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KMID : 1221920080010010073
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Journal of Korean Critical Care Nursing
2008 Volume.1 No. 1 p.73 ~ p.83
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An analysis of nursing focuses for standardization of ICU nursing records
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Kang Young-Mi
Yu Ji-Ho
Cho Yong-Ae
Ryoo Sung-Suk
Cho Jeong-Koo
Sung Young-Hee
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Abstract
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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.
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KEYWORD
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Nursing focus, NANDA Nursing diagnosis, ICU Nursing record
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