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응급실 복통환자의 간호진단과 간호중재의 분석

Other Titles
 Analysis of nursing diagnoses and nursing interventions for patients in ER with abdominal pain 
Authors
 오현식 
Issue Date
2006
Description
응급간호전공/석사
Abstract
[한글]복통은 응급실을 내원하는 환자가 호소하는 흔한 증상 중의 하나이다. 또한 복통은 경미한 증상부터 극심한 통증, 수술적 치료가 필요한 복통 등 다양하다. 환자는 즉각적인 통증 완화를 기대하며 즉각적인 간호의 중재를 기대하므로 응급실 간호사에게는 중요한 간호문제이다.본 연구의 목적은 응급실에 내원한 복통 환자에 대한 간호진단과 간호중재의 기초자료 제공의 목적이 있다.본 연구는 후향적 조사연구로서, 연구대상은 2006년 4월 1일부터 2006년 5월 31일까지 2개월 동안 서울소재 일개 대학병원 응급실에 내원한 비 외상성 복통환자로 만 15세 이상의 성인 환자의 간호기록지에서 간호진단이 도출된 115부로 하였다. 연구절차 및 분석방법은 115부의 간호기록지에서 도출된 간호진단을 NANDA가 개발한 간호진단 목록으로 어휘를 통일한 후 건수를 조사하였고, 도출된 간호진단별 간호활동의 건수를 조사한 뒤에 최종적으로 간호진단별 간호활동을 IOWA 간호중재분류 팀에 의해 개발된 간호중재를 활용하여 간호중재 영역, 과, 간호중재로 분류하여 각 진단별 간호중재 영역, 과, 간호중재의 건수를 조사하였다.본 연구의 결과는 다음과 같다.1. 응급실에 복통으로 내원한 환자 115부 기록지에서 간호진단은 19개 도출되었다. 가장 높은 건수를 보인 것은 급성통증(89건)이며 다음이 낙상의 위험(71건), 감염의 위험(39건), 체액불균형 위험성(38건) 순이었다.2. 간호진단 19개에서 도출된 간호활동 종류는 총 380개였고 간호활동의 건수는 2,267건이었다.3. 간호진단 상위 5순위까지 간호진단별 간호중재의 영역 건수를 보면 급성통증에서는 생리학적; 기본적 영역(234건), 생리학적; 복합적 영역(80건), 안전 영역(69건), 건강체계 영역(33건)이었다. 낙상위험에서는 안전 영역(116건), 가족 영역(48건)이었다. 감염의 위험에서는 안전 영역(116건), 생리학적; 복합적 영역(103건), 건강체계 영역(3건), 생리학적; 기본적 영역(1건)이었다. 체액불균형 위험성에서는 생리학적; 기본적영역(331건), 안전 영역(50건), 생리학적; 복합적 영역(50건), 행동학적 영역(19건), 건강체계 영역(5건)이었다. 비효과적 조직관류-위장관에서는 생리학적; 기본적 영역(300건), 안전 영역(44건), 생리학적; 복합적 영역(24건), 행동학적 영역(15건), 건강체계 영역(1건)이었다.4. 간호진단 상위 5순위까지 간호진단별 간호중재의 과 건수를 보면 급성통증에서는 신체 안위증진(232건), 약물관리(74건), 위험관리(67건), 정보관리(33건)순이었다. 낙상위험에서는 위험관리(116건), 수명간호(48건)순이었다. 감염의 위험에서는 위험관리(116건), 체온조절(56건), 약물관리(38건)순이었다. 체액불균형 위험성에서는 신체안위증진(132건), 영양지지(131건), 위험관리(50건), 활동과 운동관리(38건), 배설관리(30건)순이었다. 비효과적 조직관류-위장관에서는 신체안위증진(125건), 영양지지(108건), 위험관리(44건), 활동과 운동관리(31건), 배설관리(26건)순이었다.5. 간호진단 상위 5순위까지 간호진단별 간호중재의 중재 건수를 보면 급성통증에서 통증관리(186건), 투약(71건), 감시(40건)순이었다. 낙상방지에서는 낙상방지 (116건), 가족동원(48건)순이었다. 감염의 위험에서는 감염에 대한 보호(82건), 체온조절 (56건), 투약(38건)순이었다. 체액불균형 위험성에서는 튜브간호; 위장관(114건), 통증관리(69건), 감시(35건)순이었다. 비효과적 조직관류-위장관에서는 튜브간호; 위장관(108건), 통증관리(54건), 구토관리(43건), 운동요법;걷기(31건)순이었다.본 연구는 응급실에 내원한 복통환자에게 사용하고 있는 간호진단과 간호중재의 건수를 조사하여 응급실에 내원한 복통 환자에게 간호진단과 간호중재의 활용에 기초적 자료로 사용되기를 기대한다.
[영문]Abdominal pain is one of the most common complaints that patients in the ER have. Furthermore, the type of abdominal pain, from slight symptoms to excruciating pain, requiring clinical action, varies greatly. Patients expect immediate pain relief andimmediate nursing intervention and therefore nursing activity for abdominal pain is an important issue for nurses in the ER.The aim of this research was to provide a solid foundation and good basic informationfor nursing diagnoses and nursing interventions for patients who have with abdominal pain and are in the ER. The research was focus on the frequency of various actions that are currently being used and have been used in the past.This is a retrospect research project, and it was done using 115 charts of patients without traumatic injury who were seen in the ER. The patients were all over-15 years of age, complained of abdominal pain, were patients in the ER of one university hospital of Seoul and had nursing diagnoses on the medical chart. Data collection was done from, April 1 to May 31, 2006.Research process and method of analysis: After the vocabulary used on the medical charts of the 115 patients for nursing diagnosis had been united and standardized using the nursing diagnosis list developed by NANDA, the frequency for each diagnosis was tabulated. Then, the nursing actions for each nursing diagnosis ware tabulated and finally, using the nursing intervention classification(NIC) developed by the IOWA Classification of Nursing Intervention Teams nursing actions for each nursing diagnosis were classified by type/ nursing intervention domain and then classes of nursing interventions/ and nursing intervention. By doing so, nursing intervention according to nursing diagnosis and the frequency of nursing intervention were identified.The results of this research are as follows:1. The total number of nursing medical charts for patients complaining of abdominal pain in the ER was 426 and for 347 there was a nursing diagnosis. Out of the 115 that were used for this research, there were 19 with nursing diagnoses. The highest frequency was for acute pain (89 cases), then, risk of injury from falling (71 cases), risk of infection (39 cases), and risk of imbalanced in body fluids (38 cases).2. From the 19 cases with nursing diagnosis, 380 nursing actions were recorded and the frequency of nursing actions was 2,267.3. Frequency of domains of nursing interventions by nursing diagnosis (top 5): For acute pain: basic physiological (234 cases), complex physiological (80), safety (69), and health system (33). For risk for falls: safety (116), and family (48). For risk of Infection: safety (116), complex physiological (103), health system (3), and basic physiological (1). For risk for imbalance in fluid volume: basic physiological (331), safety (50), complex physiological (50), behavioral [S1](19), and health system (5). For Ineffective Tissue Perfusion (Gastrointestinal): basic physiological (300), safety (44), complex physiological (24), behavioral [S2] (15), and health system (1).4. Frequency of classes of nursing intervention according to diagnosis (top 5): For acute pain: body security promotion (232), medicine/drug management (74), risk management (67), and information management (33). For risk for falls: risk management (116), and nursing patient's longevity (48). For risk of infection: risk management (116), regulation of body temperature (56), and medicine/drug management (38). For risk for imbalance fluid volume: body security promotion (132), maintenance of good nutrition (131), risk management (50), activity and exercise management (38), and excretion management (30). For Ineffective Tissue Perfusion (Gastrointestinal): body security promotion (125), maintenance of good nutrition (108), risk management (44), activity and exercise management (31), and excretion management (26)5. Frequency of interventions of nursing intervention according to nursing diagnosis (top 5): For acute pain: pain management (186), medication administration (71), and surveillance (40). For risk for falls: fall prevention (116), and family mobilization (48). For risk of Infection: infection protection (82), temperature regulation (56), and medication management (38). For risk for imbalance fluid volume: tube care: gastrointestinal (114), pain management (69), and surveillance (35). For Ineffective Tissue Perfusion (Gastrointestinal): tube care: gastrointestinal (108), pain management (54), nausea management (43), and exercise therapy; ambulation (31).As the frequencies of nursing intervention and diagnoses currently being used for patients in the ER complaining of abdominal pain were identified in this study, it is hoped that the results will be used as a basic information for nursing action for patients with abdominal pain in the ER.
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3. College of Nursing (간호대학) > Others (기타) > 2. Thesis
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/137001
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