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간호기록지를 통해본 담낭절제수술환자 간호연구

A Study on Quality of Nursing Care for Cholecystectony Patients Through Nursing Audit

간호학논집 - 연세대학교 1978년 3권 0호 p.53 ~ 62
최공옥,
소속 상세정보
최공옥 (  ) - 연세대학교 간호대학 간호학교실

Abstract


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 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.
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.

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