Journal of Korean Academy of Nursing (대한간호학회지)

Korean Society of Nursing Science (한국간호과학회)
권호 표지

Analysis of the Nursing Practice in a Medical ICU Based on an Electronic Nursing Record

간호기록을 이용한 중환자실 간호업무 조사연구

  • 송경자 (서울대학교병원 간호부 간호행정팀)
  • Published : 2007.10.31
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: The purpose of this study was to identify the entity of critical care nursing practices through analyzing nursing statements described by electronic nursing records in a MICU. Methods: 176,459 nursing statements of 188 patients during a 6 month-stay were analyzed statement by statement according to the nursing process(nursing phenomena, nursing diagnosis, & nursing activity) and 21 nursing components of Saba's Clinical Care Classification. Results: Among 176,459 single statements, the statements of nursing activity ranked first in number. The contents of the statements were analyzed and categorized by main themes. Among 489 categorized themes, the number of themes of nursing phenomena statements was the highest. When analyzed by Saba's clinical Care Classification, the nursing statements mainly included a physiological component. Among 21 components, the respiratory component ranked in the first position in nursing phenomena, nursing diagnosis and nursing activity. The extra statements not included in the 21 components were 9,294(15.1%) in nursing phenomena and 21,949(22.7%) in nursing activity. Most are statements related to tests and the doctor. Conclusion: The entity of MICU nursing practice expressed by electronic nursing records was mainly focused on physiological components and more precisely on respiratory components.

Keywords

References

  1. Brilli, R. J., Spevetz, A., Branson, R., Campbell, G. M., Cohen, H., Dasta, J. F., Harvey, M. A., Kelly, M. A., Kelly, K. M., Rudis, M. I., St. Andre, A. C., Stone, J. R., Teres, D., Weled, B. J., & Peruzzi, W. (2001). Critical care delivery in the intensive care unit: Defining clinical roles an the best practice model. Critical Care Medicine, 29(10), 2007-2019 https://doi.org/10.1097/00003246-200110000-00026
  2. Capenito-Moyet, L. J. (2004). Nursing care plans & documentations, 4th ed., Philadelphia: Lippincott Williams & Wilkins
  3. Chi, S. A., Choi, K. S., Park, K. S., & Jung, Y. K. (1999). A basic study on improvement and computerizaton of nursing record. J Korean Acad Nurs, 29(1), 21-33 https://doi.org/10.4040/jkan.1999.29.1.21
  4. Choi, W. H. (2007). Comparison of nursing records between paper and electronic record systems in patients having hysterectomy. Unpublished master's thesis, Seoul National University, Seoul
  5. de Fatima Lucena, A., & de Barros, A. L. B. (2006). Nursing diagnoses in a Brazilian intensive care unit. Int J Nurs Terminol Classif, 17(3), 139-146 https://doi.org/10.1111/j.1744-618X.2006.00036.x
  6. Diers, D. (1981). Why write? Why publish? Image, 13, 991-997
  7. Hanson, C. U. 3rd, Deutschman, C. S., Anderson, H. L. 3rd, Resilly, D. M., Behringer, E. C., Schwab, C. W., & Price, J. (1999). Effects of an organized critical care service on outcomes and resource utilization: A cohort study. Critical Care Medicine, 27, 270-274 https://doi.org/10.1097/00003246-199902000-00030
  8. Kim, H. S. (2005). Development & application of a computerized nursing process program for orthopedic surgery inpatients-NANDA, NOC, and NIC likages-. J Korean Acad Nur, 35(6), 979-990 https://doi.org/10.4040/jkan.2005.35.6.979
  9. Kinney, M. R., Packa, D. R., & Dunbar, S. B. (1988). AACN's Clinical reference for critical-care nursing, 2nd ed., New York: McGraw Hill
  10. Korean Nurses Association (2003). Terminologies of the International Classification for Nursing Practice: ICNP BETA version
  11. Larrabee, J. H., Boldreghini, S., Elder-Sorells, K., Tumer, Z. M., Wender, R. G., Hart, J. M., & Lenzi, P. S. (2001). Evaluation of documentation before and after implementation of a nursing information system in an aute care hospital. Computers in Nursing, 12(9), 56-65
  12. Lavin, M. A., Avant, K., Craft-Rosenberg, M., Herdman, T. H., & Gebbie, K. (2004). Contexts for the study of the economics influence of nursing diagnoses on patient outcome. Intrnational Journal of Nursing Terminologlies and Classification, 15(2), 37-39
  13. Lee, I. (2007). Comparison and analysis of nursing records of open heart surgery patients before and after application of electronic nursing record. Unpublished master's thesis, Seoul National University, Seoul
  14. Lee, E., & Lee, M. (2006). Comparison of nursing interventions performed by medical-surgical nurses in Korea and the United States. Int J Nurs Terminol Classif, 17(2), 108-117 https://doi.org/10.1111/j.1744-618X.2006.00025.x
  15. Nahm, R., & Poston, I. (2000). Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction. Computers in Nursing, 18(5), 220-229
  16. Neilson, G. H. (1999). Telenurse introduction to $\beta$-ICNP, Danish Institute for Health and Nursing Research, International Council of Nurses (2002, April 24). Copenhagen
  17. Nussbaum, G. B. (2003). Spirituality in critical care patient comfort and satisfaction. Crit Care Nurs Q, 26(3), 214-220 https://doi.org/10.1097/00002727-200307000-00006
  18. Park, H. A., Kim, J. E., & Cho, I. S. (2000). Nursing diagnosis . nursing intervention .nursing outcome classification system, Seoul: Seoul National University Press
  19. Ryu, E., J., Choi, K. S., Kwon, Y. M., Joo, S. N., Yun, S. R., Choi, H. S., Kwon, S. B., Lee, J. L, Kim, B. J., Kim, H. Y., Ahn, O. H., Rho, E. S., & Park, K. S. (1999). Analysis of the nursing interventions done by MICU and SICU nurses using NIC. J Korean Acad Nurs, 28(2), 457-467
  20. Saba, V. K. (2004). The clinical care classification system, Retrieved Jan. 2007 from http://www.sabacare.com
  21. Song, M. S., Kim, M., J., Park, Y. S., Lee, E. O., Hah, Y. S., Han, K. J., Ryu, S. A., Kang, H. Y., & Kim, K. (2003). Comparison of nursing activities reflected in nursing notes and in-depth interviews of nurses in an acute hospital. J Korean Acad Nurs, 33(6), 802-811 https://doi.org/10.4040/jkan.2003.33.6.802
  22. Suh, M. J., Lee, J. H., Kim, Y. S., Lee, H. R., Park, C. J., Yoo, S. J., Park, O. J., & Choi, C. J. (1999). Adult medical surgical nursing. Seoul: Soomunsa
  23. Yoon, H. Y. (2002). Development of nursing intervention protocol based on nursing diagnosis for medical surgical ICU patients. Unpublished master's thesis, Yonsei University, Seoul
  24. Yu, O. S., Park, I. S., Woo, K. S., Shin, H. J., Ahn, T. S., Kim, E. M., Jung, E. H., Kim, Y. A., Oh, P. I., Park, H. A., Jo, E. M., & Paek, H. J. (2006). Classification of Nursing statements based on the ICNP, the HHCC and the nursing process for use in electronic nursing records. Paper presented at the 9th International Congress of Nursing Informatics, Seoul, Korea