문제중심 간호기록의 시행에 관한 실태조사

홍영혜 제주한라대학 1981 論文集 Vol.7 No.-

현대의 간호는 질병중심의 기계적간호에서 인간중심의 전인간호를 추구하게 되었으며 간호의 궁극적 목적은 대상자의 문제점을 분석하고 규명하여 이를 충족시켜주거나 스스로 해결할 수 있도록 도와주고 더 나아가 다시는 이런 문제가 재발하지 않는 위치에까지 이끌어 올리도록 도와주는 것이다. 이러한 전인간호의 영향은 질적인 간호에 중점을 두게되었고 또한 다른 건강관리 요원들과의 협동을 필요로하게 되었다. 또한 간호원의 의무인 간호기록은 환자의 유효적절한 의료 및 간호관리를 위해 정확하고 철저해야 할 뿐 아니라 행해진 간호의 질적 평가를 위한 기초가 되며 간호실무의 질적 향상을 도모하기 위해 필요한 자료물 수집할 수 있는 방안이되고 간호이론을 구축하는데 도움을 줄 수도 있다. 이러한 목적들을 효과적으로 달성하기 위해 Dr. Weed에 의해 개발된 문제중심체제(Problem Oriented System)가 간호분야에 도입되어 문제중심 간호기록(PONR)체제로 수정 채택하게 되었다. 이 PONR은 체계화된 기록체제로서 간호원들이 환자의 문제해결에 대한 간호과정을 일관성있게 기록하여 건강관리요원 상호간에 정보를 교환할 수 있도록 하는 일정한 체계를 갖춘 과학적인 방법이다. 이에 저자는 문제중심 간호기록법을 적용 실시하고 있는 서울 시내 3개 종합병원을 대상으로 문제중심 간호기록의 실행 실태와 문제중심 간호기록에 대한 간호원의 견해, PONR의 시행에서 나타난 문제점을 조사 분석하여 PONR의 적용에 관한 기초 자료를 제공하고자 한다. 연구대상은 3개 종합병원의 간호원 145명이었으며 1981년 8월 10일부터 19일 사이에 저자가 작성한 질문지를 사용하여 자료를 수집하였다. 수집된 자료는 백분율로 분석하였으며 연구결과를 요약하면 다음과 같다. A. 간호원의 일반적 특성 간호원의 연령은 20∼25세가 52.4%, 임상경력은 1∼3년이 40.7%, 직위는 일반 간호원이 80.7%로 가장 높은 구성비율을 나타냈다. 종교는 기독교가 42.8%로 가장 높고 무 종교인이 40.6%였다. 최종학력은 '간호전문학교 혹은 전문대학' 졸업이 67.6%, 간호 전문지식을 얻기 위하여 주로 이용하는 것은 '간호학 서적 및 전문지'가 60.7%로 가장 높은 구성 비율을 나타냈다. B. PONR의 실행 실태 1. PONR의 일반적 실태 PONR에 대한 지식 습득처는 '학교에서는 배우지 않았지만 실무교육, 잡지, 서적등을 통해 배웠다'가 41.4%로 가장 높았고 시행 기간은 '3개월 이내이다'가 33.1%로 가장 높으나 6개월 이상에 해당되는 경우가 42.8%였다. 실천정도는 '실천이 되다 안되다 한다'가 64.8%로 가장 높았다. 2. 문제중심 간호기록자의 정보수집 방법 간호력(Nursing History)은 '바쁘면 사용하지 못하지만 바쁘지 않으면 사용한다'가 35.9%, 환자요구 및 문제점 파악방법은 '환자나 보호자와의 대화와 관찰, 검사결과, 다른 의료요원의 정보, 간호력을 이용한다'가 44.1%, 그리고 검사결과 처리방법은 '결과를 check하여 이상유무를 의사에게 알리고 궁금한 것이 있을때는 책을 찾아 보거나 의사에게 문의' 하는경우가 55.2%로 가장 높았다. 3. 문제중심기록자의 probIem list(문제목록) 작성과 상호이용 problem list는 '간호원은 의사와 다른지면을 사용하며 작성자 제한은 없다'가 82.8%로 가장 높고 상호이용은 '간호원은 환자간호를 위해 의사의 기록을 참고' 하는 경우가 43.5%로 가장 많다. 4. 진행기록 진행기록중 서술기록(SOAPIE형식)실행에 대해 어려운 순위는 A(사정)과 S,O(정보수집), 그리고 P&I(계획과 수행)의 순으로 나타났다. 5. PONR의 감사 기록에 대한 상위자의 감사는 '수시로 지도 감독 격려'가 51.0%였다. C. PONR에 대한 간호원의 견해 PONR은 '비교적 과학적이며 체계적'(66.9%)이고 '환자의 경과파악이 쉽고 정보를 얻을 수는 있으나 시간을 많이 뺏겨 업무에 압박감'(45.5%)을 느끼며 '간호원에게 더 권한이 주어지고 그에 필요한 실력을 갖춘 후에 문제중심체제로 일한다면 직업적 성취감을 느낄 수 있을 것'(44.8%)이며 '독자적인 간호업무 수행에 꼭 필요하므로 적극 권장하면서 문제점을 보완'(56.6%)해 나가야 한다는 견해가 가장 많았다. D. PONR의 실행에 대한 문제점 PONR이 잘 실천되지 않는 이유로는 1)바빠서 기록할 시간이 없고 2)기본 과학적지식(해부, 생리, 병리등)이 부족히며 3)관찰력이 부족하고 4)PONR에 대한 이해가 부족하며 5)기능적 업무분담때문이라고 지적했다. 결론적으로 실행은 부진히며 의료요원 상호간에 기록을 참고히는 경우도 저조했다. PONR 중 가장 어려운 것은 A(사정), S,O(정보수집), P&I(계획과 수행), 순이었다. PONR에 대한 간호원의 견해는 긍정적이나 스스로가 더 많은 권한과 실력을 필요로 하고 있으며 활발한 PONR의 실행을 위해 인력보충, 실무교육강화, 업무분담 방식의 변화에 대한 행정적 뒷받침이 강력히 요구된다 하겠다. Modern nursing has been developed from disease centered nursing care to human centered comprehensive nursing care. And the ultimate goal of nursing is not ouly to assess and define the problem of the client but also to solve the problem or to help to solve it by himself, This concept starts from the individualized nursing care and is needed the qualified nursing and the cooperation of the health team. To accomplish thease goals, problem oriented nursing Record (PONR) has been developed from Problem Oriented System(POS) devised by Dr. Weed. (1968) The new system is oriented toward the patient's problems that the related health team to plan the clinical implementation each out of their own perspectives, yet communicable with other to make them into a team work. The PONR, well constructed recording system, is a scientific method to record the nursing process of solving the patient's problems, The PONR will be described in three levels : first, PONR in general which is made of Data base, problem list, Initial plan and progress note : second, the progress note level that is narrative record, Flow sheet and discharge summary : and the third is the Narrative Record level, which is made Subjective Data(S), objeective Data(0), Assessment(A), Planning(P), Implementation(I) and Evaluation (E). The present research is focussed on the current status of the PONR. 145 nurses in 3 general hospital has been chosen as the sample for research the status of Implementing PONR, nurses' attitude toward the Recording system, and problems in implementation of the PONR. Data collection was performed between August, 10 and August 19, 1981, and their evaluations has been statistically treated in terms of percentage. The following statements are the conclusion of this study, 1) 41.4% of 145 nurses has learned the PONR after the graduate and the status of Implementing PONR is not satisfactory. (31.1%) 2) 83. 5% of them are using the nursing history and 83.3% of them ate using problem list, which is rarely refered by the doctor. (32.4%) 3) At the narrative record level the nurses are feeling difficulty in order of ① Assessment ② Data collection ③ planning & Implementation. 4) The nurses have positive opinion of the PONR, and the majority of the group feels that the PONR is helpful to recognize the patient's progress, to obseve the patient, to increase communication between the nurse-patient, and the nurse-health team, and to give better nursing service, but also feels the tension in nursing activities because of the lack of the time. 5) The factors that are affecting on the poor implementatiou of the PONR are ① the lack of the time ② the lack of the scientific knowledge ③ the lack of the sense to detect the problems ④ the poor comprehension about the PONR ⑤ the functional assignment.

제주지역 초·중·고교생의 성장 발육 및 영양상태에 관한 연구

홍영혜 제주한라대학 1981 論文集 Vol.7 No.-

A study on 1429 (Boys : 712, Girls : 717) of primary, middle and high school students in Che Ju was conducted for assessing their physical growth, development and nutritional status from December, 14 to December, 22 1981. The summarized results were as follows : 1. Physical growth and development a. Rapid physical growth which was described by the straight line on the gro wth curve has been observed from age 6 to 15 in boys and from 6 to 13∼14 in girls, and after those ages the growth rate was decreased. b. The maximum annual growth rates were as follows : Body height: Boys-7.88cm from 13 to 14 girls-9.44cm from 10 to 11 Body weight:Boys-10.66kg from 14 to 15 girls-5.08kg from 13 to 14 5.05kg from 11 to 12 Chest girth: Boys-6.74cm from 14 to 15 girls-5.47cm from 10 to 11 Sitting height:Boys-5.22cm from 14 to 15 girls-4.42cm from 10 to 11 c. The greatest individual differences in growth rate were observed during 11∼14 in boys and during 10∼13 in girls, and it is 1∼2 years earlier than those of 10 years ago. d. The standards of growth of recent Cheju students show much improved than those of 1968, and show similar to those of Korean of 1980. 2. Various Indices about physical growth and development and nutritional status a. The average relative body weight was increased annually and the crossing point of boys and girls appeared at age 11 at which girls surpassed boys, and at age 15, doys surpassed girls. b. The average relative chest girth showed narrow chest style from 6 to 14 in boys and from 6 to 13 in girls, and turned to normal chest style after 15 in boys and after 14 in girls. c. The average sitting height showed maximum at age 6 in both sexes and was decreased annually. d. The Rohrer index was 1.11∼1.37 and showed lower in boys than in girls and also in the growing stage. e. The Kaup Index was lower than 2.0 from 6 to 15 in boys and from 6 to 14 in girls, but after 15 and 14 in boys and girls, it became higher than 2.0. f. The Vervaeck Index was 67.24∼85.03 in boys and 66.21∼85.77 in girls and by aging it was increased in both sexes. g. The Pelidisi Index was 88.61∼94.34 and was increased by aging but below 100.

한국 성인당뇨병 환자의 식생활에 관한 문화기술적 연구

홍영혜(Hong, Yong-Hae),조명옥(Cho, Myung-Ok),태영숙(Tae, Young-Sook) 한국간호과학회 2005 Journal of Korean Academy of Nursing Vol.35 No.2

중년기 성인이 인식하는 웰빙의 의미

홍영혜(Hong Yong Hae),조명옥(Cho Myung Ok) 한국성인간호학회 2006 성인간호학회지 Vol.18 No.2

당뇨병에 관한 국내 간호연구 분석

홍영혜(Hong Yong-Hae),김명애(Kim Myung-Ae) 기본간호학회 2001 기본간호학회지 Vol.8 No.3

간호대학생의 간호의 사회화 체험

홍영혜(Hong Yong-Hae),오혜경(Oh Hye-Kyung),한영인(Han Young-In) 질적연구학회 2007 질적연구 Vol.8 No.2

Purpose of this study was to explore the meanings and nature of the lived socialization experience of the diploma nursing students. Method of this study was adopted the hermeneutic phenomenological human science approach developed by van Manen. The participants for this study were 8 diploma students, between the age of 23 and 35, who were healthy without any particular diseases. The 8 diploma students who had agreed to participate in this research were interviewed by the researchers under a private and comfortable environment. In collecting data for this study, in-depth personal interviews, transcriptions and observations were made by the researchers for 20days from January 22nd to February 15th, 2007. During the personal interviews the semi-structured questions were asked to the diploma nursing students to speak freely about the 'lived socialization experience' and the interviews were conducted three or four times per student for 50 to 120 minutes. Collected data were analyzed by hermeneutic phenomenological way of study that was developed by van Manen. Results were as follows. The six essential themes of the lived socialization experience of the diploma nursing students were found through this study 〈Mystery of the human body〉, 〈Too heavy a burden of study〉, 〈Keen competition〉, 〈A critical situation〉, 〈Support〉, 〈Becoming matured〉. Through the study, it was found that the diploma students consider the nursing science as a process of offering care to the patients with love, while acquiring knowledge of the academic and emotional personality. Conclusion: Studying the nursing science, indeed, means facing a desperate situation in which one has to struggle to survive in fierce competition within limited time. However, the students can stand all the hardships due to the hope for the future and the definite goals. Ultimately, they become mature by enhancing their understanding toward others. This study suggests visions and possibilities of the nursing profession by comprehending the meanings and nature of the lived socialization experience of the diploma nursing students.

대구 경북지역 일부 대학생들의 에이즈에 대한 지식과 태도 조사

선영희,홍영혜 대한간호협회 1996 대한간호 Vol.35 No.1

학부모 교육운동단체의 교육운동 주장에 관한 연구

이광원,홍영혜 경남대학교 교육문제연구소 2002 敎育理論과 實踐 Vol.12 No.1

학사 학위 과정 이수 간호사의 전문직 정체성 확립 경험

김혜옥,홍영혜 질적연구학회 2010 질적연구학회 학술대회 자료집 Vol.2010 No.-

기능성 발성장애의 임상적 특성

서우정,홍영혜,최종민,정은정,성명훈,김광현,권택균,Suh, Woo-Jung,Hong, Young-Hye,Choi, Jong-Min,Jung, Eun-Jung,Sung, Myung-Whun,Kim, Kwang-Hyun,Kwon, Tack-Kyun 대한후두음성언어의학회 2006 대한후두음성언어의학회지 Vol.17 No.2

Background and Objectives : Functional dysphonia is a voice disturbance in the absence of structural or neurologic laryngeal pathology characterized by voluntary misuse of laryngeal muscles. The present report reviews clinical characteristics of 25 patients with functional dysphonia. Materials and Method : We analyzed medical records, perceptual and acoustic analysis of voice samples, aerodynamic studies and laryngoscopy. Results : There was no sex or age predilection. Eighty four percent of patients presented sudden onset of symptoms and 76% had specific events at the onset. Most patients showed breathy or strained voice and various degree of vocal fold insufficiency with supraglottic compensatory contractions. Acoustic analysis revealed non-diagnostic, but mean flow rate was lower than normal in all cases. All patients responded to voice therapy except for 4 patients who were tort to follow up. Mean number of voice therapy sessions required to get responses is 1.9 sessions. Conclusion : We concluded that patients with functional dysphonia responded very well to short-term voice therapy and should be included in differential diagnosis in patients with dysphonia cannot be explained by structural or neurologic etiology.