Standardized Nursing
Received May 25, 2016; Revised July 14, 2016; Accepted August 02, 2016.
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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
Variables | Categories | n (%) | M±SD | Range |
---|---|---|---|---|
Age (year) | 20~29 | 39 (13.6) | 44.99±13.55 | 20~84 |
30~39 | 58 (20.2) | |||
40~49 | 106 (36.9) | |||
50~59 | 39 (13.6) | |||
≥60 | 45 (15.7) | |||
Marriage status | Married | 235 (81.9) | ||
Non-married | 38 (13.2) | |||
Others | 14 (4.9) | |||
Occupation | Yes | 155 (54.0) | ||
No | 132 (46.0) | |||
Education | ≥Middle school | 61 (21.2) | ||
High school | 121 (42.2) | |||
≤College | 105 (36.6) | |||
Religion | Yes | 145 (50.5) | ||
No | 142 (49.5) | |||
Length of stay in hospital (day) | 6.42±3.65 | 3~41 | ||
Medical diagnosis | Uterine myoma | 90 (31.4) | ||
Cancer (cervix, ovary, endometrium) | 51 (17.8) | |||
Ovarian cyst | 29 (10.1) | |||
Adxetal tumor | 19 (6.6) | |||
Uterine prolapse | 16 (5.6) | |||
Ectopic pregnancy | 15 (5.3) | |||
Inflammatory disease | 15 (5.3) | |||
Endometrioma | 15 (5.3) | |||
Adenomyosis | 13 (4.5) | |||
Others | 24 (8.1) | |||
Type of surgery (n=212) | Hysterectomy | 80 (27.9) | ||
Myomectomy | 40 (14.0) | |||
Cystectomy | 33 (11.5) | |||
Adnexectomy | 15 (5.2) | |||
Colporrhaphy | 14 (4.9) | |||
Salpingectomy | 13 (4.5) | |||
Polypectomy | 10 (3.5) | |||
Oophorectomy | 2 (0.7) | |||
Others | 5 (1.7) |
Table 2Nursing Diagnosis Used in Gynecology Department Nursing Unit
Domains | Classes | Nursing diagnosis | n (%) | Rank |
---|---|---|---|---|
Comfort | Physical comfort | Acute pain† | 2,168 (53.2) | 1 |
Nausea | 2 (0.0) | 16 | ||
Safety/protection | Infection | Risk for infection† | 1,114 (27.3) | 2 |
Physical injury | Risk for injury† | 11 (0.3) | 9 | |
Risk for falls | 7 (0.2) | 11 | ||
Risk for bleeding | 6 (0.2) | 12 | ||
Impaired skin integrity | 5 (0.1) | 13 | ||
Risk for vascular trauma | 2 (0.0) | 16 | ||
Thermoregulation | Hyperthermia† | 24 (0.6) | 6 | |
Perception/cognition | Cognition | Deficient of knowledge† | 595 (14.6) | 3 |
Nutrition | Hydration | Risk for imbalanced fluid volume† | 40 (1.0) | 5 |
Deficit fluid volume† | 19 (0.5) | 7 | ||
Ingestion | Imbalanced nutrition : less than body requirements | 2 (0.0) | 16 | |
Elimination and exchange | Urinary function | Urinary retention† | 52 (1.3) | 4 |
Impaired urinary elimination† | 14 (0.3) | 8 | ||
Function urinary incontinence | 1 (0.0) | 19 | ||
Gastrointestinal function | Constipation† | 8 (0.2) | 10 | |
Diarrhea | 4 (0.1) | 15 | ||
Activity/rest | Cardiovascular/pulmonary responses | Ineffective breathing pattern | 5 (0.1) | 13 |
†The ten most nursing diagnoses.