Journal List > Korean J Adult Nurs > v.25(4) > 1076198

TOOLS
Ko and So: Construction and Application of Nursing Information System Using NANDA-NOC-NIC Linkage in Medical-Surgical Nursing Units
Original Research

Korean J Adult Nurs 2013;25(4):365-376.

Published online: 18 August 2013

DOI: https://doi.org/10.7475/KJAN.2013.25.4.365

Construction and Application of Nursing Information System Using NANDA-NOC-NIC Linkage in Medical-Surgical Nursing Units

Eun Ko1, Hyang-Sook So2,

1Department of Nursing, Nambu University, Gwangju

2College of Nursing, Chonnam National University · CRINS, Gwangju, Korea

Corresponding author: So, Hyang-Sook College of Nursing, Chonnam National University, 5 Hak 1-dong, Dong-gu, Gwangju 501-746, Korea. Tel: +82-62-530-4930, Fax: +82-62-227-4009, E-mail: hsso@chonnam.ac.kr

Received 6 February 201325 June 2013       Accepted 7 August 2013

© 2013 Korean Society of Adult Nursing

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 purpose of this study was to construct, develop, and apply a nursing information system (NIS) using NANDA-NOC-NIC linkage in medical-surgical nursing units.

Methods

This study consisted of three phases which were the construction of the database, development of the NIS, and application of the NIS. To construct the database, a questionnaire and nursing record review by an expert group were used. Collected data were analyzed by the SPSS/WIN 13.0 program.

Results

In first phase, the database was made up of 50 nursing diagnoses, 127 nursing outcomes and 300 nursing interventions. In the second phase, NIS was developed according to its flow diagram and then tested. In the third phase, the developed NIS was applied to 130 inpatients. Nursing diagnoses frequently used were acute pain, delayed surgical recovery, and deficient knowledge (specify). Nursing outcomes for a nursing diagnosis of 'acute pain' were identified as pain control, pain level and comfort level. Nursing interventions for the nursing outcome 'pain control' were pain management, patient controlled analgesia assistance and medication management.

Conclusion

The results of this study will facilitate the use of the newly proposed NIS in nursing practice and provide a guideline for evidence-based nursing.

Keywords: Nursing diagnosis, Nursing outcome, Nursing intervention, Nursing information system

REFERENCES

Beyea S. C.2003. Describing professional nursing through a universal record in perioperative settings. International Journal of Nursing Knowledge. 14(s4):23.
crossref
Bulechek G.., Butcher H.., Dochterman J. M.2007. Nursing interventions classification (NIC). 5th ed.St Louis: Mosby.
Cho E. J.., Kim N. C.2008. Validation of major nursing diagnosis-outcome-intervention (NANDA-NOC-NIC) linkage for adult surgery patients of post anesthetic care unit. Journal of Korean Clinical Nursing Research. 14(3):141–151.
Choi S. H.., Choi B. H.., Ji H. R.., Lee E. J.., Kim H. S.., Park M. J.2006. Standardized NANDA, NOC, NIC linkage. Seoul: Hyunmoon.
Fehring R. J.1986. Validation diagnostic labels: Standardized methodology. St Louis: Mosby.
Hughes R.2003. The use of NANDA, NIC, and NOC in the identification and measurement of problems, interventions, and outcomes in spinal cord injury. International Journal of Nursing Knowledge. 14(s4):18–19.
crossref
Ji M. K.., Ji S. A.2003. Linkages of nursing diagnoses, nursing intervention, and nursing outcome classification of brest cancer patients using nursing database. Journal of Korean Academy of Nursing Administration. 9:651–661.
Johnson M.., Bulechek G.., Dochterman J. M.., Maas M.., Moorhead S.., Swanson E., et al. 2005. NANDA, NOC, and NIC linkages: Nursing diagnoses, outcomes, & interventions. 2nd ed.St. Louis: Mosby.
Johnsons M.., Mass M.., Moorhead M.2000. Nursing Outcomes Classifications. 2nd ed.St. Louis: Mosby.
Jung K. I.2003. Development of the ICNP based cancer nursing information system. Journal of Korean Society of Medical Informatics. 9(1):21–24.
Killeen M. B.2003. Comfort management as a proposed NIC, and validation of three NOCs for end-of-life and chronically ill patients. International Journal of Nursing Knowledge. 14(Supplement 4):19.
Kim H. S.2005. Development and application of a computerized nursing process program for orthopedic surgery inpatients-NANDA, NOC, and NIC linkage. Journal of Korean Academy of Nursing. 35:979–990.
Kim J. K.2010. A study on nursing diagnoses, interventions, outcomes frequently used and linkage to NANDA-NOC-NIC in major nursing departments. Journal of Korean Academy of Nursing Administration. 16:121–142.
crossref
Kim M. J.2010. Analysis on military hospital nursing records by NANDA, NIC, NOC system. Journal of Korean Academy of Nursing Administration. 16:73–85.
crossref
Kim P. J.2006. Application model of the nursing process to electric medical records for cardiodiovascular patients. Unpublished doctoral dissertation, Yonsei University, Seoul.
Lee E. J.., Choi S. H.2011. Identification of nursing diagnosis-outcome-intervention(NANDA-NOC-NIC) linkage in surgical nursing unit. Korean Journal of Adult Nursing. 23:180–188.
Lee E. J.., Park H. J.2003. Development and application of the computerized nursing process program using nursing diagnoses-outcome-intervention linkage. Journal of Korean Society of Medical Informatics. 9(Suppl 1):107.
Lippens B.2003. Use of NANDA, NIC, and NOC in infection control. International Journal of Nursing Knowledge. 14(Suppl 4):20.
crossref
Lunney M.., Delaney C.., Duffy M.., Moorhead S.., Welton J.2005. Advocating for standardized nursing languages in electronic health records. Journal of Nursing Administration. 35(1):1–3.
crossref
Manning J.., McConnell E. A.1997. Technology assessment: A framework for generation questions useful in evaluation nursing information systems. Computers in Nursing. 15(3):141–146.
North American Nursing Diagnosis Association. 2007. Nursing diagnoses: Definitions & classification 2007-2008. Philadelphia: NANDA International.
Park J. E.., Chung K. A.., Cho H.., Kim H. S.2013. Construction of the nursing diagnosis ontology in obstetric and gynecologic nursing unit using nursing process and SNOMED CT. Korean Journal of Women Health Nursing. 19(1):1–12. http://dx.doi.org/10.4069/kjwhn.2013.19.1.1.
crossref
Park M. J.2010. Identification of nursing diagnosis-outcome-intervention (NANDA-NOC-NIC) linkage in MICU inpatients. Unpublished doctoral dissertation, Chonnam National University, Gwangju.
Park S. H.2006. Linkages of nursing diagnoses and nursing interventions for clinical decision support system. Unpublished doctoral dissertation, Seoul National University, Seoul.
Scroggins L. M.2008. The developmental processes for NANDA international nursing diagnoses. International Journal of Nursing Knowledge. 19:57–64. http://dx.doi.org/10.1111/j.1744-618X.2008.00082,x.
crossref
Shever L. L.., Titler M.., Dochterman J.., Fei Q.., Picone D. M.2007. Patterns of nursing intervention use across 6 days of acute care hospitalization for three older patient populations. International Journal of Nursing Knowledge. 18:18–29.
crossref
Yom Y. H.., Chi S. A.., Yoo H. S.2002. Application of nursing diagnoses, interventions and outcomes to patients undergoing abdominal surgery in Korea. International Journal of Nursing Knowledge. 13:77–87.
crossref
Yoo H. S.., Chi S. A.2001. Construction of linkage database on nursing diagnoses, interventions, outcomes in abdominal surgery patients. Journal of Korean Academy of Nursing Administration. 7:425–439.

Figure 1.
Research procedure for the development of the nursing information system by system development life cycle.
kjan-25-365f1.tif
Figure 2.
Image of the screen for the nursing information system using NANDA-NOC-NIC linkage.
kjan-25-365f2.tif
Table 1.
Nursing Diagnoses for Database Construction (N=72)
Domain n Nursing diagnosis CVI
Comfort 3 Acute pain .87
Nausea .85
Chronic pain .80
Nutrition 6 Imbalanced nutrition: less than body requirements .80
Impaired swallowing .77
Deficient fluid volume .74
Excess fluid volume .72
Risk for imbalanced fluid volume .70
Risk for deficient fluid volume .69
Elimination and exchange 10 Constipation .83
Diarrhea .81
Impaired urinary elimination .80
Risk for constipation .72
Urinary retention .71
Impaired gas exchange .70
Reflex urinary incontinence .68
Urge urinary incontinence .68
Functional urinary incontinence .67
Bowel incontinence .64
Activity/rest 13 Impaired walking .75
Self-care deficit: bathing/hygiene, dressing/grooming, feeding, toileting .74
Impaired bed mobility .73
Impaired spontaneous ventilation .73
Ineffective breathing pattern .73
Disturbed sleep pattern .69
Impaired physical mobility .68
Impaired wheelchair mobility .66
Fatigue .65
Activity intolerance .62
Delayed surgical recovery .61
Ineffective tissue perfusion .60
Decreased cardiac output .60
Perception/cognition 4 Deficient knowledge (specify) .72
Acute confusion .69
Disturbed sensory perception (kinesthetic) .62
Impaired verbal communication .62
Coping/stress tolerance 2 Anxiety .70
Fear .61
Safety/protection 12 Risk for falls .85
Hyperthermia .81
Risk for infection .81
Risk for aspiration .78
Risk for injury .78
Impaired skin integrity .73
Ineffective thermoregulation .73
Risk for impaired skin integrity .69
Impaired tissue integrity .68
Ineffective airway clearance .66
Impaired oral mucous membrane .66
Noncompliance .64

CVI=index of content validity.

Table 2.
General Characteristics of the Inpatients used in the Nursing Information System (N=130)
Characteristics Categories   n (%)
Gender Male   69 (53.1)
Female 61 (46.9)
Age (year) 20~29 15 (11.5)
30~39 16 (12.3)
40~49 23 (17.7)
50~59 26 (20.0)
60~69 29 (22.3)
≥70 21 (16.2)
Length of stay in hospital (week) ＜1 50 (38.5)
1~2 61 (46.9)
≥2 19 (14.6)
Operation Operate 72 (55.4)
Not operate 58 (44.6)
Admission department Internal medical unit Division of pulmonology 11 (8.5)
Division of gastroenterology 7 (5.4)
Division of cardiology 7 (5.4)
Department of neurology 7 (5.4)
Division of nephrology 6 (4.6)
Division of infection 6 (4.6)
Division of endocrinology 5 (3.8)
Division of allergy 4 (3.1)
Rehabilitation medicine 4 (3.1)
Division of rheumatology 2 (1.5)
Surgical unit General surgery (ES, HPBS, GES, VTS) 18 (13.9)
Neurosurgery 11 (8.5)
Orthopedic surgery 9 (6.9)
Otorhinolaryngology 8 (6.2)
Ophthalmology 6 (4.6)
Thracic & cardiovascular surgery 5 (3.8)
Plastic surgery 5 (3.8)
Urology 5 (3.8)
Gynecology 4 (3.1)

ES=endocrine surgery; HPBS=hepatopancreatic biliary surgery; GES=gastroenterological surgery; VTS=vascular transplantation surgery.

Table 3.
NANDA-NOC-NIC Linkage used in the Nursing Information System: Acute Pain
Diagnosis Outcome n (%) Intervention n (%)
Acute pain   193 (100.0)   200 (100.0)
Pain control 81 (42.0) Pain management 52 (26.0)
Patient controlled analgesia assistance 16 (8.0)
Medication management 8 (4.0)
Teaching: prescribed medication 5 (2.5)
Pain level 80 (41.4) Pain management 31 (15.5)
Heat/cold application 21 (10.5)
Analgesic administration 10 (5.0)
Medication administration: intramuscular 7 (3.5)
Environmental management: comfort 4 (2.0)
Positioning 3 (1.5)
Anxiety reduction 2 (1.0)
Medication administration: oral 2 (1.0)
Medication management 2 (1.0)
Splinting 2 (1.0)
Medication administration: intravenous 1 (0.5)
Medication prescribing 1 (0.5)
Comfort level 32 (16.6) Pain management 18 (9.0)
Medication management 8 (4.0)
Medication administration 5 (2.5)
Environmental management: comfort 1 (0.5)
Sedation management 1 (0.5)
TOOLS
Similar articles