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김명수 ( Kim Myoung-Soo ) - 부경대학교 간호학과
정현경 ( Jung Hyun-Kyeong ) - 부산대학교병원
강명자 ( Kang Myung-Ja ) - 부산대학교병원
박남정 ( Park Nam-Jung ) - 부산대학교병원
김현희 ( Kim Hyun-Hee ) - 부산대학교병원
류정미 ( Ryu Jung-Mi ) - 부경대학교 간호학과
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Abstract
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Purpose : The purpose of this study was to identify minimum data sets for oral mucous integrity?related documentation and to analyze nursing records for oral care.
Methods: To identify minimum data sets for oral status, the authors reviewed 26 assessment tools and a practical guideline for oral care. The content validity of the minimum data sets was assessed by three nurse specialists. To map the minimum data sets to nursing records, the authors examined 107 nursing records derived from 44 patients who received chemotherapy or hematopoietic stem cell transplantation in one tertiary hospital.
Results: The minimum data sets were 10 elements such as location, mucositis grade, pain, hygiene, dysphagia, exudate, inflammation, difficulty speaking, and moisture. Inflammation contained two value sets: type and color. Mucositis grade, pain, dysphagia and inflammation were recorded well, accounting for a complete mapping rate of 100%. Hygiene (100%) was incompletely mapped, and there were no records for exudate (83.2%), difficulty speaking (99.1%), or moisture (88.8%).
Conclusion: This study found that nursing records on oral mucous integrity were not sufficient and could be improved by adopting minimum data sets as identified in this study.
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KeyWords
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구강건강, 구강욕창, 구강위생, 간호기록
Oral health, Oral ulcer, Oral hygiene, Nursing records
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원문 및 링크아웃 정보
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등재저널 정보
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