Journal of Korean Clinical Nursing Research (임상간호연구)

Hospital Nurses Association (병원간호사회)
권호 표지
DOI QR코드

DOI QR Code

Analysis of Pain Records Using Electronic Nursing Records of Hospitalized Patients in Medical Units at a University Hospital

일개 대학병원 내과 병동 입원환자의 전자의무기록에 사용된 통증간호 기록 분석

  • Park, Ihn Sook (Department of Nursing, Seoul National University Hospital) ;
  • Jang, Mi (Department of Nursing, Seoul National University Hospital) ;
  • Rew, Soon Ae (Department of Nursing, Seoul National University Hospital) ;
  • Kim, Hee Jin (Department of Nursing, Seoul National University Hospital) ;
  • Oh, Phil Joo (Department of Nursing, Seoul National University Hospital) ;
  • Jung, Hee Jung (Department of Nursing, Seoul National University Hospital)
  • Received : 2010.09.30
  • Accepted : 2010.10.26
  • Published : 2010.12.31
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital. Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system. Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques. Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients' pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.

Keywords

References

  1. 김미정, 박진아, 신수진(2008). 입원 암환자의 통증 실태와 통증관리 실태. 기본간호학회지, 15(2), 161-170.
  2. 김민정(1997). 임상간호사의 통증중재법 실행에 관한 연구. 성인간호학회지, 9(2), 209-224.
  3. 김복자, 김연희, 전명희, 최진선 외(편.)(2000). 암환자 간호증상관리. 서울: 현문사.
  4. 김영조(2007). 입원 암환자의 통증 실태와 통증조절 실태 및 통증조절 만족도. 고신대학교 석사학위논문, 부산.
  5. 김정희(2003). 수술 후 통증 관리에 대한 외과계 간호사의 지식과 행태. 충남대학교 석사학위논문, 대전.
  6. 김화순(2001). 외과중환자를 위한 진통제와 진정제의 투여 양상. 대한간호학회지, 31(2), 304-314.
  7. 박명화(2006). 근거중심간호의 이해와 적용. 서울: 군자출판사.
  8. 박정숙, 박청자(1995). 통증 개념을 다룬 국내 간호 연구 분석. 대한간호학회지, 25(1), 30-44.
  9. 보건복지가족부(2008). 암성 통증관리지침 권고안 (제3판). 서울: 저자.
  10. 보건복지부⋅한국보건산업진흥원(2007). 2007 의료기관 평가 지침서. 서울: 저자.
  11. 윤영호, 김철환(1997). 암성통증 관리에 관한 전공의들의 지식 및 태도. 가정의학회지, 18(6). 591-600.
  12. 이은옥, 최명애(편.)(1993). 통증 -이론 및 중재-. 서울: 신광출판사.
  13. 이은옥, 최정명(1988). 단순형 국어통증척도의 개발과 타당도 연구. 간호학 논문집, 3(1), 73-82.
  14. 전시자, 김강미자, 박정숙, 이미화, 조경순, 김희경 등(2005). 성인간호학-상 (제4판). 서울: 현문사
  15. 정성희(2006). 입원 암환자의 암성통증관리에 대한 지식과 태도의 관계. 고신대학교 석사학위논문, 부산.
  16. 채지선(2009). 통증 관리 알고리즘 적용이 수술 후 환자의 통증 조절 만족도와 간호사의 업무 수행능력에 미치는 영향. 이화여자대학교 석사학위논문, 서울.
  17. 한국호스피스⋅완화의료학회, 대한항암요법연구회(2002). 암성 통증관리 지침. 서울: 군자출판사.
  18. 현주, 박경숙(2000). 임상간호사의 통증관리에 대한 지식과 태도. 성인간호학회지, 12(3), 369-383.
  19. Brekken, S. A., & Sheets, V. (2008). Pain management: A regulatory issue. Nursing Administration Quarterly, 32(4), 288-295. https://doi.org/10.1097/01.NAQ.0000336725.03065.44
  20. Carr, D. B., & Goudas, L. C. (1999). Acute pain. The Lancet, 353(9169), 2051–2058. https://doi.org/10.1016/S0140-6736(99)03313-9
  21. Coyne, M. L., Smith, J. F. H., Stein, D., Hieser, M. J., & Hoover, L. (1998). Describing pain management documentation. Medsurg Nursing, 7(1), 45-51.
  22. de Rond, M. E. J., de Wit, R., van Dam, F. S. A. M., & Muller, M. J. (2000). A pain monitoring program for nurses: Effects on communication, assessment and documentation of patients' Pain. Journal of Pain and Symptom Management, 20(6), 424-439. https://doi.org/10.1016/S0885-3924(00)00209-8
  23. Goldberg, G. R., & Morrison, R. S. (2007). Pain management in hospitalized cancer patients: A systematic review. Journal of Clinical Oncology, 25(13), 1792-1801. https://doi.org/10.1200/JCO.2006.07.9038
  24. Idvall, E., & Ehrenberg, A. (2002). Nursing documentation of postoperative pain management. Journal of Clinical Nursing, 11(6), 734-742. https://doi.org/10.1046/j.1365-2702.2002.00688.x
  25. Krenzischek D. A., & Wilson, L. (2003). An introduction to the ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 18(4), 228-231. https://doi.org/10.1016/S1089-9472(03)00128-X
  26. McCaffery, M., & Ferrell, B. R. (1997). Nurses' knowledge of pain assessment and management: How much progress have we made? Journal of Pain and Symptom Management, 14(3), 175-188. https://doi.org/10.1016/S0885-3924(97)00170-X
  27. Morrison, R. S., Meier, D. E., Fischberg, D., Moore, C., Degenholtz, H., Litke, A., et al. (2006). Improving the management of pain in hospitalized adults. Archives of Internal Medicine, 166(9), 1033-1039. https://doi.org/10.1001/archinte.166.9.1033
  28. Montes-Sandoval, L. (1999). An analysis of the concept of pain. Journal of Advanced Nursing, 29(4), 935-941. https://doi.org/10.1046/j.1365-2648.1999.00971.x