Korean Journal of Adult Nursing (Korean J Adult Nurs) Vol. 26 No. 4, 413-423, August 2014 ISSN 1225-4886 (Print) / ISSN 2288-338X (Online) http://dx.doi.org/10.7475/kjan.2014.26.4.413 송수미 1 소향숙 2 안민정 2 조선대학교병원 1, 전남대학교간호대학 2 Identification of Major Nursing Diagnosis, Nursing Outcomes, and Nursing Interventions (NNN) Linkage for Cancer Patients Undergoing Chemotherapy Song, Su Mi 1 So, Hyangsook 2 An, Minjeong 2 1 Chosun University Hospital, Gwangju 2 College of Nursing, Chonnam National University, Gwangju, Korea Purpose: This study was aimed to identify NANDA-NOC-NIC linkage in cancer patients receiving chemotherapy. Methods: This study was a descriptive study conducted in three steps. First, nursing diagnoses were identified from the electronic nursing records. Second, content validity of nursing diagnoses and outcomes were evaluated. Third, major nursing interventions associated with expected nursing outcomes were collected from 97 nurses who worked in the oncology unit. Data were analyzed using descriptive statistics. Results: Four major nursing diagnoses were identified: acute pain, knowledge deficit, health seeking behaviors, and ineffective protection. Associated with each respective diagnosis, 3 major outcomes (pain level, pain control, and comfort state) for acute pain, 8 major nursing outcomes (diet, disease process, treatment regimen, illness, ostomy care, prescribed activity, health behavior, and infection management) for knowledge deficit, 4 major outcomes (health promoting behavior, health promotion, health belief, and knowledge: health resource) for health seeking behaviors, and 3 major outcomes (fatigue level, immune status, and nutritional status) for ineffective protection were identified. In addition, nursing interventions frequently used in clinical practice for each major nursing outcome were identified. Conclusion: The identified NANDA-NOC-NIC linkage can contribute to improving the applications of nursing process and care plans. Key Words: Neoplasm, Nursing process, Nursing diagnosis, Chemotherapy 서론 1. 연구의필요성우리나라에서암은남녀사망원인 1위를차지하고있으며, 암발생율은 2000년 101,772명대비 2010년 202,053명으로 98.5% 가증가하였다 (National Cancer Information Center, 2013; Statistics Korea, 2012). 암의조기진단과치료방법의발전으로인해암환자의 5년생존율은 64.1% 까지향상되었는데, 이는암환자 10명중 6명이상에서 5년이상생존이가 주요어 : 암, 간호과정, 간호진단, 항암화학요법 Corresponding author: An, Minjeong College of Nursing, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju 501-84, Korea. Tel: +82-62-530-4946, Fax: +82-62-225-3307, E-mail: anminjeong@gmail.com - 이논문은제1저자송수미의석사학위논문을수정하여작성한것임. - This article is a revision of the first author's master's thesis from Chonnam National University. Received: Mar 27, 2014 / Revised: Jul 24, 2014 / Accepted: Aug 4, 2014 This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2014 Korean Society of Adult Nursinghttp://www.ana.or.kr Vol. 26 No. 4, 2014 413
송수미 소향숙 안민정 능하게되었다는것으로암이만성질환처럼지속적인관리가필요함을의미한다 (Jung et al., 2013). 항암화학요법을받는암환자는식욕부진, 오심과구토, 복통, 설사, 피부점막의손상, 탈모등과같은다양한부작용을경험할수있으므로, 이를해결하기위한전문적인간호및암의진단, 치료, 회복과재활단계에맞춘체계적인간호가제공되어야하고 (Kim & Hong, 2002), 간호과정의단계를통해유기적이고과학적으로접근하는것이필요하다. 간호과정은사정, 진단, 계획, 중재, 평가의 5단계로구성되어있지만, 실제로간호사는간호진단을통해문제를확인하고바람직한간호결과에도달하기위한간호중재를선택한다 (Johnson et al., 2011). 이를효과적으로적용하기위해 Iowa 주립대학교연구팀은표준화된간호용어를사용하여간호진단 (North American Nursing Diagnosis Association, NANDA)- 간호결과 (Nursing Outcome Clarification, NOC)- 간호중재 (Nursing Intervention Clarification, NIC) 의연계를정립하게되었다 (Johnson et al., 2011). 그러나간호진단- 간호결과-간호중재 (NANDA-NOC-NIC, NNN) 연계는전문가들의논의를거쳐형성되었기때문에실무에서사용하기위해서는임상적중요성을고려하여환자에게적용된실제적자료를기반으로임상타당성연구가선행될필요가있다 (Ko & So, 2013; Park & Choi, 2005). 또한, 임상실무에서실제효과적으로이루어지고있는 NNN을연계하여데이터베이스를구축하면, 간호대상자에게근거중심간호를원활히제공할수있고결과적으로질적간호의향상과간호기록의질향상을꾀할수있으며반복적인간호기록업무의시간을줄이는데효과적이라하였다 (Chi & Chi, 2003; Yoo & Chi, 2001). 국내에서의 NNN 연계연구는회복실환자, 유방암환자, 내외과계병동및중환자실환자를대상으로이루어져왔고, 간호사들을대상으로한설문조사나간호기록을분석하여간호정보시스템구축및전자의무기록시스템적용이있었다 (Chi & Chi, 2003; Cho & Kim, 2008; Kim, 2010; Ko & So, 2013; Lee & Choi, 2011; Park, 2010). 현재항암화학요법을받는암환자를위한간호지침은병원별로다양하게사용되고있지만, 항암화학요법중인환자를대상으로 NNN 연계체계가개발되어전자의무기록시스템에도입된연구는부족한실정이다. 이에본연구팀은항암화학요법을받는암환자에게적합한간호과정을기술하고이를전자간호정보시스템을구축하는데활용하기위해, 간호진단, 간호결과및간호중재의연계성을확인하는연구를시도하였다. 2. 연구목적본연구의구체적인목적은다음과같다. 전자간호기록지를검토하여항암화학요법환자에게적용된간호진단을확인한다. 확인된간호진단과연계된간호결과에대해전문가집단을통한내용타당도를확인한다. 간호사들을대상으로간호진단과연계된간호결과도달을위해주로적용한간호중재를확인한다. 항암화학요법환자에게적용한간호진단-간호결과-간호중재 (NNN) 연계를확인한다. 3. 용어정의 1) 항암화학요법항암화학요법은암치료를위해세포독성약물을사용하여암을치료하는방법으로완치와조절및완화를목적으로하는전신적인치료법이다 (Korean Oncology Nursing Society, 2012). 본연구에서는외래항암주사실에서시행하는하루입원및 CCRT (Concurrent Chemo-Radiotherapy), 선행항암화학요법을제외한항암화학요법을의미한다. 2) 간호진단간호진단은실제적, 잠재적건강문제와삶의과정에대한개인, 가족혹은지역사회의반응을임상적으로판단한것이다 (NANDA International., 2008). 본연구를통해항암화학요법환자에게적용하기에타당하고선정된주요간호진단을의미한다. 3) 간호결과간호결과는측정할수있는환자, 가족, 지역사회의상태, 행위및인지정도를의미한다 (Moorhead, Johnson, & Maas, 2004). 본연구를통해항암화학요법환자에게적용하기에타당하다고선정된주요간호결과를의미한다. 4) 간호중재간호중재는환자혹은대상자의결과를향상시키기위해간호사의임상적판단과지식에기초하여수행하는모든행위이다 (Dochterman & Bulechek, 2004). 본연구를통해항암화학요법환자에게적용된것으로보고된간호중재를의미한다. 414 Korean Journal of Adult Nursing
연구방법 1. 연구설계본연구는항암화학요법환자에게적합한주요간호진단과간호결과및간호중재의연계를파악하기위한서술조사연구이다. 2. 연구대상본연구는 2012년 8월 1일부터 11월 30일까지 G광역시에위치한 700병상규모의 1개 3차의료기관 C대학병원에서수행되었다. C대학병원은 2011년퇴원환자기준, 신규암환자등록현황이 891명이었고, 전자의무기록에서간호기록에 NANDA 목록을적용하고있으나 NOC과 NIC은아직적용하지않고있다. 본연구대상은주요간호진단도출을위해더이상새로운진단이나오지않을때까지전자간호기록지조사분석에포함된항암화학요법을위해입원한 30명환자와각간호진단과연계된간호결과에도달하고자수행한간호중재를조사하고자동일병원의종양계병동 ( 예 : 종양혈액내과, 호흡기내과, 소화기내과, 산부인과등 ) 에서 1년이상근무해온간호사 105명을표집대상으로하였고그중본연구의목적을이해하고연구참여에동의한 97명의간호사였다. 3. 연구과정 1) 1단계 : 주요간호진단도출환자진료과정중에전자간호기록지에나타난간호진단의주요순위분석을새로운간호진단이더이상도출되지않을때까지진행하였다. 즉항암화학요법을목적으로입원한암환자중총 30명의전자간호기록을분석하게되었다. 간호진단은 201개의간호진단목록을기준으로하여분석하기시작하였다 (NANDA International, 2008). 2) 2단계 : 간호진단과간호결과에대한내용타당도검증간호진단과연계된간호결과의내용타당도는 Fehring (1987) 의진단적내용타당도 (Diagnostic Content Validation, DCV) 모형을적용하여다음과같이검증되었다. 내용타당도검증을위한적정전문가수는 3인에서 10인이므로 (Lynn, 1986), 총 10인으로구성된종양간호관련전문가집단 ( 종양간호학전공교수 2인, 종양전문간호사 3인, 종양병동 수간호사및팀장 5인 ) 을구성하여각각의간호진단의필요성에대해서 5점 Likert 척도로 ( 아주필요하다 5점에서전혀필요하지않다 1점 ) 평가하였다. 간호결과는전문가에의한내용타당도검증결과항암화학요법환자에게적용도가높은것으로확인된간호진단에대하여, Moorhead, Johnson과 Mass (2004) 가출판하고 Choi 등 (2012) 이번역한간호결과분류체계에기초해서각간호진단과연계된간호결과전체목록을전문가집단이 5점 Likert 척도로적합도를평가하였다 ( 아주적합하다 5점에서전혀적합하지않다 1점 ). 본연구에서는내용타당도지수 (Content Validity Index, CVI) 가 0.8 이상인주요간호진단과주요간호결과만을선택하였다 (Fehring, 1987; Lynn, 1986). 3) 3단계 : 간호중재확인을통한임상타당도검증전문가에의한내용타당도검증결과, 제시된간호결과를달성하기위해서지난한달동안임상간호사가수행한간호중재목록을조사하였다. 간호결과와연계된간호중재분류 (Bulechek, Butcher, & Dochterman, 2007) 전수를검토하여간호중재목록을제작한결과, 임상타당도검증을위한설문조사에서상위 4개의간호진단목록중에서간호진단인지식부족의간호결과및간호중재목록이상대적으로많았기때문에결과편중의위험을줄이기위해간호사집단을 A, B 두그룹으로나누었고, 증인이보는가운데동전던지기를통해무작위할당한후자료를수집하였다. A형설문 ( 간호진단명 : 지식부족 ) 에참여한간호사는 44명이었으며, B형설문 (3개간호진단명 : 급성통증, 건강추구행위, 비효과적방어 ) 에참여한간호사는 53명이었다. 간호사들은제시된간호결과에대해항암화학요법환자들에게실제로빈번하게사용하고있는간호중재를확인하기위해서 4점척도로수행빈도를측정하였다 ( 하루에여러번수행한다 4점 ; 하루에한번정도수행한다 3점 ; 일주일에한번정도수행한다 2점 ; 한달에한번정도수행한다 1점 ). 본연구에서는하루에한번이상수행했다고응답한간호중재목록중에서조사에참여한간호사의 30% 이상이수행하였다고응답한간호중재목록을최종선정하였다. 4. 자료분석수집된자료는 SPSS/WIN 20.0 프로그램을이용하여다음과같은방법으로분석하였다. 의무기록분석대상인암환자와간호사의일반적인특성 Vol. 26 No. 4, 2014 415
송수미 소향숙 안민정 은실수와백분율을산출하였고, 간호사들의동질성검사는 x 2 -test로분석하였다. 주요간호진단및간호결과는내용타당도지수를산출하였다. 대상자에게적용된간호중재의수행빈도는실수와백분율로분석하였다. 5. 윤리적고려본연구는연구를수행하기전 G광역시에소재한해당대학병원의임상시험윤리위원회의승인을받았다 (IRB No.2012-05-019-001). 간호기록지분석대상자인암환자에대해서는연구대상자동의면제를받았고, 설문대상자인간호사에게는윤리적측면을고려하여연구목적, 설문지내용, 자료의익명성보장및자료허가철회등을설명하였으며, 서면동의를받은후연구원이직접설문지를수집하였다. 연구결과 1. 간호진단도출과정 3차의료기관 C대학병원에항암화학요법을목적으로입원한암환자의전자간호기록지를더이상새로운간호진단목록이나오지않을때까지검토한결과, 총 30명의간호기록을수집및분석하게되었다. 본자료대상인암환자의일반적인특성분포는남자가 16명 (53.3%) 이고평균연령은 59.2±12.91 세 ( 범위 : 36~87세 ) 였으며, 50대이하군이 16명 (53.3%) 으로과반수를차지하였다. 암부위별로는위장관암환자가 15명 (50.0%), 부인암과유방암환자가 6명 (20.0%), 혈액암과폐암환자가각각 3명 (10.0%) 등이었다. 분과별분포는종양혈액내과 13명 (43.3%) 으로가장많았고, 외과 20.0%, 부인과와호흡기내과가각각 13.3% 의순이었다. 항암화학요법의목적은보조적치료목적이 17명 (56.7%), 고식적치료목적이 10명 (33.3 %), 치료적목적이 3명 (10.0%) 이었으며, 항암제투여주기는 3주기이상이 23명 (76.7%) 이었으며, 약물프로토콜은 Cisplatin계약물과병합치료가대부분이었다. 암환자 30명의전자기록에서확인된간호진단은총 37개였고, 사용된횟수는 1,850회이었으며, 암환자 1명의전자간호기록에기술된간호진단은평균 2.2개 ( 범위 : 2~13개 ) 였다. 37개의간호진단목록은건강증진영역 (health promotion) 2 개, 영양영역 (nutrition) 3개, 배설영역 (elimination) 4개, 지 각 / 인식영역 (perception/cognition) 2개, 자아인지영역 (self perception) 3개, 활동 / 휴식영역 (activity/rest) 7개, 대응 / 스트레스내인성영역 (coping/stress tolerance) 3개, 안전 / 보호영역 (safety protection) 8개, 안위영역 (comfort) 4개로분류되었다. NANDA 목록에서제시되지않은간호진단구토는배설영역 (elimination) 내로분류하였다. 총 37개의간호진단중사용빈도가가장높은간호진단은낙상위험성이었으나, 이진단은항암화학요법환자에게내려진고유의진단이라기보다는병원에입원한환자의낙상위험관리와연관되어있어제외되었다. 주요간호진단 (CVI 0.8 이상 ) 은총 4개로서, 급성통증 (0.88), 지식부족 (0.88), 건강추구행위 (0.80) 와비효과적방어 (0.80) 였다. 2. 주요간호진단과연계된간호결과목록선정된 4개의주요간호진단에연계된주요간호결과 (CVI 0.8 이상 ) 목록은다음과같다. 간호진단급성통증과연계된주요간호결과는통증수준 (0.93), 통증조절 (0.90) 그리고안위수준 (0.85) 이었고, 간호진단지식부족과연계된주요간호결과는 8개로식이요법 (0.88), 질병과정 (0.83), 치료요법 (0.83), 질병간호 (0.83), 장루간호 (0.83), 처방된활동 (0.80), 건강행위 (0.80), 감염관리 (0.80) 였다. 간호진단건강추구행위와연계된주요간호결과는건강증진행위 (0.88), 건강증진 (0.83), 건강신념 (0.80) 및지식 : 건강자원 (0.80) 이었고, 간호진단비효과적방어와연계된주요간호결과는피로수준 (0.85), 면역상태 (0.80) 그리고영양상태 (0.80) 로확인되었다. 3. 간호사에의해확인된간호진단 -간호결과- 간호중재연계성본연구대상자인종양관련병동에서근무경력이 1년이상된간호사 97명을대상으로각간호결과에적용한간호중재수행빈도를확인함으로써임상타당성을확인하였다. 대부분의대상자연령분포는 20~35세 (74.2%) 였고, 근무연수는평균 7.7±6.58년이었으며, 종양병동근무경력은 1~3년이 65 명 (67.0%) 이었다. NOC와 NIC에대한교육경험에대해 72명 (75.8%) 이예로응답하였으며, 전자간호기록 (ENR) 사용에대한자신감에대한응답률은그렇다와그저그렇다가각각 50% 내외였다. 간호사의연령, 학력, 근무경력, 종양관련병동근무경력, NNN 교육경험, 및 ENR 사용에대한자신감에대해 A, B 두그룹간의차이가없었다 (Table 1). 항암화학요법을받고있는암환자들에게적용된간호진단 416 Korean Journal of Adult Nursing
Table 1. Demographic Characteristics of Nurses Characteristics Categories Age (year) 20~35 >35 Education Clinical experience (year) Oncology nursing experience (year) Learning opportunity about NOC and NIC Confidence regarding ENR use Diploma Bachelor Master 1~3 4~6 7 1~3 4~6 7 Yes No Confident <Confident Total (N =97) Group A (n=44) Group B (n=53) n(%) n(%) n(%) 72 (74.2) 25 (25.8) 52 (53.6) 31 (32.0) 14 (14.4) 31 (32.0) 23 (23.7) 43 (44.3) 65 (67.0) 16 (16.5) 16 (16.5) 72 (75.8) 23 (24.2) 47 (50.5) 46 (49.5) 34 (77.3) 10 (22.7) 20 (45.5) 10 (22.7) 11 (25.0) 19 (43.2) 28 (63.6) 8 (18.2) 8 (18.2) 31 (73.8) 11 (26.2) 20 (45.6) 24 (54.4) 15 (28.3) 32 (60.4) 17 (32.1) 4(7.5) 17 (32.1) 12 (22.6) 37 (69.8) 8 (15.1) 8 (15.1) 41 (77.4) 12 (22.6) 27 (55.1) 22 (44.9) NOC=nursing outcome classification; NIC=nursing intervention classification; ENR=electronic nursing record. x 2 p 0.39.532 4.84.089 0.08.994 0.42.813 0.16.688 0.86.353 과연계된간호결과와간호중재는다음과같다 (Tables 2-5). 간호진단으로급성통증에연계된주요간호결과는통증수준, 통증조절, 안위수준이었다. 기대된간호결과를위해적용된간호중재목록은 60.0% 이상사용한다고보고한항목만을열거한다 (Table 2). 간호결과로통증수준에서사용된간호중재는통증관리 (92.5%), 정맥투약과약물관리와투약처방 ( 각 90.6%), 근육투약 (86.8%), 진통제투여 (83.0%), 약물투여와구강투약 ( 각 79.2%), 열 / 냉적용 (77.4%), 진통제투약관리 (71.7%) 등의순이었으며, 15개중재목록중 13개에서 60.0% 이상의사용빈도를보고하고있다. 간호결과로통증조절에서사용된간호중재로는투약 (77.4%), 약물관리 (73.6%), 통증관리 (71.7%), 처방된약물교육 (66.0%) 순이었다. 간호결과로안위수준을위해사용된간호중재는약물투약 (88.7%), 정맥투약과통증관리 (86.8%), 구강투약, 투약관리, 환경관리 : 안위도모, 정서지지및투약처방, 진통제투여등으로 14개중재목록중 13개에서 60.0% 이상의사용빈도를보고하고있다. 간호진단으로지식부족과연계된간호결과는식이요법, 질병과정, 치료요법, 질병간호, 장루간호, 처방된활동, 건강행위, 감염관리의순이었다. 기대된간호결과를위해적용된간호중재목록은 60.0% 이상사용한다고보고한항목만을열거한다 (Table 3). 간호결과로식이요법에적용된간호중재목록은처방된약물교육 (77.3%) 이가장많았으며, 간호결과로치료요법에적용된간호중재는활동 / 운동교육과절차 / 치료에 대한교육 (68.2%), 투약관리 (65.9%) 그리고처방된약물교육 (63.7%) 순이었다. 간호결과로장루간호에적용된간호중재로는피부감시 (61.4%) 와국소피부치료 (54.5%) 등이있었고, 간호결과로처방된활동에적용된간호중재는학습준비도향상 (63.6%) 이가장높았고, 간호결과로감염관리에적용된간호중재는위험확인 (79.5%), 처방된약물교육과감염조절 (72.7 %), 투약관리 (70.5%), 치료 / 절차교육 (65.9%), 질병과정교육 (63.6%) 순이었다. 간호결과로질병과정에적용된간호중재는모두가교육관련중재목록이었으며, 간호결과로질병간호에적용된간호중재목록도약물교육, 절차 / 치료에대한교육, 개별교육, 활동 / 운동교육그리고수술전교육순이었고, 간호결과로건강행위에적용된간호중재는개별교육등이었다. 이간호결과에서는간호중재목록의사용빈도가 60.0% 미만이었다. 간호진단으로건강추구행위에연계된주요간호결과는건강증진행위, 건강증진, 건강신념, 지식 : 건강자원이었다. 기대된간호결과를위해적용된간호중재목록은 60.0% 이상사용한다고보고한항목만을열거한다 (Table 4). 간호결과로건강증진행위에연계된간호중재는위험확인 (67.9%), 자기책임증진 (64.2%), 건강교육 (64.2%) 이었으며 11개중재목록중 3 개목록에서만 60.0% 이상의사용빈도를보고하고있다. 간호결과로건강증진에연계된간호중재로는처방된활동 / 운동교육과처방된약물교육 (69.8%) 이었다. 간호결과로건강자원 Vol. 26 No. 4, 2014 417
송수미 소향숙 안민정 Table 2. Summary of NNN Linkage for Acute Pain NANDA NOC NIC Label CVI Label CVI Label n(%) Acute pain.88 Pain level.93 Pain management Medication administration: IV Medication prescribing Medication administration: IM Analgesic administration Medication administration Medication administration: oral Heat/cold application Analgesic administration management Environmental management: comfort Anxiety reduction Positioning Reduced gas production Relaxation therapy Pain control.90 Medication administration Pain management Teaching: prescribed medication Reconciliation PCA assistance Teaching: procedure/treatment Health screening Teaching: disease process Sleep enhancement Interaction goal setting Patient contracting Relaxation therapy Self-modification assistance Comfort state.85 Medication administration Medication administration: IV Pain management Medication administration: oral Environmental management: comfort Emotional support Medication administration Analgesic administration Analgesic administration management Medication: IM Humor Positioning Presence NANDA=North America Nursing Diagnosis Association; NOC=nursing outcome classification; NIC=nursing intervention classification. 49 (92.5) 48 (90.6) 48 (90.6) 48 (90.6) 46 (86.8) 44 (83.0) 42 (79.2) 42 (79.2) 41 (77.4) 36 (67.9) 32 (60.4) 49 (77.4) 39 (73.6) 30 (56.6) 29 (54.7) 26 (49.1) 26 (49.1) 25 (47.2) 23 (43.4) 20 (37.7) 18 (34.0) 47 (88.7) 46 (86.8) 46 (86.8) 45 (84.9) 44 (83.0) 43 (81.1) 42 (79.2) 42 (79.2) 40 (75.5) 39 (73.6) 33 (62.3) 33 (62.3) 30 (56.6) (N=53) 에대한지식과연계된중재는건강교육 (75.5%), 퇴원계획 (69.8%), 학습촉진 (62.3%) 이었다. 간호결과로건강신념과연계된간호중재는자기수정보조, 자존감강화, 건강교육, 위험확인등이었으나사용빈도가 60.0% 미만이었다. 간호진단으로비효과적방어에연계된주요간호결과는피로수준, 면역상태, 영양상태이었다. 기대된간호결과를위해 적용된간호중재목록은 60.0% 이상사용한다고보고한항목만을열거한다 (Table 5). 간호결과로피로수준에적용된간호중재는통증관리 (71.7%) 가가장많이사용되었고, 에너지관리, 영양관리등은사용빈도가 60.0% 미만으로낮았다. 간호결과로면역상태에적용된간호중재는처방된약물교육 (81.1 %), 에너지관리와투약관리 (71.7%), 감염보호, 감염통제, 개 418 Korean Journal of Adult Nursing
Table 3. Summary of NNN Linkage for Knowledge Deficit: Chemotherapy NANDA NOC NIC Label CVI Label CVI Label n(%) Knowledge deficit: chemotherapy.88 Diet.88 Teaching: prescribed drug Promote learning Teaching: prescribed diet Health education Education: individual Disease progress.83 Teaching: prescribed drug Teaching: activity/exercise Teaching: prescribed diet Education: individual Health education Treatment regimen.83 Education: activities/exercise Teaching procedure/treatment Teaching: prescribed drug Learning facilitation Illness care.83 Teaching: prescribed drug Teaching procedure/treatment Education: individual Education: activities/exercise Education: preoperative Ostomy care.83 Skin surveillance Skin care: topical treatment Education: individual Ostomy care Teaching: psychomotor skill Prescribed activity.80 Learning preparation improvement Exercise promotion Education: activities/exercise Education: individual Health behavior.80 Teaching: individual Learning preparation improvement 4. Prediction supervise 6. Parent education: Infant 8. Active listening Infection management.80 10. Risk identification 12. Teaching: prescribed drug 14. Infection control Teaching procedure/treatment Teaching: disease process NANDA=North America Nursing Diagnosis Association; NOC=nursing outcome Classification; NIC=nursing intervention classification. (N=44) 34 (77.3) 21 (47.7) 20 (45.5) 16 (36.4) 15 (34.1) 26 (59.1) 23 (52.3) 22 (50.0) 17 (38.6) 30 (68.2) 30 (68.2) 29 (65.9) 28 (63.7) 27 (61.4) 26 (59.1) 25 (56.8) 23 (52.3) 22 (50.0) 21 (47.7) 27 (61.4) 24 (54.5) 28 (63.6) 16 (36.4) 19 (43.2) 17 (38.6) 17 (38.6) 17 (38.6) 16 (36.4) 35 (79.5) 32 (72.7) 32 (72.7) 31 (70.5) 29 (65.9) 28 (63.6) 별교육과건강교육, 위험확인, 항암치료관리등으로 14개간호중재목록중 11개목록은사용빈도가 60.0% 이상을보였다. 간호결과로영양상태에적용된간호중재는섭식장애관리 (66.0%), 수분 / 전해질관리과처방된식이교육 (62.3%) 으로 8개중재목록중 7개중재목록의사용빈도가 60.0% 이상이라고보고하였다. 논의본연구결과로항암화학요법을받는암환자에게주로적용되는간호진단은 4개로서급성통증, 지식부족, 비효과적방어와건강추구행위였다. 이를우리나라에서암발생률이가장높은 6대암 ( 위암, 폐암, 간암, 대장암, 유방암과자궁경부암 ) Vol. 26 No. 4, 2014 419
송수미 소향숙 안민정 Table 4. Summary of NNN Linkage for Health Seeking Behaviors NANDA NOC NIC Label CVI Label CVI Label n(%) Health seeking behaviors.80 Health promoting behavior.88 Risk identification Self-responsibility facilitation Health education Smoking cessation assistance Emotional support Exercise promotion Weight management Exercise promotion: strength training Behavior modification Exercise promotion: height Immunization/vaccination management Health promoting.83 Teaching: prescribed activity/exercise Teaching: prescribed drug Health education Teaching: Individual Learning facilitation Teaching: Prescribed diet Learning preparation improvement Health beliefs.80 Self-modification assistance Self-esteem enhancement Health teaching Risk identification Values clarification Counseling Knowledge: health resource.80 Health education Discharge planning Learning facilitation Teaching: individual Support system enhancement Learning preparation improvement Health system guidance NANDA=North America Nursing Diagnosis Association; NOC=nursing outcome classification; NIC=nursing intervention classification. (N=53) 36 (67.9) 34 (64.2) 34 (64.2) 31 (58.5) 31 (58.5) 31 (58.5) 28 (52.8) 25 (47.2) 23 (43.4) 23 (43.4) 37 (69.8) 37 (69.8) 30 (56.6) 23 (43.4) 29 (54.7) 29 (54.7) 28 (52.8) 28 (52.8) 40 (75.5) 37 (69.8) 33 (62.3) 31 (58.5) 28 (58.5) 26 (49.1) 으로고통받고있는환자를대상으로핵심간호진단을보고한 Lee와 Zierler (2007) 의연구보고와비교한결과, 급성통증이일치되게도출되었고, 일반적인암환자를대상으로간호진단을연구한 Jang (2003) 의연구에서도급성통증이일치함을확인하였다. 유방암환자를대상으로연계성을연구하였던 Chi 와 Chi (2003) 의연구보고와비교한결과에서는 2개의간호진단즉급성통증과지식부족이일치되게도출되었고, 간호대상자가약절반가량이암환자인가정간호에서빈번하게사용되는간호진단에서도 2개의간호진단인급성통증과지식부족이일치하였다 (Hur, Kim, & Storey, 2000). 하지만, 본연구결과에서는급성통증과지식부족이가장많이적용되는진단으로선정된데반해, 두연구결과에서는간호진단순위에서차이가있었다. 각연구간의수행시기가 10여년의시간적차 이가있지만여전히국내암환자에게급성통증과지식부족이공통된주요한간호문제임을확인하였다. 특히, 간호진단급성통증은단순히하나의간호진단이아니라보편적으로암환자들에게해당되는진단인동시에간호사들이우선적으로해결해야하는간호문제로인식되어야함을시사한다. 국외에서는 Speksnijder, Mank와 Achterberg (2011) 이혈액종양말기암환자를대상으로가장빈번하게사용되는간호진단으로 11개를보고하였고, 이중급성통증만이본연구결과와일치하였다. 본연구에서도혈액종양환자들이 43% 를차지하여비슷한간호진단들이확인될것이라생각되었지만차이가있었다. 이결과의차이는 Speksnijder, Mank 와 Achterberg (2011) 의연구에서는대상자가모두혈액종양말기인환자로대상자의특징및질병심각도의차이로인한것이라 420 Korean Journal of Adult Nursing
Table 5. Summary of NNN Linkage for Ineffective Protection NANDA NOC NIC Label CVI Label CVI Label n(%) Ineffective protection.80 Fatigue level.85 Pain management Energy management Nutrition management Self-care assistance Mood management Sleep enhancement Immune status.80 Teaching: Prescribed drug Energy management Infection protection Infection control Teaching: Individual Health education Risk identification Chemotherapy management Weight management Respiratory monitoring Health screening Purities management Radiation therapy management Nutritional status.80 Eating disorders management Water/Electrolyte management Teaching: prescribed diet Self care assistance: Eating Nutrition therapy Nutrition management Weight management Nutrition counseling NANDA=North America Nursing Diagnosis Association; NOC=nursing outcome classification; NIC=nursing intervention classification. (N=53) 26 (49.1) 26 (49.1) 25 (47.2) 20 (37.7) 43 (81.1) 37 (69.8) 36 (67.9) 34 (64.2) 32 (60.4) 32 (60.4) 31 (58.5) 30 (56.6) 33 (62.3) 33 (62.3) 32 (60.4) 30 (60.4) 30 (60.4) 30 (60.4) 28 (52.8) 사료된다. 또한 Ogasawara 등 (2005) 은유방암말기환자들에게빈번하게사용하는진단을연구하였다. 연구보고에의하면, 간호진단만성통증, 감염위험성, 활동지속성장애, 손상위험성및불안이가장빈번하게사용되었고, 이중항암요법을받고있는환자에서는간호진단감염위험성빈도가제일높았다. 본연구결과와비교하였을때일치하는간호진단이없었는데, 이는 Ogasawara 등 (2005) 의연구대상자가대부분이전이가된상태의심각한유방암말기환자였던데반해, 본연구에서유방암비율은 6.7% 로낮아서종양의종류및심각도의차이가있었고, 이에따라환자의간호요구도가다르기때문에그결과에영향을끼쳤을것이라사료된다. 또한, 이결과는종양의유형별그리고심각도에따른 NNN 연계개발과그검증의필요성을시사한다. 암환자를대상으로 NNN 연계성을보고한연구가제한되어있기때문에, 좀더간호단위를확대해서외과계입원환자와내외과계간호단위를대상으로 NNN 연계성을보고한 Lee 와 Choi (2011) 와 Ko와 So (2013) 의연구결과를포함하여논의하고자한다. 본연구결과에서나타난간호진단급성통증에대한 NNN 연계성을언급된연구결과와비교해봤을때, 간호결과로통증조절, 통증수준, 안위수준이일치하였고 (Chi & Chi, 2003; Ko & So, 2013; Lee & Choi, 2011), 기대되는간호결과에적용된 25개의간호중재목록중에서통증관리, 진통제투여, 구강투약, 열냉적용, 환경관리 : 안위도모, 처방된약물교육, 정맥내투약, 약물투여즉 7가지중재가세연구의결과와일치하여 (Chi & Chi, 2003; Ko & So, 2013; Lee & Choi, 2011), 본연구결과는기존의급성통증에대한 NNN 연계성결과를지지하였다. 이외에정서적지지, 자가진통제투여보조, 이완요법, 절차 / 치료교육, 투약처방, 체위의 6가지중재가유방암환자의간호결과별간호중재와유사하였다 (Chi & Chi, 2003). 이는본연구와 Chi와 Chi (2003) 의연구에서만나타난것으로서, 암환자를위한특이적인중재로간호사가인식하는것으로사료된다. 따라서간호사는암환자를위 Vol. 26 No. 4, 2014 421
송수미 소향숙 안민정 한통증관리를위한간호계획시기존의알려진중재와이런특이적인중재를함께고려하는것이중요하다. 이결과가임상에서실제로중재를담당하는간호사에의해확인되었기는하지만, 두연구만으로이러한결과를내리기에는성급하므로다양한병원환경에서여러암유형의환자에게수행된중재를재확인하여검증하는반복연구가필요하다. 본연구에서확인된주요간호진단으로비효과적방어와건강추구행위의간호결과-간호중재연계성은기존의연구결과에서는보고되지않았는데, 이는점차적으로암조기검진율의증가, 치료방법발전, 간호환경변화, 그리고종양전문간호사및간호사의역할확대에따라잠재적인건강문제에대한예방을중요하게인식하고있음을확인할수있다. 특히, 간호진단비효과적방어의주요간호결과로피로수준, 면역상태와영양상태가확인되었는데이는여러선행연구에서보고한항암화학요법환자들이경험하는주요한부작용즉오심, 구토와식욕부진및구내염으로인한영양불량상태초래, 주기적으로반복되는항암화학요법으로인해피로증가및면역약화를반영한결과로사료된다 (Lim & Yi, 2014; Min & Hwang, 2010; Kim & Seo, 2010). 또한, 간호사들에의해확인된간호결과연계간호중재들은간호사들이향후항암화학요법환자들을위한간호계획및항암환자요법후환자들이경험할잠재적인부작용과효과적인관리를위한환자교육에적용함으로써환자간호의질을향상시킬수있을것이라사료된다. 본연구에서는항암화학요법을받고있는암환자들을위한 NNN 연계를확인하기위해내용타당도와임상타당도를검증하였다. 이는임상실무에서발생한암환자들의간호요구와이를충족하기위해간호사들이제공한간호중재를바탕으로개발된것이므로, 간호과정에대한지식이나자신감의부족으로인해실무에서간호과정적용을회피하거나어려움을겪고있는간호사에게표준화된간호용어를이용한실무중심의 NNN 연계의제공은간호사로하여금좀더개선된간호계획을수립및수행하도록도와주어환자간호의결과와질을향상시킬수있다. 이는또한임상에서한정된시간에간호기록을수행해야하는간호사에게정확한간호기록을할수있도록도와주고수행한간호업무를가시화시켜실무에서의간호지식체발전에이바지할수있으리라사료된다. 본연구의주요한제한점은연구대상자선정에있다. 암전문병원이아닌 1개일반대학병원의항암화학요법을받고있는암환자의기록지분석을통해주요간호진단을확인하였고, 암유형은절반이상이위장관암이었다. 그리고 NNN 연계에참여한간호사의과반수는종양관련병동의경력이 1~3 년으로짧았다. 그러므로본연구결과를다른분야또는모든암환자를대상으로일반화하는데에는신중을기해야한다. 결론및제언본연구는항암화학요법을받는암환자에게적합한주요간호진단과간호결과에대해내용타당도를검증하고, 실제임상에서수행되고있는간호중재에기반을두어 NNN 연계성을확인했다는데의의가있다. 본연구는암환자간호단위에서의간호과정적용을촉진하는실증적자료로서향후간호표준으로활용될수있으며, 간호정보기록시스템의데이터베이스로사용될수있다. 본연구결과를기초로항암화학요법환자의간호진단, 간호결과및간호중재연계를적용한간호정보전산시스템개발및그효과를측정하기를제언한다. 다양한암환자집단과치료방법을고려한반복연구를통해암환자집단별특정주요간호진단과 NNN 연계분류표가도출되어공통된간호표준화를이룰수있도록 NNN 연계를재검증할것을제언한다. REFERENCES Bulechek, G. M., Butcher, H., & Dochterman, J. M. (2007). Nursing Interventions Classification (NIC). (5th ed.). St. Louis, MO: Mosby Elsevier. Chi, M. K., & Chi, S. A. (2003). Linkages of nursing diagnosis, nursing intervention and nursing outcome classification of breast cancer patients using nursing database. Journal of Korean Academy of Nursing Administration, 9(4), 651-661. Cho, E. J., & Kim, N. C. (2008). Validation of major nursing diagnosis-outcome-intervention(nanda-noc-nic) linkage for adult surgery patients of post-anesthetic care unit. Journal of Korean Clinical Nursing Research, 14, 141-151. Choi, S. H., Lee, E. J., Park, M. J., Kim, H. S., Kim, M. Y., & Choi, J. Y. (2012). Nursing outcomes measurement indicators. Gwangju, Korea: Chonnam University Publishers. Dochterman, J. M., & Bulechek, G. M. (2004). Nursing Interventions Classification (NIC). (4th ed.). New York: Mosby. Fehring, R. J. (1987). Methods to validate nursing diagnoses. Heart & Lung, 16(6 Pt 1), 625-629. Hur, H. K., Kim, S., & Storey, M. (2000). Nursing diagnoses and interventions used in home care in Korea. Nursing Diagnosis, 11, 97-108. Jang, M. R. (2003). An analysis of nursing diagnoses in cancer patients receiving chemotherapy. Unpublished master's thesis, Seoul National University, Seoul, Korea. 422 Korean Journal of Adult Nursing
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