• 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.

• Journal of Korean Academy of Nursing
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• v.29 no.1
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• pp.72-83
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• 1999

The purpose of this study was to classify, from collected home health care records data, nursing diagnoses according to the NANDA system and nursing interventions according to the NIC system, and to link nursing interventions to nursing diagnoses. For this study, 101 home health care records of clients seen between September, 1994 and November, 1996 at Yonsei Medical Center, Seoul, were analyzed. The results of this study are summarized as follows : 1. The most frequent nursing diagnoses were ‘Risk for infection’ and ‘Altered nutrition : Less than body requirements’, then ‘Impaired skin intergrity’ and ‘Ineffective airway clearance’ in the Exchange pattern of NANDA nine human response patterns. 2. The most frequent nursing interventions were the interventions in the Physiological : Complex domain, there were 690(50.7%) interventions among a total 1347 interventions. This results corresponds to Yom, Young Hee(1995)’s research, both Korean and U.S. nurses used the interventions in the Physiological : Complex do main most often on a daily basis. And respiratory nursing interventions were most frequent because 32.7% of the subjects were respiratory patients. 3. The next step was to link the nursing interventions to nursing diagnoses. The most frequent nursing diagnosis was ‘Risk for infection’ and 19 interventions for ‘Risk for infection’ were used 267 times. Then 14 interventions for ‘Impaired skin integrity’ were used 258 times, 12 interventions for ‘Ineffrective airway clearance’ were used 193 times, 12 interventions for ‘Altered nutrition : Less than body requirements’ were used 122 times, 10 interventions for ‘Activity intolerance’ were used 75 times, and 11 interventions for ‘Knowledge deficit’ were used 52 times. 4. The use of standardized classification in the areas of nursing diagnoses and nursing interventions facilitates clinical decision making and prompt nursing activity, and so enhances the effectiveness of nursing care.

• Journal of Korean Academy of Nursing Administration
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• v.6 no.1
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• pp.135-146
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• 2000

The purpose of this study was to develope, based on the Nursing Intervention Classification (NIC) system. a set of standardized nursing interventions which had been validated. and their associated activities. for use with nursing diagnoses related to home health care for women who have had a caesarian delivery and for their newborn babies. This descriptive study for instrument development had three phases: first. selection of nursing diagnoses. second, validation of the preliminary home health care interventions. and third, application of the home care interventions. In the first phases, diagnoses from 30 nursing records of clients of the home health care agency at P. medical center who were seen between April 21 and July 30. 1998. and from 5 textbooks were examined. Ten nursing diagnoses were selected through a comparison with the NANDA (North American Nursing Diagnosis Association) classification In the second phase. using the selected diagnoses. the nursing interventions were defined from the diagnoses-intervention linkage lists along with associated activities for each intervention list in NIC. To develope the preliminary interventions five-rounds of expertise tests were done. During the first four rounds. 5 experts in clinical nursing participated. and for the final content validity test of the preliminary interventions. 13 experts participated using the Fehring's Delphi technique. The expert group evaluated and defined the set of preliminary nursing interventions. In the third phases, clinical tests were held at in a home health care setting with two home health care nurses using the preliminary intervention list as a questionnaire. Thirty clients referred to the home health care agency at P. medical center between October 1998 and March 1999 were the subjects for this phase. Each of the activities were tested using dichotomous question method. The results of the study are as follows: 1. For the ten nursing diagnoses. 63 appropriate interventions were selected from 369 diagnoses interventions links in NlC., and from 1.465 associated nursing activities. From the 63 interventions. the nurses expert group developed 18 interventions and 258 activities as the preliminary intervention list through a five-round validity test 2. For the fifth content validity test using Fehring's model for determining lCV (Intervention Content Validity), a five point Likert scale was used with values converted to weights as follows: 1=0.0. 2=0.25. 3=0.50. 4=0.75. 5=1.0. Activities of less than O.50 were to be deleted. The range of ICV scores for the nursing diagnoses was 0.95-0.66. for the nursing interventions. 0.98-0.77 and for the nursing activities, 0.95-0.85. By Fehring's method. all of these were included in the preliminary intervention list. 3. Using a questionnaire format for the preliminary intervention list. clinical application tests were done. To define nursing diagnoses. home health care nurses applied each nursing diagnoses to every client. and it was found that 13 were most frequently used of 400 times diagnoses were used. Therefore. 13 nursing diagnoses were defined as validated nursing diagnoses. Ten were the same as from the nursing records and textbooks and three were new from the clinical application. The final list included 'Anxiety', 'Aspiration. risk for'. 'Infant behavior, potential for enhanced, organized'. 'Infant feeding pattern. ineffective'. 'Infection'. 'Knowledge deficit'. 'Nutrition, less than body requirements. altered', 'Pain'. 'Parenting'. 'Skin integrity. risk for. impared' and 'Risk for activity intolerance'. 'Self-esteem disturbance', 'Sleep pattern disturbance' 4. In all. there were 19 interventions. 18 preliminary nursing interventions and one more intervention added from the clinical setting. 'Body image enhancement'. For 265 associated nursing activities. clinical application tests were also done. The intervention rate of 19 interventions was from 81.6% to 100%, so all 19 interventions were in c1uded in the validated intervention set. From the 265 nursing activities. 261(98.5%) were accepted and four activities were deleted. those with an implimentation rate of less than 50%. 5. In conclusion. 13 diagnoses. 19 interventions and 261 activities were validated for the final validated nursing intervention set.

• Proceedings of the Korean Society for Information Management Conference
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• 2006.08a
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• pp.191-196
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• 2006

Traditionally, nurses keep the written patient records, which are referred as nursing care plan. Nursing care plan reports are one of the most important documents in the application of nursing processes. Typically, nurses prepare the plans by including general patient information as well as the patient's medical history information. In addition, the patient's developmental history and other specific health related information are part of the plans. The plans are usually concluded with the goals of the nursing care plan, nursing diagnoses, expected outcomes of the care, and possible nursing interventions. The nursing diagnoses, outcomes, and interventions are defined by North American Nursing Diagnosis Association (NANDA). This means that the nurses will select the appropriate diagnoses, outcomes, and interventions from an approved set. We developed a web-based nursing care plan generation system. In this paper, we report our work on developing a visual interface to the NANDA nursing diagnoses, outcomes, and interventions database as a part of the web-based nursing care plan generation system.

• The Korean Nurse
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• v.35 no.4
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• pp.37-50
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• 1996

Nursing Diagnosis has evolved in the guest to define nursing and its functions. But for the application to clinical practice an unified system of terminology that helps nurses to assess selected data and identify potential or actual client problems is required. Consistent terminology that captures the real meanings of the nursing diagnosis makes oral and written communication more accurate and efficient. Therefore,' this study was performed to deliver a Korean-translated version of the nursing diagnoses through the process of content validity tests and translations. Data collection for the first content validity test was done from June 27, 1996 to August 1. 1996. Among 20 questionnaires only 16 were used for analysis. With the results of content validity, the list of 109 nursing diagnoses were reviewed by two linguists, one specialized in Korean and the other in English. To clear confusion on a diagnostic label "Incontinence" a urology specialist was invited for consultation. From this analysis and discussions a total of 98 nursing diagnoses was delivered and quesitons containing 98. 98 diagnoses were mailed to 741 subjects to test content validity from August 13, 1996 to October 7, 1996. Among 741 questionnaires, 343 were used for analysis. Total mean score of the diagnoses was 4.30 on the 5 point likert scale. The diagnoses that acquired less than 3.50 were "High risk for altered body temperature"(3.34), "Ineffective thermoregulation" (3.34), "Perceived cosntipation"(3.24). "Stress incontinence"(3.42), "Ineffective airway clearance"(3. 48), "Altered sexuality patterns"(3.35).

• Journal of Korean Academy of Nursing
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• v.20 no.3
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• pp.368-380
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• 1990

A central issue in the development of nursing practice is to describe the phenomenon with which nursing is concerned. To identify the health problems which can be diagnosed and managed by the nurse is the first step to organize and ensure the development of nursing science. Therefore the academic world has been discussing the application of the nursing diagnosis in nursing practice as a means of improving quality of care. The objectives of this study were to develop a standardized nursing care plan for ten selected nursing diagnoses to form a database for computerized nursing service. The research approach used in the study was (1) the selection of the ten nursing diagnoses which occur most frequently on medical-surgical wards, (2) the development of a standardized nursing care plan for the ten selected nursing diagnoses, (3) application of the plan to hospitalize patients and evaluation of the content validity by the nurses, and (4) evaluation of the clinical effects after the use of the standardized nursing care plans. The subjects were 56 nurses and 395 hospitalized patients on two medical and two surgical unit. The results of this study were as follows ; 1) The ten selected nursing diagnoses for the development of the standardized nursing care plans were “PAIN, SLEEP DISTURBANCE, ALTERED HEALTH MAINTENANCE, ALTERATION IN NUTRITION, ANXIETY, CONSTIPATION, ALTERED PATTERNS OF URINARY ELIMINATION, DISTURBANCE IN BODY IMAGE, POTENTIAL FOR ACTIVITY INTOLERANCE AND ACTIVITY INTOLERANCE”. 2. The developed standardized nursing care plans included the nursing diagnosis, definition, defining characteristics, etiologic or related factors that contribute to the condition, recording pattern, desired outcomes and nursing orders (nursing interventions). 3. The plan was used with hospitalized patients on medical - surgical wards to test for content validity. The patient's satisfaction with the nursing care and nurses' job satisfaction were investigated to evaluate the clinical effects after the use of the standardized nursing care plans. A comparison of patient satisfaction with nursing care before and after the introduction of the standardized nursing care plans showed a statistically significant higher level of satisfaction with the standardized care plans. There was no difference in the level of job satisfaction expressed by the nursing staff before and after the standardized nursing care plans were introduced. However, when opinions about the use of the standardized nursing care plans were examined it was found that there was a positive effect on clarity in defining the nursing problems, determining nursing cost, more feasible goal setting, effective and systematic nursing records and indications for nursing research. The results of this study suggest that in order to increase the use of nursing diagnoses in the clinical area, it would be effective to select some wards as a pilot project, give the nurses training in the use of nursing diagnosis and develop and use the standardized nursing care plans. In addition to the ten diagnosis used in this study it is recommended that continual development of nursing diagnoses be done using diagnoses that are appropriate to Korea and testing them for validity through standardized care plans.

• Proceedings of the Korean Society for Information Management Conference
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• 2006.08a
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• pp.163-168
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• 2006

Nursing diagnosis process is described as nurses assessing the patients' conditions by applying reasoning and looking for patterns, which fit the defining characteristics of one or more diagnoses. This process is similar to using a typical document retrieval system if we consider the patients' conditions as queries, nursing diagnoses as documents, and the defining characteristics as index terms of the documents. However, there is a small fixed number of nursing diagnoses and infinite number of patients' conditions in a typical hospital setting. This state is more suitable to applying document routing mode of information access, which is defined as a number of archived profiles, compared to individual documents. In this paper, we describe a ROUting-based Nursing Diagnosis (ROUND) system and its Natural Language Processing-based query processing component, which converts the defining characteristics of nursing diagnoses into query representations.

• Asian Pacific Journal of Cancer Prevention
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• v.17 no.7
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• pp.3207-3211
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• 2016

Background: Skin cancer has a remarkable importance given the high incidence in the population. In Brazil, it is estimated that there were 98,420 new cases of non-melanoma skin cancer among men and 83,710 new cases among women in 2014. Objectives: To verify signs and symptoms present in patients with skin neoplasms according to the literature and relate them to the nursing diagnoses of NANDA International. Materials and Methods: Integrative literature review carried out from March to May 2015 in the databases: Cumulative Index to Nursing and Allied Health Literature, SCOPUS, National Library of Medicine and Nattional Institutes of Health, Latin American and Caribbean Sciences of Health and Web of Science. The descriptors used were: 'Signs and Symptoms' and 'Skin Neoplasms'. Sixteen articles were identified as the final sample. After review, the signs and symptoms of skin cancer identified in the literature were related to the defining characteristics present in NANDA International, with the aim to trace possible nursing diagnoses. Results: The most prevalent signs and symptoms were: asymmetric and well circumscribed nodules with irregular borders; speckles with modified color aspect; ulcerations; blisters; pain; itching; and bleeding. The principal nursing diagnoses outlined were: risk for impaired skin integrity; impaired skin integrity; acute pain; risk of shock; and impaired comfort. Conclusions: The identification of signs and symptoms present in patients with skin cancer and the relationships of these with the nursing diagnoses of NANDA International provide a basis for qualified and systematized nursing care to this clientele.

• Journal of Korean Academy of Nursing
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• v.23 no.4
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• pp.569-584
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• 1993

This study was done to verify validity of nursing diagnoses related to difficulty in respiratory function. First, content validity was examined by an expert group considering the etiology and the signs / symptoms of three nursing diagnoses - ineffective airway clearance, ineffective breathing pattern, impaired gas exchange. Second, clinical validity was examined by comparing the frequencies of the etiologies and signs / symptoms of the three nursing diagnoses in clinical case studies with the results of the content validity. This study was a descriptive study. The sample consisted of 23 experts (professors, head nurses and clinical instructors) who had had a variety of experiences using nursing diagnoses in clinical practice, and 102 case reports done by senior student nurses of the college of nursing of Y-university. These reports were part of their clinical practice in the ICU. The instrument used for this study was a checklist for etiologies and signs and symptoms based on the literature, Doenges and Moorhouse (1988), Kim, McFarland, McLane (1991), Lee Won Hee et al. (1987), Kim Cho Ja et at. (1988). The data was collected over four month period from May 1992 to Aug. 1992. Data were analyzed using frequencies done with the SPSS / PC＋ package. The results of this study are summarized as follows : 1. General Characteristics of the Expert Group A bachelor degree was held by 43.5% and a master or doctoral degree by 56.5% of the expert group. The average age of the expert group was 35.3 years. Their average clinical experience was 9.3 years and their average experience in clinical practice was 5.9 years. The general characteristics of the patients showed that there were more women than men, that the age range was from 1 to over 80. Most of their medical diagnoses were diagnoses related to the respiratory. system, circulation or neurologic system, and 50% or more of them had a ventilator with intubation or a tracheostomy. The number of cases for each nursing diagnoses was : · Ineffective airway clearance, 92 cases. · Ineffective breathing pattern, 18 cases. · Impaired gas exchange, 22 cases. 2. The opinion of the expert group as to the classification of the etiology, and signs and symptoms of the three nursing diagnoses was as follows : · In 31.8% of the cases the classification of etiology was clear. · In 22.7%, the classification of signs and symptoms was clear. · In 17.4%, the classification of nursing interventions was clear. 3. In the expert group 80% or mere agreed to ‘dysp-nea’as a common sign and symptom of the three nursing diagnoses. The distinguishing signs and symptoms of (Ineffective airway clearance) were ‘sputum’, ‘cough’, ‘abnormal respiratory sounds : rales’. The distinguishing sings and symptoms of (Ineffective breathing pattern) were ‘tachypnea’, ‘use of accessory muscle of respiration’, ‘orthopnea’ and for (Impaired gas exchange) it was ‘abnormal arterial blood gas’, 4. The distribution of etiology, and signs and symptoms of the three nursing diagnoses was as follows : · There was a high frequency of ‘increased secretion from the bronchus and trachea’ in both the expert group and the case reports as the etiology of ineffective airway clearance. · For the etiologies for ineffective breathing pat-tern, ‘rain’, ‘anxiety’, ‘fear’, ‘obstructions of the tract, ca and bronchus’ had a high ratio in the ex-pert group and ‘decreased expansion of lung’ in the case reports. · For the etiologies for impaired gas exchanges, ‘altered oxygen -carrying capacity of the blood’ and ‘excess accumulation of interstitial fluid in lung’ had a high ratio in the expert group and ‘altered oxygen supply’ in the case reports. · For signs and symptoms for ineffective airway clearance, ‘dyspnea’, ‘altered amount and character of sputum’ were included by 100% of the expert group. ‘Abnormal respiratory. sound(rate, rhonchi)’ were included by a high ratio of the expert group. · For the signs and symptoms for ineffective breathing pattern. ‘dyspnea’, ‘shortness of breath’ were included by 100% of the expert group. In the case reports, ‘dyspnea’ and ‘tachypnea’ were reported as signs and symptoms. · For the sign and symptoms for impaired gas exchange, ‘hypoxia’ and ‘cyanosis’ had a high ratio in the expert group. In the case report, ‘hypercapnia’, ‘hypoxia’ and ‘inability to remove secretions’ were reported as signs and symptoms. In summary, the similarity of the etiologies and signs and symptoms of the three nursing diagnoses related to difficulty in respiratory function makes it difficult to distinguish among them But the clinical validity of three nursing diagnoses was established through this study, and at last one sign and symp-tom was defined for each diagnosis.