간호기록지를 통해본 담낭절제 수술환자 간호연구

Abstract

[한글]

A Study on Quality of Nursing Care for Cholecystectomy Patients through Nursing

Audit

Choi, Gong Ok

Department of Nursing, Graduate School of Yonsei University

(Directed by Associate Professor Kim, Mo Im)

Nurses observe and record patient's conditions, carrying out doctor's orders for

the patient, and reporting on the patient's reactions to the prescribed treatment

or drugs. If these notes are accurate and complete, they should give an indication

of the nursing care what the patient received, and an examination of them give some

indication of the type of nursing care the hospital provides. This process of

examination has been termed, as a "nursing audit".

The purpose of this study is to evaluate quality of nursing care for the

cholecystectomy patient at X-Hospital through the "nursing audit".

For this purpose the researcher examined the charts of 50 cholecystectomy

patients discharged from 1 Jan. 1972 to 31 Dec. 1972.

Six different nursing care indices were constructed in terms of types and

functions of nursing. And the index scores were grouped arbitrarily into 4

categories such as "excellent", "good", "incomplete", and "poor" based upon

investigator's personal judgement.

The study findings were follows :

1. The patient observation index showed that 82% of patients fell within "poor"

category.

2. The physical care index indicated that total patients fell within "poor"

category.

3. The index of carrying out the routine nursing procedure for the

cholecystectomy patient disclosed that 68% of patients fell within "good" category.

4. The index of carrying out the routine doctor's order for the cholecystectomy

patient appeared that 94% of the patients fell within "excellent" category.

5. The expressive function index revealed that 98% of patients fell within

"poor"category.

6. The instrumental function index exhibited that 68% of patients fell within

"excellent" category.

7. There were statistically significant differences in the instrumental function

index scores among age groups.

8. There were also statistically significant differences in total nursing care by

number of hospital days before operation.

From these findings it is disclosed that more instrumental functions than

expressive functions were carried out by nurses in X-Hospital with regard to

pre-post operative nursing care for cholecystectomy patients.

[영문]

Nurses observe and record patient's conditions, carrying out doctor's orders for the patient, and reporting on the patient's reactions to the prescribed treatment or drugs. If these notes are accurate and complete, they should give an indication

of the nursing care what the patient received, and an examination of them give some indication of the type of nursing care the hospital provides. This process of examination has been termed, as a "nursing audit".

The purpose of this study is to evaluate quality of nursing care for the cholecystectomy patient at X-Hospital through the "nursing audit".

For this purpose the researcher examined the charts of 50 cholecystectomy patients discharged from 1 Jan. 1972 to 31 Dec. 1972.

Six different nursing care indices were constructed in terms of types and functions of nursing. And the index scores were grouped arbitrarily into 4 categories such as "excellent", "good", "incomplete", and "poor" based upon investigator's personal judgement.

The study findings were follows :

1. The patient observation index showed that 82% of patients fell within "poor" category.

2. The physical care index indicated that total patients fell within "poor" category.

3. The index of carrying out the routine nursing procedure for the cholecystectomy patient disclosed that 68% of patients fell within "good" category.

4. The index of carrying out the routine doctor's order for the cholecystectomy patient appeared that 94% of the patients fell within "excellent" category.

5. The expressive function index revealed that 98% of patients fell within "poor"category.

6. The instrumental function index exhibited that 68% of patients fell within "excellent" category.

7. There were statistically significant differences in the instrumental function index scores among age groups.

8. There were also statistically significant differences in total nursing care by number of hospital days before operation.

From these findings it is disclosed that more instrumental functions than expressive functions were carried out by nurses in X-Hospital with regard to pre-post operative nursing care for cholecystectomy patients