128个护理诊断(8页).doc

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1、-128个护理诊断-第 8 页NANDA确定的128个护理诊断文章来源：护理园地2004-11-29 11:38:20文字大小：【】【】【】 通过的以人类反应型态(Human ResPonse Patterns)的分类方法。现将人类反应型态分类方法的128个诊断分列如下：一、交换(Exchanging) 营养失调：高于机体需要量(Altered Nutrition：More Than Body Requirements)营养失调：低于机体需要量(Altered Nutrition： less Than Body Requirements)营养失调：潜在高于机体需要量(Altered Nutri

2、tion：Potential for More Than Body Requirements)有感染的危险(Risk for Infection)有体温改变的危险(Risk for Altered Body Temperature)体温过低(Hypothermia)体温过高(Hyperthermia)体温调节无效(Ineffective Thermoregulatlon)反射失调(Dysre flexia)(Constipation)感知性便秘(Perceived Consttipation)结肠性便秘(Colonic Constipation)(Diarrhea)(Bowel Incontt

3、inence)排尿异常(Altered Urinary Elimination)压迫性(Sires Incontlnence)反射性尿失禁(Reflex Incontlnence)急迫性尿失禁(Unge Incontlnence)功能性尿失禁(Functional Incontlnence)完全性尿失禁(Total Incontlnencd尿储留(Urinary Retentron)组织灌注量改变(肾、脑、心肺、胃肠、周围血管)(Altered Tissue Perfuslorl( Renal， Cereral， Cardlopulmonary Gastrolntestlnal，Periphe

4、ral)体液过多(Fluid Volume Excess)体液不足(Fluid Volume Deficit)体液不足的危险(Risk for Fluid VolUme Deficit)心输出量减少(Deer。A。Ed CardlacouPu)气体交换受损(Imnaired Gas Exc5anse)清理呼吸道无效(Ineffecthe Airway Clearance)低效性呼吸型态(Ineffective Breathing Pattern)不能维持自主呼吸( Inability to Sustain Spontaneous Ventilation)呼吸机依赖( Dysfunctional

5、 Ventilatory Weaning ResPonse，DVWR)有受伤的危险(Risk for Injury)有窒息的危险(Risk for Suffocation)有外伤的危险(Risk for Trauma)有误吸的危险(Risk for Aspiration)自我防护能力改变(Altered Protection)组织完整性受损(ImPaired Tissue Integrity)改变(Altered Oral Mucous Membrance)皮肤完整性受损(ImPaired Skin Integrity)有皮肤完整性受损的危险(Risk for ImPaired Skin In

6、tegrity)调节颅内压能力下降( Decreased AdaPtive CaPacity Intracranial)精力困扰(Energy Field distubance)二、沟通(Communicating)语言沟通障碍(impaired VerbalCommunlcatlon)三、关系(Relating)社会障碍(Impaired Soial Interatlon)社交孤立(Social Isolition)有孤立的危险(Risk forLonelines。)角色紊乱(Altered Role Performance)父母不称职(Altered Parenting)有父母不称职的危险

7、(Risk for Altered Parenting)有父母亲子依恋改变的危险(Risk for Altered ParentInfantChild Att8Chffi6llt)(Sexual Dysfunction)家庭作用改变(Altered Family Process)照顾者角色障碍(Caresiver Role Strain)有照顾者角色障碍的危险(Risk for Caregiver Role Strain)家庭作用改变：酗酒(Altered Family Process： Alcoholism)父母角色冲突(Parental Role Conflict)性生活型态改变(Alte

8、red SexualityPatterns)四、赋予价值(Valuing)精神困扰(Spiritual Distress)增进精神健康：潜能性(Potential for Enhance Spiritual Well-Belug)五、选择(Choosing)个人应对无效(Ineffctive Individual Coping)调节障碍(ImPaired Adjustment)防卫性应对(Defensive Coping)防卫性否认(Ineffective Denial)家庭应对无效：失去能力( Ineffective Family Coping：Disabling)家庭应对无效：妥协性 (I

9、neffectiv Family Coping：Compromised)家庭应对：潜能性(Family CoPing： Potential for Growth)社区应对：潜能性(Potential for Enhanced Community CoPing)社区应对无效(Ineffective Community Coping)遵守治疗方案无效(个人的)(Ineffective Management of Therapeutic Regimen)(Individual)不合作(特定的)(Noncompliance)(Specitfy)遵守治疗方案无效(家庭的)(Ineffective Man

10、agement of Therapeutic Regimen： ( (Families)遵守治疗方案无效(社区的)(Ineffective Management of Therapeutic Regimen： Community)遵守治疗方案有效(个人的)(Effective Management of Therapeutic Regimen：Individual)抉择冲突(特定的)(Decisional Conflict)(Specify)寻求健康行为(特定的)(Health Seeking Behaviors)(Specity)六、活动(Moving)躯体移动障碍(ImPaired Phy

11、sical Mobility)有周围血管神经功能障碍的危险(Risk for PeriPheralNeurovascular Dysfunction)有围期外伤的危险 (Risk for Perloperatlve Positioning Injury)活动无耐力(Activity Intolerance)疲乏(Fatigue)有活动无耐力的危险(Risk for Activity Intolerance)睡眠状态紊乱(SleepPattern Disturbance)娱乐活动缺乏(Diversional Activity Deficit)持家能力障碍(Impaired Home Mainte

12、nance Management)保持健康的能力改变(Altered Health Maintenance)进食自理缺陷(Feeding Self Care Deficit)吞咽障碍(Impaired Swallowing)母乳喂养无效(Ineffective Breast Feeding)母乳喂养中断(Interrunted Breast1ceding)母乳喂养有效(Effective Breast feeding)婴儿吸吮方式无效(Ineffective Infant Feeding Pattern)沐浴卫生自理缺陷(BathingHygiene Self Care Deficit)穿戴修

13、饰自理障碍(DressingGrooming Self Care Deficit)入厕自理缺陷(Toileting Self Care Deficit)生长发育改变(Altered Growth and Development)环境改变应激综合征(Relocation Stress Syndrome)有婴幼儿行为紊乱的危险( Risk for Disorganized Infant Behavior)婴幼儿行为紊乱(Disorganized Infant Behavior)增进婴幼儿行为(潜能性)(potential for Disorganized Infant ganlzed Infant

14、khavlor)七、感知(Perceiving)自我形象紊乱(Body Imagse Disturbance)自尊紊乱(SolfEsteem disturbance)长期自我贬低(Chronic Low Self Esteem)情境性自我贬低(Situational Low Self Esteem)自我认同紊乱(Personal Identity disturbance)感知改变(特定的)(视、听、运动、味、触、嗅)(SensoryPerceptual Alterations)(specify)(Visual，Auditory，Kinesthetlc，Gustatory，Taotile，Olf

15、actory)单侧感觉丧失(Unilateral Neglect)绝望(Honelessness)无能为力(Powerlessness)八、认知(Knowing)知识缺乏(特定的)(Knowledge Deficit)(Specify)定向力障碍(Impaired Environmental Interpretation)突发性意识模糊(Acute Confusion)渐进性意识模糊(Chronic Confusion)思维过程改变(Altered Thought Processes)记忆力障碍(ImPaired Memoryy)九、感觉(Feeling)疼痛(Pain)慢性疼痛(Chroni

16、c Pain)功能障碍性悲哀(Dysfunctional Crievins)预感性悲哀(AnticiPatory Crieving)有暴力行为的危险：对自己或对他人(Risk for Violence： Self-Directed or drected at Others)有自伤的危险(Risk for SelfMutilation)后反应(PostTrauma Response)强奸创伤综合征(RaPeTrauma Syndrome)强奸创伤综合征：复合性反应(RepeTrauma Syndrome:Compound Reaction)强奸创伤综合征：沉默性反应( RapeTrauma Syndrome：Silent)焦虑(Anxiety)恐惧(Fear)