護(hù)理常用個(gè)護(hù)理診斷

1、NANDANANDA 通過(guò)的以人類反應(yīng)型態(tài)(HumanHuman ResPonseResPonse PatternsPatterns的分類方法?，F(xiàn)將人類反應(yīng)型態(tài)分類方法的 128128 個(gè)護(hù)理診斷分列如下：( 1 1)交換( ExchangingExchanging)營(yíng)養(yǎng)失調(diào)：高于機(jī)體需要量( AlteredAltered NutritionNutrition ： MoreMore ThanThan BodyBody RequirementsRequirements ) 營(yíng)養(yǎng)失調(diào)：低于機(jī)體需要量( AlteredAltered NutritionNutrition ： lessless Tha

2、nThan BodyBody RequirementsRequirements) 營(yíng)養(yǎng)失調(diào)： 潛在高于機(jī)體需要量 ( AlteredAltered NutritionNutrition ：PotentialPotential forfor MoreMore ThanThan BodyBody RequirementsRequirements ) 有感染的危險(xiǎn)( RiskRisk forfor InfectionInfection )有體溫改變的危險(xiǎn)( RiskRisk forfor AlteredAltered BodyBody TemperatureTemperature ) 體溫過(guò)低( H

3、ypothermiaHypothermia )體溫過(guò)高( HyperthermiaHyperthermia )體溫調(diào)節(jié)無(wú)效( IneffectiveIneffective ThermoregulatlonThermoregulatlon )反射失調(diào)( DysreDysre flexiaflexia )便秘( ConstipationConstipation )感知性便秘( PerceivedPerceived ConsttipationConsttipation)結(jié)腸性便秘( ColonicColonic ConstipationConstipation )腹瀉( DiarrheaDiarrh

4、ea )大便失禁( BowelBowel InconttinenceInconttinence )排尿異常( AlteredAltered UrinaryUrinary EliminationElimination )壓迫性尿失禁( SiresSires IncontlnenceIncontlnence)反射性尿失禁( ReflexReflex IncontlnenceIncontlnence) 急迫性尿失禁( UngeUnge IncontlnenceIncontlnence) 功能性尿失禁( FunctionalFunctional IncontlnenceIncontlnence )完全

5、性尿失禁( TotalTotal IncontlnencdIncontlnencd尿儲(chǔ)留( UrinaryUrinary RetentronRetentron )組織灌注量改變(腎、腦、心肺、胃腸、周圍血管)(AlteredAltered TissueTissuePerfuslorlPerfuslorl( RenalRenal， CereralCereral ， CardlopulmonaryCardlopulmonary GastrolntestlnalGastrolntestlnal ， PeripheralPeripheral ) 體液過(guò)多( FluidFluid VolumeVolum

6、e ExcessExcess ) 體液不足( FluidFluid VolumeVolume DeficitDeficit ) 體液不足的危險(xiǎn)( RiskRisk forfor FluidFluid VolUmeVolUme DeficitDeficit ) 氣體交換受損( ImnairedImnaired GasGas Exc5anseExc5anse ) 清理呼吸道無(wú)效( IneffectheIneffecthe AirwayAirway ClearanceClearance ) 低效性呼吸型態(tài)( IneffectiveIneffective BreathingBreathing Patt

7、ernPattern ) 不能維持自主呼吸( InabilityInability toto SustainSustain SPontaneousSPontaneous VentilationVentilation ) 呼吸機(jī)依賴( DysfunctionalDysfunctional VentilatoryVentilatory WeaningWeaning ResPonseResPonse ， DVWRDVWR ) 有受傷的危險(xiǎn)( RiskRisk forfor InjuryInjury ) 有窒息的危險(xiǎn)( RiskRisk forfor SuffocationSuffocation )

8、有外傷的危險(xiǎn)( RiskRisk forfor TraumaTrauma ) 有誤吸的危險(xiǎn)( RiskRisk forfor AspirationAspiration ) 自我防護(hù)能力改變( AlteredAltered ProtectionProtection ) 組織完整性受損( ImPairedImPaired TissueTissue IntegrityIntegrity ) 口腔粘膜改變( AlteredAltered OralOral MucousMucous MembranceMembrance ) 皮膚完整性受損( ImPairedImPaired SkinSkin Integ

9、rityIntegrity ) 有皮膚完整性受損的危險(xiǎn)( RiskRisk forfor ImPairedImPaired SkinSkin IntegrityIntegrity ) 調(diào)節(jié)顱內(nèi)壓能力下降( DecreasedDecreased AdaPtiveAdaPtive CaPacityIntracranialCaPacityIntracranial ) 精力困擾( EnergyEnergy FieldField distubancedistubance )( 2 2)溝通( CommunicatingCommunicating )語(yǔ)言溝通障礙( impairedimpaired Ver

10、balCommunlcatlonVerbalCommunlcatlon )3 3)關(guān)系( RelatingRelating )社會(huì)障礙( ImpairedImpaired SoialSoial InteratlonInteratlon )社交孤立( SocialSocial IsolitionIsolition ) 有孤立的危險(xiǎn)( RiskRisk for.Lonelines.for.Lonelines. ) 角色紊亂( AlteredAltered RoleRole PerformancePerformance ) 父母不稱職( AlteredAltered ParentingParenti

11、ng ) 有父母不稱職的危險(xiǎn)( RiskRisk forfor AlteredAltered ParentingParenting ) 有父母親子依戀改變的危險(xiǎn)( RiskRisk forfor AlteredAltered ParentParent InfantInfant ChildChild Att8Chffi6lltAtt8Chffi6llt ) 性功能障礙( SexualSexual DysfunctionDysfunction) 家庭作用改變( AlteredAltered FamilyFamily ProcessProcess ) 照顧者角色障礙( CaresiverCaresi

12、ver RoleRole StrainStrain ) 有照顧者角色障礙的危險(xiǎn)( RiskRisk forfor CaregiverCaregiver RoleRole StrainStrain ) 家庭作用改變：酗酒( AlteredAltered FamilyFamily ProcessProcess ： AlcoholismAlcoholism) 父母角色沖突( ParentalParental RoleRole ConflictConflict ) 性生活型態(tài)改變( AlteredAltered SexualityPatternsSexualityPatterns )( 4 4)賦予價(jià)

13、值( ValuingValuing )精神困擾( SpiritualSpiritual DistressDistress )增進(jìn)精神健康：潛能性( PotentialPotential forfor EnhanceEnhance SpiritualSpiritual Well-BelugWell-Belug )( 5 5)選擇( ChoosingChoosing)個(gè)人應(yīng)對(duì)無(wú)效( IneffctiveIneffctive IndividualIndividual CopingCoping ) 調(diào)節(jié)障礙( ImPairedImPaired AdjustmentAdjustment ) 防衛(wèi)性應(yīng)對(duì)(

14、 DefensiveDefensive CopingCoping) 防衛(wèi)性否認(rèn)( IneffectiveIneffective DenialDenial )家庭應(yīng)對(duì)無(wú)效：失去能力( IneffectiveIneffective FamilyFamily CopingCoping ： DisablingDisabling)家庭應(yīng)對(duì)無(wú)效：妥協(xié)性 ( IneffectivIneffectiv FamilyFamily CopingCoping ：CompromisedCompromised )家庭應(yīng)對(duì)：潛能性( FamilyFamily CoPingCoPing ： PotentialPotenti

15、al forfor GrowthGrowth )社區(qū)應(yīng)對(duì)：潛能性( PotentialPotential forfor EnhancedEnhanced CommunityCommunity CoPingCoPing )社區(qū)應(yīng)對(duì)無(wú)效( IneffectiveIneffective CommunityCommunity CopingCoping )遵守治療方案無(wú)效(個(gè)人的)( IneffectiveIneffective ManagementManagement ofof TherapeuticTherapeutic RegimenRegimen )( IndividualIndividual

16、) 不合作(特定的)( NoncomplianceNoncompliance)( SpecitfySpecitfy)遵守治療方案無(wú)效(家庭的)( IneffectiveIneffective ManagementManagement ofof TherapeuticTherapeutic RegimenRegimen ： ( ( FamiliesFamilies) 遵守治療方案無(wú)效(社區(qū)的) ( IneffectiveIneffective ManagementManagement ofof TheraThera peuticpeutic RegimenRegimen： CommunityCo

17、mmunity ) 遵守治療方案有效(個(gè)人的)( EffectiveEffective ManagementManagement ofof TheraThera peuticpeutic RegimenRegimen： IndividualIndividual ) 抉擇沖突(特定的)( DecisionalDecisional ConflictConflict )( SpecifySpecify) 尋求健康行為(特定的)( HealthHealth SeekingSeeking BehaviorsBehaviors )( SpecitySpecity)( 6 6)活動(dòng)( MovingMovin

18、g )軀體移動(dòng)障礙( ImPairedImPaired PhysicalPhysical MobilityMobility )有周圍血管神經(jīng)功能障礙的危險(xiǎn)( RiskRisk forfor PeriPheralNeurovasPeriPheralNeurovas cularcular DysfunctionDysfunction ) 有圍手術(shù)期外傷的危險(xiǎn) ( RiskRisk forfor PerloperatlvePerloperatlve PositioningPositioning InjuryInjury ) 活動(dòng)無(wú)耐力( ActivityActivity IntoleranceInt

19、olerance ) 疲乏( FatigueFatigue ) 有活動(dòng)無(wú)耐力的危險(xiǎn)( RiskRisk forfor ActivityActivity IntoleranceIntolerance ) 睡眠狀態(tài)紊亂( SleepPatternSleepPattern DisturbanceDisturbance ) 娛樂(lè)活動(dòng)缺乏( DiversionalDiversional specifyspecify)ActivityActivity DeficitDeficit ) 持家能力障礙( ImpairedImpaired HomeHome MaintenanceMaintenance Mana

20、gementManagement ) 保持健康的能力改變( AlteredAltered HealthHealth MaintenanceMaintenance ) 進(jìn)食自理缺陷( FeedingFeeding SelfSelf CareCare DeficitDeficit )吞咽障礙( ImpairedImpaired SwallowingSwallowing )母乳喂養(yǎng)無(wú)效( IneffectiveIneffective BreastBreast FeedingFeeding)母乳喂養(yǎng)中斷( InterruntedInterrunted Breast1cedingBreast1cedin

21、g )母乳喂養(yǎng)有效( EffectiveEffective BreastBreast feedingfeeding)嬰兒吸吮方式無(wú)效( IneffectiveIneffective InfantInfant FeedingFeeding PatternPattern )沐浴衛(wèi)生自理缺陷( BathingBathing HygieneHygiene SelfSelf CareCare DeficitDeficit )穿戴修飾自理障礙( DressingDressing GroomingGrooming SelfSelf CareCare DeficitDeficit )入廁自理缺陷( Toile

22、tingToileting SelfSelf CareCare DeficitDeficit )生長(zhǎng)發(fā)育改變( AlteredAltered GrowthGrowth andand DevelopmentDevelopment )環(huán)境改變應(yīng)激綜合征( RelocationRelocation StressStress SyndromeSyndrome)有嬰幼兒行為紊亂的危險(xiǎn)( RiskRisk forfor DisorganizedDisorganized InfantInfant BehaviorBehavior )嬰幼兒行為紊亂( DisorganizedDisorganized Infa

23、ntInfant BehaviorBehavior )增進(jìn)嬰幼兒行為(潛能性)( potentialpotential forfor DisorganizedDisorganized InfantInfant ganlzedganlzed InfantkhavlorInfantkhavlor )( 7 7)感知( PerceivingPerceiving)自我形象紊亂( BodyBody ImagseImagse DisturbanceDisturbance)自尊紊亂( SolfEsteemSolfEsteem disturbancedisturbance)長(zhǎng)期自我貶低( ChronicChr

24、onic LowLow SelfSelf EsteemEsteem )情境性自我貶低( SituationalSituational LowLow SelfSelf EsteemEsteem )自我認(rèn)同紊亂( PersonalPersonal IdentityIdentity disturbancedisturbance )感知改變(特定的)(視、聽(tīng)、運(yùn)動(dòng)、味、觸、嗅)( SensorySensory PerceptualAlterationsPerceptualAlterations )VisualVisual ， AuditoryAuditory ， KinesthetlcKinesthe

25、tlc， GustatoryGustatory ， TaoTao tiletile ， OlfactoryOlfactory )單側(cè)感覺(jué)喪失( UnilateralUnilateral NeglectNeglect )絕望( HonelessnessHonelessness)無(wú)能為力( PowerlessnessPowerlessness)( 8 8)認(rèn)知( KnowingKnowing )知識(shí)缺乏(特定的)( KnowledgeKnowledge DeficitDeficit )( SpecifySpecify)定向力障礙( ImpairedImpaired EnvironmentalEnvironmental InterpretationInte