The nursing process, composed of diagnosis, intervention and outcome, is practical and scientific approach. In addition, many studies on the nursing process have been performed. However, the nursing process has not applied to clinical fields. Therefore, we developed a nursing information system that supports nurses nursing diagnosis and intervention management. This system provides expected nursing diagnoses and interventions for subjective patients automatically so that nurses can make more accurate diagnoses and perform more adequate interventions. For that purpose, we have analyzed the relations of medical diagnoses and standardized nursing classifications and developed the outputs into a database system. In this study, we performed clinical tests for the system and verify the usefulness of the system with case database accumulated through the tests. We expect the system can be used in many hospitals efficiently after some upgrade based on the results of this study is completed.
Classification ; Diagnosis* ; Humans ; Information Systems ; Nursing Diagnosis* ; Nursing Process ; Nursing*

PURPOSE: The purpose of this study was to compare changes in learning objectives in Fundamentals of Nursing which were established between 2000 and 2004. METHOD: 2000, 2004 learning objectives were analyzed with frequencies and percents. RESULTS: There was an increase in the total number of learning objectives used in 2004(n=534) over 2000(n=527). In 2004 compared to 2000, there was an increase in learning objectives related to nursing process, need of oxygenation, need of nutrition, need of temperature regulation, need of activity and exercise, need of comfort, medication, preoperative care. According to Bloom's taxonomy, learning objectives established in 2004, mainly consisted of three domains, 35.5% for comprehension, 23.6% for synthesis, 20.4% for knowledge. Changes in learning objectives established in 2004 compared to 2000 decreases in the comprehension domain and increases in the synthesis domain. CONCLUSION: The learning objectives established in 2004 showed remarkable change when compared to those established in 2000. But the learning objective domains in Bloom's taxonomy were distributed unevenly. For better learning objectives in Fundamentals of Nursing, constant revision will be needed.
Classification ; Comprehension ; Learning* ; Nursing Process ; Nursing* ; Oxygen ; Preoperative Care

A nursing activity classification for hospitalized patients was performed based on an article review regarding nursing definition and nursing activity classification system. The study was conducted as follows: 1) Taxonomy was developed by the research team through the Delphi process and review article. The taxonomy consists of four nursing processes, (assessment, diagnosis, intervention and evaluation) and twelve nursing activity domains space (resperation, nutrition, elimination, exercise/alignment maintenance, comfort, hygiene, safety, spiritual support, counseling/ education, medication, communication, patient and information management). 2) First, nursing activities of the intervention process were listed and then classified by the nursing process of assessment, diagnosis, intervention and evaluation. The list consists of twelve nursing activity domains and 136 nursing activities. 3) A pilot study was conducted in two hospitals to verify validity and appropriateness of nursing activities. 4) The content validity index, which was calculated by 6 clinical practice experts, was 0.95. Also, a nursing activity classification system should also be developed in the department of community nursing and home health care nursing.
Classification* ; Diagnosis ; Education ; Home Health Nursing ; Humans ; Hygiene ; Korea* ; Nursing Process ; Nursing* ; Pilot Projects

This study examines that North American Nursing Diagnosis Association(NANDA) and Home Health Care Classification(HHCC) is appropriate to classify home health care client's nursing problems and suggests a modified nursing diagnosis classification system. Two hundred and forty-nine clients' records at a general hospital were reviewed and nursing problems were diagnosed according to each classification system. Results of this study are as follows. The major client's medical diagnosis are pregnancy, childbirth and puerperium, malignant neoplasm, and benign neoplasm. Of four hundred and sixty-three nursing problems, all nursing problems made a diagnos according to HHCC, while three hundred and eighty-five made a diagnosis according to NANDA. The HHCC diagnosis included 78 more nursing problems than NANDA. The discrepancy in the results may indicate a significant advantage to HHCC diagnosis because HHCC nomenclature was created empirically from hard data. However, this may be due to limitations in the data collection method so determination of which classification system is more useful is difficult to judge. However, nursing components of the HHCC are more concrete and clearer than human response patterns of the NANDA. Also the HHCC facilitates the documentation of patient care by computer, while using a conceptual framework consisting of 20 Care Components based on the nursing process: assessment, diagnosis, outcome identification, planning, implementation and evaluation. Accordingly, the practical application of HHCC is more useful than NANDA. Limitations of this study include a retrospective data collecting method and universality of samples. Further research for various samples that use prospective data collection method is recommended.
Classification* ; Data Collection ; Delivery of Health Care* ; Diagnosis ; Hospitals, General ; Humans ; Nursing Diagnosis* ; Nursing Process ; Nursing* ; Parturition ; Patient Care ; Postpartum Period ; Pregnancy ; Retrospective Studies

PURPOSE: The purpose of this study was to identify the entity of critical care nursing practices through analyzing nursing statements described by electronic nursing records in a MICU. METHODS: 176,459 nursing statements of 188 patients during a 6 month-stay were analyzed statement by statement according to the nursing process(nursing phenomena, nursing diagnosis, & nursing activity) and 21 nursing components of Saba's Clinical Care Classification. RESULTS: Among 176,459 single statements, the statements of nursing activity ranked first in number. The contents of the statements were analyzed and categorized by main themes. Among 489 categorized themes, the number of themes of nursing phenomena statements was the highest. When analyzed by Saba's clinical Care Classification, the nursing statements mainly included a physiological component. Among 21 components, the respiratory component ranked in the first position in nursing phenomena, nursing diagnosis and nursing activity. The extra statements not included in the 21 components were 9,294(15.1%) in nursing phenomena and 21,949(22.7%) in nursing activity. Most are statements related to tests and the doctor. CONCLUSION: The entity of MICU nursing practice expressed by electronic nursing records was mainly focused on physiological components and more precisely on respiratory components.
Humans ; *Intensive Care Units ; Medical Records Systems, Computerized/*statistics & numerical data ; Nursing Diagnosis ; Nursing Process/*classification ; Retrospective Studies ; Task Performance and Analysis