| 중환자실 간호기록 표준화를 위한 간호초점 분석 |
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강영미, 유지호, 조용애, 류성숙, 조정구, 성영희 |
1삼성 서울 병원 신경소아중환자실
2삼성 서울 병원 신경소아중환자실
3삼성 서울 병원 중환자간호팀 성균관 대학
4삼성 서울 병원 암센터외과중환자실
5삼성 서울 병원 신경소아중환자실
6삼성 서울 병원 간호본부 성균관대학 |
| An analysis of nursing focuses for standardization of ICU nursing records |
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Young-Mi Kang, Ji-Ho Yu, Yong-Ae Cho, Sung-Suk Ryoo, Jeong-Koo Cho, Young-Hee Sung |
1Department of Neurology & Pediatrics intensive care unit, Samsung Medical Center
2Department of Neurology & Pediatrics intensive care unit, Samsung Medical Center
3Critical care nursing, Samsung Medical Center and Department of Clinical Nursing Science, Sungkyunkwan University School of Medicine
4Department of Surgery intensive care unit, Cancer center, Samsung Medical Center
5Department of Neurology & Pediatrics intensive care unit, Samsung Medical Center
6Samsung Medical Center and Sungkyunkwan University School of Medicine |
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| Abstract |
Purpose
Purpose of this study was to analyze the nursing focuses for standardization of ICU nursing records.
Methods
The data were collected from 1,000days'nursing records of 197 ICU patients at a tertiary hospital in Seoul. Nursing focuses were unified at the consulting group meeting and they were cross-mapped with the NANDA nursing diagnoses.
Results
The 62 nursing focuses in 7 NANDA categories were extracted from nursing record. Among total nursing focuses 41 correspond to the NANDA nursing diagnoses and 21 were added to ICU nursing focuses. The 10 most frequently used nursing focuses are 'Ineffective airway clearance', 'Impaired gas exchange', 'Ineffective tissue perfusion: cardiopulmonary', 'Ineffective breathing pattern', 'Ineffective tissue perfusion: renal', 'Ineffective infant feeding pattern', 'Risk for impaired skin integrity', 'Hyperthermia', 'Impaired skin integrity', 'Decreased cardiac output',
Conclusion
Nursing focuses list of ICU was extracted from the result of this study. These nursing focuses might form a framework for development of research-based assessment guideline and care plans for ICU patients through standardization of nursing records. |
| Key Words:
Nursing focus, NANDA Nursing diagnosis, ICU Nursing record |
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