply nursing diagnoses. 3. Among the 40 hospitals, 27 hospitals used a computerized system and expressed willingness to utilize the computerized system of nursing diagnoses that is planned for the future.

• Journal of Korean Academy of Nursing
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• v.28 no.2
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• pp.468-478
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• 1998

The purpose of this study was to develop the computerized nursing diagnoses system for clinical application and activation of nursing diagnoses based on validity verification. In addition, our research team also performed system tests in clinical situations, to identify ways to improve the program and make it more practical. Nursing Diagnoses System will increase nurses' knowledge and experience of the application of nursing diagnoses in clinical situations and development of nursing interventions by nurses as well as the effectiveness of hospital computerized systems. We expect this system can contribute to an improvement in the quality of nursing care. Also we will continuously evaluate and revise the system related to the utilization of the program.

• Journal of Korean Academy of Nursing
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• v.33 no.2
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• pp.210-219
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• 2003

Purpose: The purpose of this study was to identify nursing importance and the performance of nursing interventions linked to five nursing diagnoses and find out core nursing interventions to each of the five nursing diagnosis. The five nursing diagnoses were Pain, Diarrhea, Constipation, Hyperthermia, and Infection: Risk for. Method: Data was collected from nurses working in four different hospitals. Data were analyzed using mean, SD, and paired t-test to compare difference between importance and performance of each intervention. Result: In general interventions related to medication, such as Medication Administration: IV, Medication Administration: IM, Medication Administration: Oral, Medication Management were all considered highly important and performed very often regardless of nursing diagnoses. And the level of importance was higher than the performance in most of all the interventions linked to five nursing diagnoses. Only two interventions, Medication Administration and Intravenous (IV) insertion had higher level of performance than importance in the diagnoses of Pain and Diarrhea respectively. Conclusion: Using the above findings, we now know which intervention should be performed more frequently to solve nursing problems and which interventions are more critically important to nursing diagnosis. This information can be very helpful for developing nursing information system.

• Women's Health Nursing
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• v.22 no.3
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• pp.170-181
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• 2016

Purpose: The aim of this study was to identify the nursing diagnosis-outcome-intervention (NANDA-NOC-NIC) linkages for gynecology inpatients shown in their electronic nursing records. Methods: This retrospective and descriptive research was conducted in two steps and based on the 287 electronic nursing records for 253 patients. First, nursing diagnoses, outcomes and interventions were collected. To identify major nursing diagnoses, a comparison was done with the top 10 nursing diagnoses from this research and with previous research selected using a content validity index developed by a team of professionals. Second, nursing outcomes and interventions that were associated with major nursing diagnoses were identified. Results: Nineteen nursing diagnoses, 12 nursing outcomes, and 40 nursing interventions were collected. The top 5 major nursing diagnoses were identified and 7 nursing outcomes and 18 nursing interventions associated with these diagnoses were checked. Conclusion: The identified NANDA-NOC-NIC linkages can contribute to improving nursing practice and will help in the establishment of standardized nursing care.

• Quality Improvement in Health Care
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• v.10 no.2
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• pp.204-215
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• 2003

Background : ICD-10 Classification, which is used domestically as well as internationally, has limited use in the clinical practice since it is developed for at disease statistics and epidemiology. Therefore, the purposes of this study were to improve the quality of diagnosis by constructing a new disease classification based on the diagnoses doctors currently make in the clinical setting and connecting this classification with OCS and EMR, and to meet the demands of doctors for high quality medical study data in medical research. Methods : The specialists in each ophthalmic subfield collected clinical diagnoses and abbreviations based on the ophthalmology textbooks and confirmed the classifications. Total number of clinical diagnoses collected was totaled 672, for which ideal diagnoses had been selected and a new model of disease classification model in connection with ICD-10 was constructed. The constructed classification of clinical diagnoses consisted of six steps: the first step was the classification by ophthalmic subspecialty field; the second to fifth steps were the detailed classification by each specialty field; the sixth step was the classification by site. Results : After introducing the new disease classification, research on the use and a pre-post comparison was conducted. The result from the research on the use of the clinical diagnoses in inpatient and outpatient care has shown a gradually increasing tendency. From the pre-post comparison of EMR discharge summary diagnoses, the result demonstrated that the diagnosis was stated correctly and in detail. Since the diagnosis was stated correctly, code classification became correct as well, which makes it possible to construct high quality medical DB. Conclusion : This construction of clinical diagnoses provides the medical team with high quality medical information. It is also expected to increase the accuracy and efficiency of service in the department of medical record and department of insurance investigation. In the future, if hospitals wish to construct a classification of clinical diagnosis and a standard proposal of clinical diagnosis is presented by a medical society, the standardization of diagnosis seems to be possible.

• The Korean Journal of Rehabilitation Nursing
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• v.2 no.1
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• pp.22-28
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• 1999

The development of standards and guidelines of rehabilitation nursing has been the major concerns for providing better nursing to the rehabilitation clients. As the patients with stroke and spinal cord injuries are the most prevalent physical disabilities in Korea, this study focussed on the nursing diagnoses of these two groups of patients. In order to identify the nursing diagnoses frequently used In their practice for the patients with stroke and spinal cord injuries, a survey was done with the questionnaire form developed by the research team. The surveyee were the staff nurses working at rehabilitation wards more than 2 years from 8 general hospitals in Korea, They identified and set the priorities of 13 nursing diagnoses from 79 stroke patients and 10 nursing diagnoses from 35 patients with spinal cord injuries during the periods from March 1 to June 2, 1999. The identified nursing diagnoses for the stroke patients are impaired physical immobility, sensory-perceptual alteration, activity intolerance, self-care deficit, altered defecation, altered urination, risk for injury, unilateral neglect, impaired skin integrity, altered thought processes, pain, altered health maintenance, dysreflexia. The identified nursing diagnoses for spinal cord injuries are altered urination, altered defecation, impaired skin integrity, pain, risk for injury, reflex incontinence, impaired physical immobility, self-care deficit, activity intolerance, knowledge deficit.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.22 no.1
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• pp.16-24
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• 2015

Purpose: This study was done to identify essential nursing diagnoses using NANDA and their related factors and defining characteristics of patients who were cared in an emergency room. Methods: The research checklist developed by the researcher consisted of 44 nursing diagnoses with defining characteristics and related factors and was applied to 235 patients who were admitted to an emergency room from November 1 to December 31, 2012. Results: Forty-one of forty-four nursing diagnoses were identified. The most frequent nursing diagnoses were acute pain, risk for falls, and activity intolerance. The most frequent defining characteristic for the nursing diagnosis of 'acute pain' was verbal report of pain. The agreement rate with NANDA (2009)'s defining characteristics was 66.7%. Conclusion: Results indicate that identification of essential nursing diagnoses and their defining characteristics and related/risk factors is important for emergency patient nursing care to facilitate use of NANDA taxonomy in the emergency nursing practice and documentation systems.