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Korean J Adult Nurs : Korean Journal of Adult Nursing

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Original Research

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

Eun Ko1, Hyang-Sook So2
Korean Journal of Adult Nursing 2013;25(4):365-376.
Published online: August 18, 2013

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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: February 6, 2013   • Accepted: August 7, 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.

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  • 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.
  • Key Words: Nursing diagnosis; Nursing outcome; Nursing intervention; Nursing information system
Figure 1.
Research procedure for the development of the nursing information system by system development life cycle.
kjan-25-365f1.jpg
Figure 2.
Image of the screen for the nursing information system using NANDA-NOC-NIC linkage.
kjan-25-365f2.jpg
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)
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    Korean J Adult Nurs. 2013;25(4):365-376.   Published online August 31, 2013
    DOI: https://doi.org/10.7475/kjan.2013.25.4.365
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    DOI: https://doi.org/10.7475/kjan.2013.25.4.365
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    Construction and Application of Nursing Information System Using NANDA-NOC-NIC Linkage in Medical-Surgical Nursing Units
    Image Image
    Figure 1. Research procedure for the development of the nursing information system by system development life cycle.
    Figure 2. Image of the screen for the nursing information system using NANDA-NOC-NIC linkage.

    Figure 1.

    Figure 2.

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

    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.

    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.

    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)
    Table 1. Nursing Diagnoses for Database Construction (N=72)

    CVI=index of content validity.

    Table 2. General Characteristics of the Inpatients used in the Nursing Information System (N=130)

    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

    Table 1.

    Table 2.

    Table 3.

    Korean J Adult Nurs : Korean Journal of Adult Nursing

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