• Research in Community and Public Health Nursing
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• v.13 no.3
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• pp.433-443
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• 2002

Objectives; The purpose of this study was to develop a framework for home care and a Home Care Need Assessment Tool. Method 1. Identifying common domains in the provision of home care. 2. Charts of 253 home care clients were reviewed to obtain a classification of the nursing diagnoses. 3. A focus group methodology was used to develop the domains. 4. The tool was applied to 439 home care clients.(Kappa value=0.460-1.000, sensitivity, 0.444-1.000: specificity, 0.743-1.000). 5. Some refinements and extractions of the defining characteristics and related factors were made based on the results of the focus group. Results Home Care Need Assessment Tool consists of three parts; -Part I : factors related to basic conditions -Part II : a screening component that enables home care nurses to assess 30 multiple domains of 53 nursing diagnoses. -Part III : summative nursing diagnoses and nursing need intensity for the clients. Conclusion This tool provides a comprehensive assessment that helps the recognition of many strengths as well as problems of the clients. It will be usefully utilized in scheduling home care nursing plans and evaluating client outcomes.

• Journal of Korean Academy of Nursing
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• v.24 no.4
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• pp.696-705
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• 1994

This study was done to provide a basis for home health care management for women following Cesarean delivery. Furthermore it was initiated as an possible application of home health care in the future. In this study, client selection criteria was developed by the researcher and assessment tools for home health care, recording system and problem oriented recording system were revised from Jun's(1993) methods. The selection criteria tool for home health care for women who had a Cesarean delivery was structured and consisted of five areas : physical status, functional status, psychological-emetional status, educational needs status and environmental status. The structured assessment tool consisted of general items, obstetric history, past medical history, methods of feeding, medications taken before ad-mission, laboratory results, discharge instructions, discharge medications, family tree, economic status, environmental status, a map, health assessment of women and their newborns. The visit note consisted of the date : nursing problems : nursing process including initial assessment : nursing goals : visit plan : health status of the postpartum women and their newborn : nursing diagnoses : nursing implementation evaluation : summary : next visit plan and revision. The problem oriented recording system consisted of the date, problem numbers, nursing diagnoses, problem appearance date, problem resolution date. The results of the research are as follows : The seven cases having had a Cesarean delivery were discharged on an average on the 5th day after the Cesarean birth. The total number of home visits was 13. According to Cordon's functional health patterns the total possible nursing diagnoses was 34 diagnoses for the methers and their newborns. Among the 34 diagnoses, there were 13 diagnoses in the health perception /management pattern, 7 in the psychosocial health perception / management pattern, 8 in the psychosocial self-perception, 2 in the nutrition / metabolism pattern of physical function, 2 in the knowledge deficit of newborn management, anxiety related to newborn management, knowledge deficit related to disease process of new-born, anxiety related to disease process of newborn anxiety related to prognosis of baby's condition, knowledge deficit related to newborn jaundice each appeared once. The changes in the number of nursing diagnoses was related to not the number of visits but to the number of nursing diagnoses decreasing. The con-tent of the home health care was categorized ac-cording to assessment, direct care, counseling, education, family care. The recommendation based on the results of this research are Home health care nurses for Cesarean postpartum women and their neonates requires comprehensive knowledge of pregnancy, delivery, and the postpartum period and of the neonate so that they can provide appropriate care and holistic views. Most of cases terminated after the second visit, this outcome may be related to the subjects being discharged on the 5th day after delivery. Therefore, study done with earlier discharge after delivery may have different outcome. It is very hard to assess psychological aspects that need follow-up and to develop communication channels.

• Journal of Korean Academic Society of Home Health Care Nursing
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• v.5
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• pp.47-60
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• 1998

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.

• Journal of East-West Nursing Research
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• v.17 no.1
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• pp.66-70
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• 2011

Purpose: The aim of this study was to examine the types of nursing problems in oriental nursing practice. Methods: This study employed a descriptive survey design. Nursing documentation was retrospectively reviewed for patients discharged from an oriental medicine hospital during three months. Nursing diagnoses documented were mapped into the Clinical Care Classification System. Data were summarized using descriptive statistics. Results: Data were collected from 110 patients using nursing documentation. The number of nursing diagnoses documented was 204 with a mean of 1.9 per patient. The frequently occurring nursing diagnoses were 'risk for trauma' (48.0%), 'pain' (13.7%), and 'urinary elimination alteration' (7.8%). According to the Clinical Care Classification system, the safety component (51.5%) was the most common nursing problem in oriental nursing practice. Conclusion: The study finding suggested that major nursing problems in oriental nursing practice were related to patient safety. Therefore, oriental nursing education on patient safety should be emphasized to improve the quality of nursing care in oriental medicine hospitals.

• Journal of Korean Academy of Nursing
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• v.35 no.6
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• pp.979-990
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• 2005

Purpose: The purpose of this study was to develop and to apply the NANDA, NOC, and NIC (NNN) linkages into a computerized nursing process program using the classification systems of nursing diagnoses, nursing outcomes and nursing interventions. Method: The program was developed with planning, analysis, design and performance stages. The program was applied to 117 patients who were admitted to orthopedic surgery nursing units from January to February, 2004. Results: Thirty-five of fifty-three nursing diagnoses were identified. Five nursing diagnoses in order of frequency were: Acute pain $(28.4\%)$, Impaired physical mobility $(15.6\%)$, Impaired walking $(8.7\%)$, Chronic pain $(5.5\%)$ and Risk for disuse syndrome $(5.0\%)$. The nursing outcomes of the 'Acute pain' nursing diagnosis tended to have higher frequencies (cumulative) in order of Pain management $(95.2\%)$, Comfort level $(35.5\%)$ and Pain level $(17.7\%)$. The nursing interventions of the 'Acute pain' nursing diagnosis tended to have higher frequencies (cumulative) in order of Pain management $(71.0\%)$, Splinting $(24.2\%)$ and Analgesic administration $(17.7\%)$. In comparison of outcome indicator scores between before and after the intervention according to the 61 nursing outcomes, the mean scores of 52 outcome indicators after the intervention were significantly higher than before the intervention. Conclusion: It is expected that this program will help nurses perform their nursing processes more efficiently.

• Korean Journal of Adult Nursing
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• v.26 no.4
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• pp.413-423
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• 2014

Purpose: This study was aimed to identify NANDA-NOC-NIC linkage in cancer patients receiving chemotherapy. Methods: This study was a descriptive study conducted in three steps. First, nursing diagnoses were identified from the electronic nursing records. Second, content validity of nursing diagnoses and outcomes were evaluated. Third, major nursing interventions associated with expected nursing outcomes were collected from 97 nurses who worked in the oncology unit. Data were analyzed using descriptive statistics. Results: Four major nursing diagnoses were identified: acute pain, knowledge deficit, health seeking behaviors, and ineffective protection. Associated with each respective diagnosis, 3 major outcomes (pain level, pain control, and comfort state) for acute pain, 8 major nursing outcomes (diet, disease process, treatment regimen, illness, ostomy care, prescribed activity, health behavior, and infection management) for knowledge deficit, 4 major outcomes (health promoting behavior, health promotion, health belief, and knowledge: health resource) for health seeking behaviors, and 3 major outcomes (fatigue level, immune status, and nutritional status) for ineffective protection were identified. In addition, nursing interventions frequently used in clinical practice for each major nursing outcome were identified. Conclusion: The identified NANDA-NOC-NIC linkage can contribute to improving the applications of nursing process and care plans.

• Journal of Korean Academy of Fundamentals of Nursing
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• v.8 no.3
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• pp.402-415
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• 2001

The purpose of this study was to identify nursing diagnoses and nursing interventions that are found in the home health care patients, and to establish a basis for a standardized Nursing Intervention List that would help nurses doing home health care nursing. For this study, the records of 150 home health care clients who were discharged, from the Home Health Care Center at Yonsei Medical Center, between January to July. 2001 were analyzed. Of the 43 nursing diagnoses recorded for these clients are 43, the most frequent diagnoses were in the area of Exchanging. There were 2.814 nursing interventions which is a mean of 4.73 nursing interventions Per diagnosis. We confirmed that most of the interventions were related to 'education' and 'advice'. We present a Home Health Care Nursing Intervention List that was developed based on the results of this study. It has the five 5 criteria of the ICNP classification, Observing, Management, Performance, Caring, and Informing.

• Journal of Korean Academy of Nursing Administration
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• v.8 no.2
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• pp.207-219
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• 2002

The purposes of this research were to: a) define the changing trends of DRGs in comparison to the National Data, b) define the changing trends of Nursing Diagnoses and Nursing Interventions for the 5 most frequently occurring Diagnostic Related Groups (DRGs) across 3 years, and c) define the relationships between nursing diagnoses and nursing Interventions for the 5 most frequently occurring DRGs across the 3 years. This study was a secondary data analysis of medical and nursing data based on the United States Nursing Minimum Data Set and the Uniform Hospital Discharge Data Set retrieved from a Midwestern USA medical center. The results showed interesting comparisons with national statistics as well as practice relevant trends within the nursing data. Additionally, the results showed the possibility that nursing data can be extracted from the medical data, so they can used in the nursing productivity and cost issues etc. In conclusion, this study supports the power of minimum data sets and nursing classifications to begin to describe a more global perspective the inter-relationships and trends of nursing data within the medical diagnosis context.

• Journal of Korean Academy of Nursing
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• v.21 no.3
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• pp.349-364
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• 1991

Recognition of the usefulness and the importance of the nursing diagnosis is increasing. There is a prevailing opinion that nursing diagnosis should be used to improve the quality of nursing care. Developing standardized nursing care palns based on nursing diagnoses is therefore considered one of the most essential projects for professional growth and improvement in the nursing world of Korea. Consequently, in the first stage of this research project, the ten nursing diagnses used most frequently with patients on medical and surgical wards were determined and related nursing care plans were developed, implemented and evaluated. The application of the standardized nursing care plans raised the nurses' confidence and proved to be effective in enhancing the quality of nursing care. This study was initiated as the next stage, to develop, test, and determine the validity of nursing care plans for the remaining nursing diagnoses. Nineteen medical and surgical wards were selected for the study ; the 176 staff nurses working on those wards and 1211 patients hospitalized there (603 patients during the nursing care plan use) took part in the project. The following summarizes the results of the study : 1. After listing all the nursing diagnoses up to the 20th in frequency from each ward except the ten used in the first study, 22 nursing diagnoses were selected. Two related to ‘self care deficit’, were combined into one. Standardized nursing care plans were established for these 21 nursing diagnoses. 2. The first page of each nursing care plan lists the related factors and defining characteristics as supporting data. The application rate distribution revealed that the majority were recorded less than 50% of the time. For each nursing diagnosis, only one to three related factors were recorded more than 50% of the time regardless of the number of suggested related factors, and similarly, only one to five defining characteristics were recorded more than 50% of the time regardless of the number of suggested defining characteristics. Therefore, these factors and defining characteristics were proposed as the common related factors and the typical signs and symptoms for each nursing diagnosis. 3. The application rate distribution for the expected outcomes, and the nursing orders that were the main data of each nursing care plan occurred more than 50% of the time, unlike the related factors and the characteristics that occurred less frequently. These findings supported the clinical validity. 4. In an effort to evaluate indirectly the effect of the use of the standardized nursing care plans, nurses' job satisfaction and perceptions of their ability in the use of the nursing process were measured and compared. Scores after the use of the plans were significantly higher than those before. The experience in actually using the standardized nursing care plans with patients increased the nurses' professional and emotional satisfaction and their confidence in using the nursing process. Also when the nurses who actually used the nursing care plans were asked to rate their effectiveness, the highest score was given to ‘the ease of establishing the nursing goal’, followed by ‘improved professional advice and care for patients’, ‘the efficiency and systemization of charting’, ‘the definite recognition of the nursing problem’, and ‘the selection of effective and appropriate nursing interventions’ in descending order. The results indicate the nurses were very positive about the effect of the real clinical application of standardized nursing care plans, and that the objective of this study to utilize the nursing diagnosis to strengthen the nursing process was attained.

• Korean Journal of Adult Nursing
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• v.15 no.2
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• pp.183-192
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• 2003

Purpose: This study was performed to validate the linkage between nursing diagnoses and nursing interventions by identifying performance and importance of nursing interventions linked to five NANDA nursing diagnoses. Method: Data was collected from 153 staff and head nurses working in 4 hospitals in K city. The results were analyzed using mean, SD and spearman correlation for ranking correlation. Result: The most importantly considered interventions were Medication Administration (IV) for pain, Pain Management for Constipation, Intravenous (IV) Insertion for Diarrhea, treatment, Vital Sign Monitoring for Hyperthermia, and Vital Sign Monitoring for Infection risk. The most frequently performed interventions was Medication Administration (IV) for Pain, Fluid Management for Constipation, Intravenous (IV) Insertion for Diarrhea, Vital Sign Monitoring for Hyperthermia, and Vital Sign Monitoring for Infection: Risk for. The rank correlations between importance and performance were highest in Diarrhea and lowest in Constipation. Conclusion: The above findings can be used to develop a nursing information system which can be used to facilitate documenting the nursing process, and a nursing information system developed by this research process will ultimately contribute to identifying nurses contribution to patient health.