護(hù)理常用個(gè)護(hù)理診斷

1、NANDA通過(guò)的以人類反應(yīng)型態(tài)(Human ResP on slatterns )的分類方法?，F(xiàn)將人類反應(yīng)型態(tài)分類方法的 128 個(gè)護(hù)理診斷分列如下：( 1)交換( Exchanging )營(yíng)養(yǎng)失調(diào)：高于機(jī)體需要量( Altered Nutrition：More Than Body Requirements )營(yíng)養(yǎng)失調(diào)：低于機(jī)體需要量( Altered Nutrition ： less Than Body Requirements )營(yíng)養(yǎng)失調(diào)：潛在高于機(jī)體需要量( Altered Nutrition ：Potential for More Than BodyRequirements )有感染的

2、危險(xiǎn)( Risk for Infection )有體溫改變的危險(xiǎn)( Risk for Altered Body Temperature )體溫過(guò)低( Hypothermia )體溫過(guò)高( Hyperthermia )體溫調(diào)節(jié)無(wú)效( Ineffective Thermoregulatlon )反射失調(diào)( Dysre flexia )便秘( Constipation )感知性便秘( Perceived Consttipation )結(jié)腸性便秘( Colonic Constipation )腹瀉( Diarrhea )大便失禁( Bowel Inconttinence )排尿異常( Altered

3、Urinary Elimination )壓迫性尿失禁( 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，Peripheral )尿儲(chǔ)留( Urinary Retentron ) 組織灌注量改變(腎、腦、心肺、胃腸、周圍血管)( Altered Tissue Perfuslorl ( Renal ， Cereral ， Cardlopulmonary Gastrolntes

4、tlnal 體液過(guò)多( Fluid Volume Excess ) 體液不足( Fluid Volume Deficit ) 體液不足的危險(xiǎn)( Risk for Fluid VolUme Deficit) 氣體交換受損( Imnaired Gas Exc5anse )清理呼吸道無(wú)效( Ineffecthe Airway Clearance ) 低效性呼吸型態(tài)( Ineffective Breathing Pattern ) 不能維持自主呼吸( Inability to Sustain SPontaneous Ventilation)呼吸機(jī)依賴( Dysfunctional Ventilator

5、y Weaning ResPonse， DVW)R有受傷的危險(xiǎn)( Risk for Injury ) 有窒息的危險(xiǎn)( Risk for Suffocation ) 有外傷的危險(xiǎn)( Risk for Trauma ) 有誤吸的危險(xiǎn)( Risk for Aspiration ) 自我防護(hù)能力改變( Altered Protection ) 組織完整性受損( ImPaired Tissue Integrity ) 口腔粘膜改變( Altered Oral Mucous Membrance ) 皮膚完整性受損( ImPaired Skin Integrity ) 有皮膚完整性受損的危險(xiǎn)( Risk f

6、or ImPaired Skin Integrity)調(diào)節(jié)顱內(nèi)壓能力下降( Decreased AdaPtive CaPacityIntracranial精力困擾( Energy Field distubance )2)溝通( Communicating )語(yǔ)言溝通障礙( impaired VerbalCommunlcatlon )(3) 關(guān)系( Relating )社會(huì)障礙( Impaired Soial Interatlon)社交孤立( Social Isolition )有孤立的危險(xiǎn)( Risk for.Lonelines. )角色紊亂( Altered Role Performance

7、 )父母不稱職( Altered Parenting )有父母不稱職的危險(xiǎn)( Risk for Altered Parenting)有父母親子依戀改變的危險(xiǎn)( Risk for Altered Parent Infant ChildAtt8Chffi6llt )性功能障礙( Sexual Dysfunction )家庭作用改變( Altered Family Process )照顧者角色障礙( Caresiver Role Strain )有照顧者角色障礙的危險(xiǎn)( Risk for Caregiver Role Strain) 家庭作用改變：酗酒( Altered Family Process

8、 ： Alcoholism ) 父母角色沖突( Parental Role Conflict )性生活型態(tài)改變( Altered SexualityPatterns)(4) 賦予價(jià)值( Valuing )精神困擾( Spiritual Distress )增進(jìn)精神健康：潛能性( Potential for Enhance Spiritual Well-Belug)(5) 選擇( Choosing)個(gè)人應(yīng)對(duì)無(wú)效( Ineffctive Individual Coping )調(diào)節(jié)障礙( ImPaired Adjustment )防衛(wèi)性應(yīng)對(duì)( Defensive Coping )防衛(wèi)性否認(rèn)( Ine

9、ffective Denial )家庭應(yīng)對(duì)無(wú)效：失去能力( Ineffective Family Coping：Disabling )家庭應(yīng)對(duì)無(wú)效：妥協(xié)性 (Ineffectiv Family Coping：Compromised)家庭應(yīng)對(duì)：潛能性( Family CoPing ： Potential for Growth ) 社區(qū)應(yīng)對(duì)：潛能性( Potential for Enhanced Community CoPing ) 社區(qū)應(yīng)對(duì)無(wú)效( Ineffective Community Coping )遵守治療方案無(wú)效(個(gè)人的)( Ineffective Management of Ther

10、apeutic Regimen)( Individual )不合作(特定的)( Noncompliance )( Specitfy )遵守治療方案無(wú)效(家庭的)( Ineffective Management of Therapeutic Regimen：( ( Families )遵守治療方案無(wú)效(社區(qū)的)( Ineffective Managementof Thera peutic Regimen： Community)遵守治療方案有效(個(gè)人的)( Effective Management of Thera peutic Regimen ： Individual )抉擇沖突(特定的)( D

11、ecisional Conflict )( Specify )尋求健康行為(特定的)( Health Seeking Behaviors )( Specity )(6) 活動(dòng)( Moving)軀體移動(dòng)障礙( ImPaired Physical Mobility )有周圍血管神經(jīng)功能障礙的危險(xiǎn)( Risk for PeriPheralNeurovas cular Dysfunction )有圍手術(shù)期外傷的危險(xiǎn) (Risk for Perloperatlve Positioning Injury)疲乏( Fatigue )有活動(dòng)無(wú)耐力的危險(xiǎn)( Risk for Activity Intoleran

12、ce )睡眠狀態(tài)紊亂( SleepPattern Disturbance )娛樂活動(dòng)缺乏( Diversional Activity Deficit)持家能力障礙( Impaired Home Maintenance Management ) 保持健康的能力改變( Altered Health Maintenance ) 進(jìn)食自理缺陷( Feeding Self Care Deficit ) 吞咽障礙( Impaired Swallowing )母乳喂養(yǎng)無(wú)效( Ineffective Breast Feeding )母乳喂養(yǎng)中斷( Interrunted Breast1ceding )母乳喂養(yǎng)

13、有效( Effective Breast feeding)嬰兒吸吮方式無(wú)效( Ineffective Infant Feeding Pattern)沐浴衛(wèi)生自理缺陷( Bathing Hygiene Self Care Deficit)穿戴修飾自理障礙( Dressing Grooming Self Care Deficit)入廁自理缺陷( Toileting Self Care Deficit生長(zhǎng)發(fā)育改變( Altered Growth and Development )環(huán)境改變應(yīng)激綜合征( Relocation Stress Syndrome )有嬰幼兒行為紊亂的危險(xiǎn)( Risk for

14、Disorganized Infant Behavior )嬰幼兒行為紊亂( Disorganized Infant Behavior )增進(jìn)嬰幼兒行為(潛能性)( potential for Disorganized Infant ganlzedInfantkhavlor )(7) 感知( Perceiving )自我形象紊亂( Body Imagse Disturbance )自尊紊亂( SolfEsteem disturbance )長(zhǎng)期自我貶低( Chronic Low Self Esteem )情境性自我貶低( Situational Low Self Esteem)自我認(rèn)同紊亂(

15、Personal Identity disturbance)感知改變(特定的)(視、聽、運(yùn)動(dòng)、味、觸、嗅)(Sensory /PerceptualAlterations)( specify )( Visual ，Auditory ，Kinesthetlc ，Gustatory ，Taotile ，Olfactory )單側(cè)感覺喪失( Unilateral Neglect )絕望( Honelessness )無(wú)能為力( Powerlessness )(8) 認(rèn)知( Knowing)知識(shí)缺乏(特定的)( Knowledge Deficit )( Specify )定向力障礙( Impaired Environmental Interpretation)突發(fā)性意識(shí)模糊( Acute Confusion )漸進(jìn)性意識(shí)模糊( Chronic Confusion )思維過(guò)程改變( Altered Thought Processes )記憶力障礙( ImPaired Memoryy )(9) 感覺( Feeling )疼痛( Pain)慢性疼痛( Chronic Pain )功能障礙性悲哀( Dysfunctional Crievins )預(yù)感性悲哀( AnticiPatory Crieving)有暴力行為的危險(xiǎn)： 對(duì)自己或?qū)λ?(Risk for Violenc