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International Nursing Diagnosis

Corresponding author: Kim, Hye Young. College of Nursing, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 54896, Korea. Tel: +82-63-270-4618, Fax: +82-63-270-3127, Email: tcellkim@jbnu.ac.kr

Received May 25, 2016; Revised July 14, 2016; Accepted August 02, 2016.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The aim of this study was to identify the nursing diagnosis-outcome-intervention (NANDA-NOC-NIC) linkages for gynecology inpatients shown in their electronic nursing records.Methods

This retrospective and descriptive research was conducted in two steps and based on the 287 electronic nursing records for 253 patients. First, nursing diagnoses, outcomes and interventions were collected. To identify major nursing diagnoses, a comparison was done with the top 10 nursing diagnoses from this research and with previous research selected using a content validity index developed by a team of professionals. Second, nursing outcomes and interventions that were associated with major nursing diagnoses were identified.Results

Nineteen nursing diagnoses, 12 nursing outcomes, and 40 nursing interventions were collected. The top 5 major nursing diagnoses were identified and 7 nursing outcomes and 18 nursing interventions associated with these diagnoses were checked.Conclusion

The identified NANDA-NOC-NIC linkages can contribute to improving nursing practice and will help in the establishment of standardized nursing care.

Keywords: Nursing process; Gynecology department; Inpatient

Tables

Table 1Demographic Characteristics of Patients Nursing Record in Gynecology Department Nursing Unit

VariablesCategoriesn (%)M±SDRange
Age (year)20~2939 (13.6)44.99±13.5520~84
30~3958 (20.2)
40~49106 (36.9)
50~5939 (13.6)
≥6045 (15.7)
Marriage statusMarried235 (81.9)
Non-married38 (13.2)
Others14 (4.9)
OccupationYes155 (54.0)
No132 (46.0)
Education≥Middle school61 (21.2)
High school121 (42.2)
≤College105 (36.6)
ReligionYes145 (50.5)
No142 (49.5)
Length of stay in hospital (day)6.42±3.653~41
Medical diagnosisUterine myoma90 (31.4)
Cancer (cervix, ovary, endometrium)51 (17.8)
Ovarian cyst29 (10.1)
Adxetal tumor19 (6.6)
Uterine prolapse16 (5.6)
Ectopic pregnancy15 (5.3)
Inflammatory disease15 (5.3)
Endometrioma15 (5.3)
Adenomyosis13 (4.5)
Others24 (8.1)
Type of surgery (n=212)Hysterectomy80 (27.9)
Myomectomy40 (14.0)
Cystectomy33 (11.5)
Adnexectomy15 (5.2)
Colporrhaphy14 (4.9)
Salpingectomy13 (4.5)
Polypectomy10 (3.5)
Oophorectomy2 (0.7)
Others5 (1.7)

Table 2Nursing Diagnosis Used in Gynecology Department Nursing Unit

DomainsClassesNursing diagnosisn (%)Rank
ComfortPhysical comfortAcute pain2,168 (53.2)1
Nausea2 (0.0)16
Safety/protectionInfectionRisk for infection1,114 (27.3)2
Physical injuryRisk for injury11 (0.3)9
Risk for falls7 (0.2)11
Risk for bleeding6 (0.2)12
Impaired skin integrity5 (0.1)13
Risk for vascular trauma2 (0.0)16
ThermoregulationHyperthermia24 (0.6)6
Perception/cognitionCognitionDeficient of knowledge595 (14.6)3
NutritionHydrationRisk for imbalanced fluid volume40 (1.0)5
Deficit fluid volume19 (0.5)7
IngestionImbalanced nutrition : less than body requirements2 (0.0)16
Elimination and exchangeUrinary functionUrinary retention52 (1.3)4
Impaired urinary elimination14 (0.3)8
Function urinary incontinence1 (0.0)19
Gastrointestinal functionConstipation8 (0.2)10
Diarrhea4 (0.1)15
Activity/restCardiovascular/pulmonary responsesIneffective breathing pattern5 (0.1)13

The ten most nursing diagnoses.