As home care in developing and becoming part of the health care delivery system in Korea, it is necessary to examine the use of nursing diagnoses and related nursing interventions with a view to increasing the standardization of nursing
recording.
This
study was done to examine the nursing diagnosis and related nursing interventions used in home care. Data were collected using a chart review of the nursing notes written for the home care given to 38 patients who had pulmonary diseases or
traumatic
brain or spinal cord injuries and who had received home care as part of a demonstration home care project in a college of Nursing in Seoul. Early on in the project discussions as to format and use to nursing diagnosis was done and a tool was
developed
based on Gordon's eleven functional catergories with the addition of categories to cover family ad environment. This tool was used in the data collection. Data included nursing diagnosis, etiologies and interventions. Real numbers and percentages
were
used in the analysis.
The results show that the most frequently used diagnoses were in the category of physical function (75.6%), followed by the category of emotional and social function (21.8%). The least frequently used category was the one for family and
environment
(2.6%). The order of the frequency of recorded nursing interventions was the same, 82.3% for physical function, 16.2% of emotional and social function and 1.5% for family and environment. Under the category of physical functioning the most
frequently
used nursing diagnoses were related to mobility (62.2%), nutrition (23.6%) and elimination (11.9%). The frequencies of nursing interventions for these diagnostic categories were 69.8%, 16.0% and 10.8% respectively. For emotional and social
functioning,
the most frequently used diagnoses were for cognition-perception (37.1%), self-perception (30.6%) and perception of health (23.7%). The ordering of the frequency of nursing interventions varied slightly.
The most frequently used interventions were for the category of self-perception (31.7%) followed by cognition-perception (24.1%) and perception of health (22.9%). Looking at individual diagnoses, it was found that within the categroy of physical
functioning, the most frequently used diagnosis was "impaired physical mobility" (29.5%) and this diagnosis involved 43.9% of the interventions.
This was followed by "ineffective breathing pattern" (19.4%) with 17.7% of interventions, and "alteration in nutrition, less than body requirements" (11.2%) with 8.1% of the interventions. For the emotional social category, noncompliance was the
most
frequently used nursing diagnosis (18.2%) with 19.2% of the interventions. This was followed by "anxiety" (13.4%) with 13.6% of the interventions and by "knowledge deficit" (13.4%) but with only 5.5% of the interventions. The other diagnoses and
interventions did not follow this pattern of frequency.
Although have were a large number of diagnostic and intervention events, the number of actual diagnoses and interventions used were relatively small ranging from six interventions for "knowledge deficit" to 40 interventions for "imparied physical
mobility". From this it can be concluded that the results of this study could be used as basic data for the development of standardized charts with respect to nursing diagnosis and interventions for clients with pulmonary disease and clients with
traumatic brain or spinal cord injuries.
Interventions that were direct care activities (1178) were much more fredquent that edducation (430). And assessment and observation (148). There were also few dagnoses or interventions related to family and the environment This suggests two
areas
that
need to be developed in home care and that need to be considered in the development of standardized records for use in home care.
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