A Comparison of NANDA and CCC used in Hospital-based Home Health Care

Park, Hyeoun-Ae,Lee, Jin-Kyung,Lee, Hyun-Jung The Research Institute of Nursing Science Seoul Na 2008 간호학의 지평 Vol.5 No.1

Background: Recent changes in the medical environment have increased the need for the home health care nursing in Korea. Even though the number of home health care patients is increasing, the major nursing problems have not been identified due to lack of a standardized nursing diagnosis. Aim: An investigative study was conducted to determine the frequency and appropriateness of nursing problems in hospital-based home health care patients in Korea using two internationally standardized nursing diagnosis classification systems. Methods: Nursing records of 249 hospital-based home health care patients were reviewed and nursing problems were identified using the North American Nursing Diagnosis Association Nursing Diagnosis Taxonomy I (NANDA) and the Clinical Care Classification of Nursing Diagnoses (CCC). Findings: Out of 463 nursing problems. 403 nursing problems were described using the NANDA whereas 427 nursing problems were described using the CCC. Nursing diagnoses not captured by the NANDA classification include nausea/vomiting, anorexia, risk for nutrition deficit, decreased blood pressure, dying process, blood sugar impairment. infection unspecified, and disuse syndrome. Nursing diagnoses not captured by the CCC include nausea/vomiting and anorexia. Conclusions: In describing nursing problems of home health care patients, it was found that the CCC was able to represent more diagnoses than the NANDA.

Usage Patterns of Nursing Diagnoses among Student Nurses in Psychiatric Unit: Relation with NANDA and SNOMED CT

( Hae Sook Hong ),( Jeong Eun Park ),( Wan Ju Park ) 한국간호과학회 정신간호학회(구 대한간호학회정신간호학회) 2015 정신간호학회지 Vol.24 No.1

Purpose: The aim of this study was to explore how nursing diagnoses are made by undergraduate students of psychiatric unit in Korea. Methods: Data were collected from case reports and analyzed based on NANDA (North American Nursing Diagnosis Association) nursing diagnoses and Systematized Nomenclature of Medicine- Clinical Terms (SNOMED CT) as reference terminology. Results: The 30 different nursing diagnoses from 135 distinct nursing diagnosis statements were assessed after removing repetition of case studies from a of total of 1,140 statements of nursing diagnoses. The most frequently used NANDA diagnosis was "ineffective coping" The thirty nursing diagnoses were grouped under 10 out of the 13 NANDA domains. In addition, 98 related factors were classified into SNOMED CT hierarchies of Clinical Finding, Procedure, and Observable Entity. The content validity index for the mapping of nursing diagnoses was 0.97, indicating a relatively strong agreement. Conclusion: These results can help students to improve their knowledge and better formulate appropriate diagnoses. Using standardized terminology would improve competency of education and help to ratify the steps of the nursing process, especially nursing planning. Educational strategies that enhance diagnostic accuracy are recommended.

간호정보의 처리, 분석, 관리 기술개발-인공신경망을 이용한 간호진단시스템 구현-

유지수,유황빈,박지원,고일선 대한의료정보학회 1998 Healthcare Informatics Research Vol.4 No.2

가정간호에서 사용된 간호진단과 간호중재 분류

서미혜,허혜경,Suh, Mi-Hae,Hur, Hae-Kung 한국가정간호학회 1998 가정간호학회지 Vol.5 No.-

This study was done to identify basic information in classifying nursing diagnoses and nursing interventions needed for the further development of computerized nursing care plans. Data were collected by reviewing charts of 123 home care clients who had active disease, for whom at least one nursing diagnosis was on the chart, and who had been discharged. Data included demographics, medical orders, nursing diagnoses and nursing interventions. The results of the study, which found the most frequent medical diagnoses to be cancer (40.7%) and brain injury (26.8%), showed that 'Impaired Skin Integrity'(18.3%), 'Risk for Infection'(15.0%), 'Altered Nutrition, Less than Body Requirements'(13.8%), and 'Risk for Impaired Skin Integ rity'(9.9%) were the most frequent nursing diagnoses. 'Pressure Ulcer Care'(28.4%) was the most frequent intervention for 'Impaired Skin Integrity', 'Infection Protection'(16.0%) for 'Risk of Infection', 'Nutrition Counseling'(26.8%) for 'Altered Nutrition' and 'Positioning'(22.0%) for 'Risk for Skin Integrity Impairment', Comparison of interventions with the Nursing Intervention Classification(NIC) showed that the most frequent interventions were in the domain 'Basic Physiological' (33.94%), followed by 'Behavioral'(27.8%), and 'Complex Physiological' (22.6%). Interventions related to teaching family to give care at home could not be classified in the NIC scheme. Examination of the frequency of NIC interventions showed that for the domain 'Activity & Exercise Management', 75% of the interventions were used, but for seven domains, none were used. For the domain 'Immobility Management', 93% of the times that an intervention was used, it was 'Positioning', for the domain 'Tissue Perfusion Management', 'IV Therapy' (59.1%) and for the domain 'Elimination Management', 'Tube Care: Urinary'(54.0%). The nursing diagnoses 'Altered Urinary Elimination' and 'Im paired Physical Mobility' were both used with these clients, but neither 'Fluid Volume Deficit' nor 'Risk of Fluid Volume Deficit' were used rather 'IV Therapy' was an intervention for 'Altered Nutrition, Less than Body Requirements', A comparison of clients with cancer and those with brain injury showed that interventions for the nursing diagnosis 'Impaired Skin Integrity' were more frequent for the clients with cancer, interventions for 'Risk of Infection' were similar for the two groups but for clients with cancer there were more interventions for' Altered Nutrition'. Examination of the nursing diagnoses leading to the intervention 'Positioning' showed that for both groups, it was either 'Impaired Skin Integrity' or 'Risk for Skin Integrity Impairment'. This study identified a need for further refinement in the classification of nursing interventions to include those unique to home care and that for the purposes of computerization identification of the nursing activities to be included in each intervention needs to be done.

임상 빅데이터를 이용한 영적간호진단 적용 현황 분석

김형순(Kim, Hyoungsoon),박현숙(Park, Hyunsook),정현숙(Chung, Hyun Sook),김미경(Kim, Mi Kyoung),박은영(Park, Eunyoung),김동연(Kim, Dong Yeon) 한국근거기반간호학회 2021 근거와 간호 Vol.9 No.1

Purpose: The aim of this retrospective study was to analyze spiritual nursing diagnosis records using clinical big data to learn spiritual nursing activities and to help improve spiritual nursing practice in the future. Methods: Eleven types of spiritual nursing diagnoses were applied to 422,733 patients who were admitted to a certified tertiary hospital between April 2011 and September 2018. Descriptive statistics and x2 tests were used to analyze the characteristics of the patients and nursing records. Results: There were 51,423 (12.2%) patients who were diagnosed through spiritual nursing. The patients received a total of 59,925 spiritual nursing diagnoses, including duplicate diagnoses. The most common spiritual nursing diagnoses was anxiety (58.4%), followed by dying (16.5%) and helplessness (7.6%) over the past eight years. Spiritual nursing data have a tense and anxious appearance, decreased activity, and decreased speech. Spiritual care plans and interventions have been used to encourage, listen, and express interest in expressing emotions. Conclusion: Through an analysis of big data, this study found the frequency of various spiritual nursing diagnoses, care plans, and interventions. Improving nurses’ perceptions of the spiritual nursing process, spiritual care education, and encouraging the performance of spiritual care may be an effective pathway to enhance the spiritual care competence of nurses.

수술 후 노인 회복 환자에 대한 주요 간호진단-간호중재-간호결과 연계체계에 관한 연구

박현주 ( Park Hyun Ju ) 이화간호과학연구소 2017 Health & Nursing Vol.29 No.1

Purpose: The purpose of this study was to identify the nursing diagnosis-nursing interventions-nursing outcomes (NNN) system to provide a standardized language for elderly patients in a postanesthetic care unit. Method: Measurements for this study came from three sources: the standardized language of nursing diagnoses developed by NANDA, the intervention of the NIC, and the outcomes of NOC for elderly patients. Results: We were able to establish NNN connections by selecting 6 major nursing diagnoses and arranging nursing interventions and nursing outcomes according to their frequencies in each respective category. The 6 major NNN connection for elderly patients following surgery recovery are Hypothermia-Temperature regulation-Thermoregulation; Acute pain-Analgesic administration-Pain level; Decreased cardiac output-Vital signs monitoring-Vital signs status; Ineffective breathing pattern-Respiratory monitoring- Respiratory: ventilation; Impaired oral mucous membrane-Oral health maintenance-Oral hygiene; Nausea-Nausea management-Nausea and Vomiting control. Conclusion: The NNN connection can be applied to elderly patients recovering from surgery for science-based and individualized nursing care.

온톨로지에 기반한 간호진단 지식모델의 설계

이인근(In Keun Lee),김화선(Hwa Sun Kim),이성희(Sung Hee Lee) 한국지능시스템학회 2012 한국지능시스템학회논문지 Vol.22 No.4

간호사는 NANDA, NIC, NOC과 같은 간호과정의 표준 가이드라인에 따라 간호 실무를 수행하고, 간호과정에 대한 정보를 전자의무기록 시스템에 기록하고 있다. 특히, NANDA는 간호진단 분류체계로써 간호진단의 추상적인 개념을 나타내고 있어, 상세한 간호진단 내용의 표현에 어려움이 있다. 그로 인해, 국내 병원에서는 자체적으로 간호진단 목록을 정의하여 사용하고 있으나, 이들은 표준이 적용되지 않아 간호기록의 전산화가 어려운 문제점이 있다. 따라서 본 논문에서는 NANDA와 SNOMED-CT와 같은 표준 용어체계를 참조하여 간호진단 개념을 표현하기 위한 온톨로지로 구축 방법론을 제시한다. 제안한 방법은 각 병원 및 분야에서 주로 사용하는 간호진단 목록을 체계적으로 구축함으로써 의료정보 시스템 간의 상호 운용이 가능하고 지식의 확장이 용이하도록 한다. 제안한 방법에 따라 경북대학교병원의 여성건강 간호기록 진술문을 분석하고, 간호진단 정보의 추출 및 정련을 통해 112개의 간호진단 용어를 생성하였다. 그리고 이 용어를 이용하여 여성건강 간호진단 온톨로지를 구축하였고, 전문가 평가 및 실험을 통해 개발한 온토롤지의 타당도와 실용성을 확인하였다. Nurses have performed their nursing practice according to the standard guidelines such as NANDA, NIC, and NOC, and recorded the information on nursing process into EMR system. In particular, NANDA, nursing diagnosis taxonomy, has difficulty expressing nursing diagnosis in detail because it represents abstract concepts of nursing diagnosis. So, the hospitals in KOREA have developed and used the list of nursing diagnosis on their own without referring the international standard terminologies, and it caused the delay of computerization of nursing records. Therefore, we proposed a ontology development methodology on nursing diagnosis based on NANDA and SNOMED-CT. The developed ontology, systematically developed with the frequently used nursing diagnosis terminologies in each hospital, based on the proposed methodology enables knowledge expansion and interoperable exchange of nursing records between EMR systems. We developed an ontology using the 112 nursing diagnosis terms defined by extracting and refining information on nursing diagnosis recorded in Kyungpook National University Hospital. We also confirmed the content validity and the usefulness of the developed ontology through expert assessment and experiment.

회복실 성인 수술환자의 주요 간호진단, 간호결과 및 간호중재 연계검증

조은장 (Cho, Eun Jaung),김남초 (Kim, Nam Cho) 병원간호사회 2008 임상간호연구 Vol.14 No.3

Purpose: This study aimed at applying a standardized nursing process to adult surgery patients of post anesthetic care unit, and examining the validity of linkages in the measuring index of nursing outcome by which nursing outcome was applied. Method: The subjects were 184 surgery adult patients admitted at the post anesthetic care unit of Y university hospital. This study was used the measured tool developed by Choi et al.(2004) and by Lee (2004) who had already verified a validity based on Johnson and Bulechek's study(2001). Results: The nursing diagnosis of an acute pain, an urinary retention, a nausea, a decreased cardiac output, an ineffective airway clearance and an ineffective airway clearance were used in taking care for patients. The related factors according to the main nursing diagnosis were as the following: an injurious physical factor in an acute pain, reflex arc inhibition in an urinary retention, post surgical anesthesia in a nausea, stroke volume change in a decreased cardiac output, secretory stasis in an ineffective airway clearance, pain in an ineffective breathing pattern. Conclusion: The study results could be facilitated in nursing process application for nurses at post anesthetic care unit. Also this study would provide basic data to develop a computerized program for the improvement of nursing process application.

한국형 Nursing Minimum Data Set[NMDS]구축을 통한 환자결과에 대한 연구

이은주 대한간호학회 간호행정학회 2006 간호행정학회지 Vol.12 No.1

Purpose: The purpose of this study is developing the nursing information system which contains the core elements of nursing practice, the Nursing Minimum Data Set (NMDS) that should be collected and documented all the settings in which nursing care is provided. Method: The program was developed under the hospital information system by TCP/IP protocol and used NANDA, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) to fill out the elements of NMDS. The Oracle was used as DBMS under the Windows 98 environment and Power Builder 5.0 was used as a program language. Results: This study developed linkage among the NANDA-NOC-NIC to facilitate choosing correct nursing diagnosis, interventions and outcomes and stimulate nurses' critical thinking. Also the system developed includes nursing care sensitive patient outcomes, so nurses can actively involve in nursing effectiveness research by analyzing the data stored in the database or by making relational databases with other health care related databases. Conclusion: The program developed in this study ultimately can be used for the nursing research, Policy development, reimbursement of nursing care, and calculating staffing and nursing skill mix by providing tool to describe and organize nursing practice and measure the nursing care effectiveness.

아동병동 입원 환아를 대상으로 간호학생이 내린 간호진단의 네트워크 분석

문미경 ( Mikyung Moon ) 한국보건정보통계학회(구 한국보건통계학회) 2017 보건정보통계학회지 Vol.42 No.3

Objectives: The purpose of this study was to identify key nursing diagnoses and sub groups of nursing diagnoses for children admitted in pediatric units using a Network Analysis. Methods: Data were obtained from 205 case reports submitted from nursing students who had done a clinical practicum in pediatric units. Five hundred and twenty-four NANDA-I nursing diagnoses were extracted from the case reports. Frequency, Centrality, and Clusters were generated by Network analysis with NetMiner 4.0. Results: Seventy eight different nursing diagnoses were identified. In general pediatric units, Hyperthermia was the most frequently used and highest degree centrality diagnosis. Ineffective airway clearness showed the highest between centrality. In a pediatric intensive unit, Impaired gas exchange showed the highest frequency, degree centrality, and between centrality. Four sub-groups in general pediatric units and 2 sub-groups in a pediatric intensive unit were identified. Conclusions: The results from this study could support clinical decision for selecting nursing diagnoses accurately and promptly.