128個(gè)護(hù)理診斷及措施

NANDA通過(guò)的以人類反響型態(tài)(HumanResPonsePatterns)的分類方法。現(xiàn)將人類反響型態(tài)分類方法的128型態(tài)1：交換養(yǎng)分失調(diào)：高于身體需要量 養(yǎng)分失調(diào)：低于身體需要量 養(yǎng)分失調(diào)：潛在的高于身體需要量有照看者角色困難的危急 家庭作用轉(zhuǎn)變：酗酒父母角色沖突性生活型態(tài)轉(zhuǎn)變無(wú)能為力型態(tài)8：生疏學(xué)問(wèn)缺乏〔特定的〕生疏環(huán)境受損綜合征有感染的危急有體溫轉(zhuǎn)變的危急體溫過(guò)低體溫過(guò)高體溫調(diào)整無(wú)效反射失調(diào)便秘感知性便秘結(jié)腸性便秘腹瀉大便失禁排尿特別壓迫性尿失禁反射性尿失禁急迫性尿失禁功能性尿失禁完全性尿失禁尿潴留組織灌注量轉(zhuǎn)變：〔特定型〕〔腎、腦、心肺、胃腸、外周血管〕 體液過(guò)多體液缺乏有體液缺乏的危急心輸出量削減氣體交換受損清理呼吸道無(wú)效低效性呼吸型態(tài)不能維持自主呼吸呼吸機(jī)依靠有受損害的危急有窒息的危急有中毒的危急有外傷的危急有誤吸的危急有廢用綜合征的危急保護(hù)力量轉(zhuǎn)變組織完整性受損口腔粘膜轉(zhuǎn)變皮膚完整性受損有皮膚完整性受損的危急 適應(yīng)力量下降：顱內(nèi)的能量場(chǎng)困擾型態(tài)2：溝通語(yǔ)言溝通障礙型態(tài)3：關(guān)系社交活動(dòng)障礙社交孤立有孤獨(dú)的危急角色紊亂父母不稱職有父母不稱職的危急有親子依戀轉(zhuǎn)變的危急 性功能障礙家庭作用轉(zhuǎn)變照看者角色困難4：賜予價(jià)值精神困擾潛在的精神安康增加型態(tài)5：選擇個(gè)人應(yīng)對(duì)無(wú)效調(diào)整障礙防衛(wèi)性應(yīng)對(duì)無(wú)效性否認(rèn)家庭應(yīng)對(duì)無(wú)效：無(wú)能性 家庭應(yīng)對(duì)無(wú)效：妥協(xié)性 家庭應(yīng)對(duì)：潛能性潛在的社區(qū)應(yīng)對(duì)增加社區(qū)應(yīng)對(duì)無(wú)效執(zhí)行治療方案無(wú)效：個(gè)人 不合作〔特定的〕執(zhí)行治療方案無(wú)效：家庭 執(zhí)行治療方案無(wú)效：社區(qū) 執(zhí)行治療方案有效：個(gè)人 決擇沖突〔特定的〕尋求安康行為〔特定的〕型態(tài)6：移動(dòng)身體移動(dòng)障礙有四周神經(jīng)血管功能障礙的危急 有圍手術(shù)期受傷的危急 活動(dòng)無(wú)耐力疲乏有活動(dòng)無(wú)耐力的危急睡眠型態(tài)紊亂缺乏消遣活動(dòng)持家力量障礙保持安康力量轉(zhuǎn)變進(jìn)食自理缺陷吞咽障礙母乳喂養(yǎng)無(wú)效母乳喂養(yǎng)中斷母乳喂養(yǎng)有效嬰兒喂養(yǎng)困難沐浴/衛(wèi)生自理缺陷穿著/修飾自理缺陷入廁自理缺陷生長(zhǎng)發(fā)育轉(zhuǎn)變遷居應(yīng)激綜合征有嬰兒行為紊亂的危急 嬰兒行為紊亂潛在的嬰兒行為調(diào)整增加型態(tài)7：感知自我形象紊亂自尊紊亂長(zhǎng)期性自卑情境性自卑自我認(rèn)同紊亂感知轉(zhuǎn)變〔特定的〕〔視、聽(tīng)、運(yùn)動(dòng)、味、觸、嗅覺(jué)〕 單側(cè)感覺(jué)喪失無(wú)望急性意識(shí)障礙慢性意識(shí)障礙思維過(guò)程轉(zhuǎn)變記憶力障礙9：感覺(jué)苦痛慢性苦痛功能障礙性哀痛預(yù)感性哀痛有暴力行為的危急：對(duì)自己或他人有自傷的危急創(chuàng)傷后反響強(qiáng)暴創(chuàng)傷綜合征強(qiáng)暴創(chuàng)傷綜合征：復(fù)合反響 強(qiáng)暴創(chuàng)傷綜合征：沉默反響 焦慮可怕交換(Exchanging)養(yǎng)分失調(diào)：高于機(jī)體需要量(AlteredNutrition：MoreThanBodyRequirements)養(yǎng)分失調(diào)：低于機(jī)體需要量(AlteredNutrition：lessThanBodyRequirements)養(yǎng)分失調(diào)：潛在高于機(jī)體需要量(AlteredNutritionPotentialforMoreThanBodyRequirements)有感染的危急(RiskforInfection)有體溫轉(zhuǎn)變的危急(RiskforAlteredBodyTemperature)(Hypothermia)體溫過(guò)高(Hyperthermia)體溫調(diào)整無(wú)效(IneffectiveThermoregulatlon)(Dysreflexia)便秘(Constipation)(PerceivedConsttipation)(ColonicConstipation)腹瀉(Diarrhea)(BowelInconttinence)(AlteredUrinaryElimination)(SiresIncontlnence)反射性尿失禁(ReflexIncontlnence)(UngeIncontlnence)功能性尿失禁(FunctionalIncontlnence)(TotalIncontlnencd尿儲(chǔ)留(UrinaryRetentron)組織灌注量轉(zhuǎn)變(腎、腦、心肺、胃腸、四周血管)(AlteredTissuePerfuslorl(RenalCereralCardlopulmonaryGastrolntestlnal，Peripheral)(FluidVolumeExcess)(FluidVolumeDeficit)體液缺乏的危急(RiskforFluidVolUmeDeficit)心輸出量削減(Deer.a.edCardlacouPu)氣體交換受損(ImnairedGasExc5anse)清理呼吸道無(wú)效(IneffectheAirwayClearance)低效性呼吸型態(tài)(IneffectiveBreathingPattern)不能維持自主呼吸(InabilitytoSustainSPontaneousVentilation)呼吸機(jī)依靠(DysfunctionalVentilatoryWeaningResPonse ，DVWR)有受傷的危急(RiskforInjury)(RiskforSuffocation)(RiskforTrauma)有誤吸的危急(RiskforAspiration)自我防護(hù)力量轉(zhuǎn)變(AlteredProtection)組織完整性受損(ImPairedTissueIntegrity)(AlteredOralMucousMembrance)皮膚完整性受損(ImPairedSkinIntegrity)有皮膚完整性受損的危急(RiskforImPairedSkinIntegrity)調(diào)整顱內(nèi)壓力量下降(DecreasedAdaPtiveCaPacityIntracranial)(EnergyFielddistubance)溝通(Communicating)語(yǔ)言溝通障礙(impairedVerbalCommunlcatlon)關(guān)系(Relating)(ImpairedSoialInteratlon)(SocialIsolition)有孤立的危急(Riskfor.Lonelines.)(AlteredRolePerformance)(AlteredParenting)有父母不稱職的危急(RiskforAlteredParenting)有父母親子依戀轉(zhuǎn)變的危急(RiskforAlteredParent/Infant/ChildAtt8Chffi6llt)(SexualDysfunction)(AlteredFamilyProcess)照看者角色障礙(CaresiverRoleStrain)有照看者角色障礙的危急(RiskforCaregiverRoleStrain)家庭作用轉(zhuǎn)變：酗酒(AlteredFamilyProcess：Alcoholism)(ParentalRoleConflict)性生活型態(tài)轉(zhuǎn)變(AlteredSexualityPatterns)(Valuing)(SpiritualDistress)增進(jìn)精神安康：潛能性(PotentialforEnhanceSpiritualWell-Belug)選擇(Choosing)個(gè)人應(yīng)對(duì)無(wú)效(IneffctiveIndividualCoping)(ImPairedAdjustment)防衛(wèi)性應(yīng)對(duì)(DefensiveCoping)(IneffectiveDenial)家庭應(yīng)對(duì)無(wú)效：失去力量(IneffectiveFamilyCoping：Disabling)家庭應(yīng)對(duì)無(wú)效：妥協(xié)性(IneffectivFamilyCoping：Compromised)家庭應(yīng)對(duì)：潛能性(FamilyCoPing：PotentialforGrowth)社區(qū)應(yīng)對(duì)：潛能性(PotentialforEnhancedCommunityCoPing)(IneffectiveCommunityCoping)遵守治療方案無(wú)效(個(gè)人的)(IneffectiveManagementofTherapeuticRegimen)(Individual)不合作(特定的)(Noncompliance)(Specitfy)遵守治療方案無(wú)效(家庭的)(IneffectiveManagementofTherapeuticRegimen ：((Families)遵守治療方案無(wú)效(社區(qū)的)(IneffectiveManagementofThera-peuticRegimen ：Community)遵守治療方案有效(個(gè)人的)(EffectiveManagementofThera-peuticRegimen ：Individual)選擇沖突(特定的)(DecisionalConflict)(Specify)尋求安康行為(特定的)(HealthSeekingBehaviors)(Specity)活動(dòng)(Moving)軀體移動(dòng)障礙(ImPairedPhysicalMobility)有四周血管神經(jīng)功能障礙的危急(RiskforPeriPheralNeurovas-cularDysfunction)有圍手術(shù)期外傷的危急(RiskforPerloperatlvePositioningInjury)(ActivityIntolerance)疲乏(Fatigue)有活動(dòng)無(wú)耐力的危急(RiskforActivityIntolerance)(SleepPatternDisturbance)消遣活動(dòng)缺乏(DiversionalActivityDeficit)持家力量障礙(ImpairedHomeMaintenanceManagement)保持安康的力量轉(zhuǎn)變(AlteredHealthMaintenance)(FeedingSelfCareDeficit)(ImpairedSwallowing)母乳喂養(yǎng)無(wú)效(IneffectiveBreastFeeding)母乳喂養(yǎng)中斷(InterruntedBreast1ceding)(EffectiveBreastfeeding)嬰兒吸吮方式無(wú)效(IneffectiveInfantFeedingPattern)沐浴/衛(wèi)生自理缺陷(Bathing/HygieneSelfCareDeficit)穿戴/修飾自理障礙(Dressing/GroomingSelfCareDeficit)(ToiletingSelfCareDeficit)生長(zhǎng)發(fā)育轉(zhuǎn)變(AlteredGrowthandDevelopment)環(huán)境轉(zhuǎn)變應(yīng)激綜合征(RelocationStressSyndrome)有嬰幼兒行為紊亂的危急(RiskforDisorganizedInfantBehavior)嬰幼兒行為紊亂(DisorganizedInfantBehavior)增進(jìn)嬰幼兒行為(潛能性)(potentialforDisorganizedInfantganlzedInfantkhavlor)感知(Perceiving)自我形象紊亂(BodyImagseDisturbance)(SolfEsteemdisturbance)(ChronicLowSelfEsteem)情境性自我貶低(SituationalLowSelfEsteem)自我認(rèn)同紊亂(PersonalIdentitydisturbance)感知轉(zhuǎn)變(特定的)(視、聽(tīng)、運(yùn)動(dòng)、味、觸、嗅)(Sensory/PerceptualAlterations)(specify)(Visual ，Auditory，Kinesthetlc，Gustatory，Tao-tile，Olfactory)單側(cè)感覺(jué)喪失(UnilateralNeglect)無(wú)望(Honelessness)無(wú)能為力(Powerlessness)認(rèn)知(Knowing)學(xué)問(wèn)缺乏(特定的)(KnowledgeDeficit)(Specify)(ImpairedEnvironmentalInterpretation)突發(fā)性意識(shí)模糊(AcuteConfusion)漸進(jìn)性意識(shí)模糊(ChronicConfusion)思維過(guò)程轉(zhuǎn)變(AlteredThoughtProcesses)(ImPairedMemoryy)感覺(jué)(Feeling)苦痛(Pain)(ChronicPain)功能障礙性哀痛(Dysfunction