Identification of Nursing Diagnosis-Outcome-Intervention Linkages for Inpatients in Gynecology Department Nursing Units

Min Ji Yang; Hye Young Kim

doi:10.4069/kjwhn.2016.22.3.170

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Yang and Kim: Identification of Nursing Diagnosis-Outcome-Intervention Linkages for Inpatients in Gynecology Department Nursing Units

Original Article

Korean Journal of Women Health Nursing 2016; 22(3): 170-181.

Published online: 27 September 2016

DOI: https://doi.org/10.4069/kjwhn.2016.22.3.170

Identification of Nursing Diagnosis-Outcome-Intervention Linkages for Inpatients in Gynecology Department Nursing Units

Min Ji Yang¹, Hye Young Kim²

¹Chonbuk National University Hospital, Jeonju, Korea.

²College of Nursing · Research Institute of Nursing Science, Chonbuk National University, Jeonju, Korea.

Corresponding author: Kim, Hye Young. College of Nursing, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 54896, Korea. Tel: +82-63-270-4618, Fax: +82-63-270-3127, tcellkim@jbnu.ac.kr

Received 25 May 2016 Revised 14 July 2016 Accepted 2 August 2016

(open-access):

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 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

Figures and Tables

Table 1

Demographic 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)
Occupation	No	132 (46.0)
Education	≥Middle school	61 (21.2)
	High school	121 (42.2)
	≤College	105 (36.6)
Religion	Yes	145 (50.5)
Religion	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 2

Nursing Diagnosis Used in Gynecology Department Nursing Unit

Domains	Classes	Nursing diagnosis	n (%)	Rank
Comfort	Physical comfort	Acute pain^†	2,168 (53.2)	1
Comfort	Physical comfort	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
	Hydration	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
	Gastrointestinal function	Diarrhea	4 (0.1)	15
Activity/rest	Cardiovascular/pulmonary responses	Ineffective breathing pattern	5 (0.1)	13

^†The ten most nursing diagnoses.

Table 3

Nursing Outcome Used in Gynecology Department Nursing Unit

Domains	Classes	Nursing Outcome	n (%)	Rank
Health knowledge and behavior	Health behavior	Pain control^†	1,292 (41.9)	1
Health knowledge and behavior	Health knowledge	Knowledge: disease process^†	593 (19.2)	3
Physiologic health	Cardiopulmonary	Blood coagulation^†	6 (0.2)	8
	Cardiopulmonary	Respiratory status: ventilation^†	5 (0.2)	9
	Fluid and electrolytes	Fluid balance^†	19 (0.6)	7
	Immune response	Immune status^†	177 (5.7)	4
	Immune response	Infection severity^†	62 (2.0)	5
	Metabolic regulation	Thermoregulation^†	24 (0.8)	6
	Digestion and nutrition	Nutritional status	2 (0.1)	11
	Tissue integrity	Wound healing: primary intention^†	898 (29.1)	2
	Tissue integrity	Tissue integrity: skin and mucous membranes^†	5 (0.2)	9
Perceived health	Symptom status	Nausea and vomiting severity	2 (0.0)	11

^†The ten most nursing outcome.

Table 4

Nursing Intervention Used in Gynecology Department Nursing Unit

Domains	Classes	Nursing intervention	n (%)	Rank
Behavioral	Patient education	Teaching: individual^†	2,046 (13.7)	2
		Teaching: disease process^†	664 (4.5)	10
		Teaching: procedure/treatment	116 (0.8)	18
		Chemotherapy management	120 (0.8)	17
		Teaching: prescribed medication	110 (0.7)	19
	Psychological comfort promotion	Relaxation therapy^†	2,085 (14.0)	1
		Distraction^†	810 (5.4)	8
		Guided imagery	195 (1.3)	14
Physiological - basic	Elimination management	Urinary elimination management	145 (1.0)	15
		Urinary retention care	28 (0.2)	28
		Constipation/impaction management	17 (0.1)	33
		Diarrhea management	8 (0.1)	37
		Urinary bladder training	1 (0.0)	40
	Nutrition support	Total parenteral nutrition (TPN) administration	51 (0.3)	23
	Physical comfort promotion	Massage^†	1,054 (7.1)	5
		Nausea management	24 (0.2)	30
		Heat/cold application	31 (0.2)	27
	Self-care facilitation	Tube care	10 (0.1)	35
Physiological - complex	Drug management	Patient-controlled analgesia (PCA) assistance^†	1,337 (9.0)	4
		Medication administration: IV^†	1,015 (6.8)	7
		Medication administration: oral	524 (3.5)	11
		Medication administration: IM	46 (0.3)	24
		Medication administration	4 (0.0)	39
	Respiratory management	Respiratory monitoring	10 (0.1)	35
	Respiratory management	Ventilation assistance	5 (0.0)	38
	Skin/wound management	Incision site care^†	1,576 (10.6)	3
		Wound care: closed drainage^†	1,017 (6.8)	6
		Skin surveillance	35 (0.2)	26
	Thermoregulation	Fever treatment	63 (0.4)	21
	Tissue perfusion management	Fluid monitoring	145 (1.0)	15
		Fluid/electrolyte management	99 (0.7)	20
		Hypovolemia management	19 (0.1)	32
		Fluid management	58 (0.4)	22
		Bleeding precautions	40 (0.3)	25
		Invasive hemodynamic monitoring	15 (0.1)	34
	Neurologic management	Seizure precautions	25 (0.2)	29
Safety	Risk management	Infection protection^†	741 (5.0)	9
Safety	Risk management	Fall prevention	24 (0.2)	30
Health system	Health system mediation	Admission care	287 (1.9)	12
Health system	Health system mediation	Discharge planning	287 (1.9)	12

^†The ten most nursing intervention; IV=intravascular; IM=intramuscular.

Table 5

NANDA-NOC-NIC Linkage Used in Gynecology Department Nursing Unit

NANDA	Nursing outcomes classification	Nursing Interventions Classification	n
Acute pain	Pain control	Relaxation therapy	2,085
		Patient-controlled analgesia (PCA) assistance	1,337
		Medication administration: IV	1,015
		Distraction	810
		Medication administration: oral	524
		Guided imagery	195
		Medication administration: IM	46
		Heat/cold application	14
Risk for infection	Wound healing: primary intention	Incision site care	1,576
	Wound healing: primary intention	Wound care: closed drainage	1,017
	Immune status	Infection protection	741
	Infection severity	Tube care	10
Deficient of knowledge	Knowledge: disease process	Teaching: individual	2,046
		Teaching: disease process	664
		Teaching: procedure/treatment	116
Risk for imbalanced fluid volume	Fluid balance	Fluid/electrolyte management	7
Risk for imbalanced fluid volume	Fluid balance	Fluid management	3
Hyperthermia	Thermoregulation	Fever treatment	63

NANDA=North America Nursing Diagnosis Association; IV=intravascular; IM=intramuscular.

Notes

This article is based on a part of the first author's master's thesis from Chonbuk National University.

Summary Statement

▪ What is already known about this topic?

A computer-based nursing process documentation system was developed through NANDA-NOC-NIC linkages to facilitate the standardized nursing process.

▪ What this paper adds?

The NANDA-NOC-NIC linkages for inpatients of gynecology department nursing unit were identified through their electronic nursing records. The top 5 major nursing diagnoses were identified and 7 nursing outcomes and 18 nursing interventions associated with these diagnoses were checked.

▪ Implications for practice, education and/or policy

The identified NANDA-NOC-NIC linkages can contribute to improving standardized nursing care and provide evidence-based nursing.

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