新版216个护理诊断NANDA护理诊断

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北美护理协会 最新155个护理诊断

北美护理协会  最新155个护理诊断

北美护理协会最新155个护理诊断( 按 NANDA 分类法排列〉NANDA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155个护理诊断分列如下:一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection)121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险。

老年健康服务《电子教材:新版216个护理诊断NANDA护理诊断》

老年健康服务《电子教材:新版216个护理诊断NANDA护理诊断》

新版216个护理诊断NANDA护理诊断NANDA-I护理诊断2021~2021〔共216页〕1. 领域1:健康促进〔Health otion〕2. 类别1:健康意识〔Health Awareness〕3. 娱乐活动缺乏〔Deficient Diversional Activity〕〔00097〕4. 静态的生活方式〔Sedentary Lifestyle〕〔00168〕5. 类别2:健康管理〔Health Management〕6. 缺乏公共卫生〔Deficient Community Health〕〔00215〕7. 有危险倾向的健康行为〔Ris-muniation Status〕〔00186〕8. 防护无效〔Ineffective ent〕〔00078〕9. 有增强自我健康管理的愿望〔Readiness for EnhancedSelf-Health Management〕〔00162〕家庭执行治疗方案无效〔Ineffective Family Therabrane〕〔00045〕10. 有围手术期体位性损伤的危险〔Ris for e〕〔00156〕11. 有窒息的危险〔Ris for Suffocation〕〔00036〕12. 术后恢复延迟〔Delayed Surgical Recovery〕〔00100〕13. 有烫伤的危险〔Ris for Thermal Injury〕〔0022021组织完整性受损〔Ima〕〔00038〕14. 有血管受损的危险〔Ris for Vascular Trauma〕〔00213〕15. 类别3:暴力〔Violence〕16. 有虐待他人的危险〔Ris for Other-Directed Violence〕〔00138〕17. 有自虐的危险〔Ris for Self-Directed Violence〕〔00140〕18. 自残〔Self-Mutilation〕〔00151〕19. 有自残的危险〔Ris for Self-Mutilation〕〔00139〕20. 有自杀的危险〔Ris for Suicide〕〔00150〕21. 类别4:环境危害〔Environmental Haards〕22. 污染〔Contamination〕〔00181〕23. 有污染的危险〔Ris for Contamination〕〔00180〕24. 有中毒的危险〔Ris for oregulation〕25. 有体温平衡失调的危险〔Ris for Imbalanced BodyTemia〕〔00007〕26. 体温过低〔Hyia〕〔00006〕27. 体温调节无效〔Ineffective Thermoregulation〕〔00008〕28. 领域12:舒适〔Comfort〕29. 类别1:身体舒适〔fort〕30. 类别2:环境舒适〔Environmental Comfort〕31. 类别3:社交舒适〔Social Comfort〕32. 舒适的改变〔Imfort〕〔00214〕33. 有增加舒适的愿望〔Readiness for EnhancedComfort〕〔00183〕34. 恶心〔Nausea〕〔00134〕35. 急性疼痛〔Acute ent〕36. 类别1:生长〔Growth〕37. 有生长不成比例的危险〔Ris for Disent〕38. 生长发育缓慢〔Delayed Growth and Develoent〕〔00112〕39. 一、新增诊断〔16项〕:40. 领域1:健康促进〔Health otion〕41. 类别2:健康管理〔Health Management〕42. 缺乏公共卫生〔Deficient Community Health〕〔00215〕43. 领域2:营养〔Nutrition〕44. 类别1:摄入〔Ingestion〕45. 母乳缺乏〔Insufficient Breast Mil〕〔00216〕46. 类别4:代谢〔Metabolism〕47. 有新生儿黄疸的危险〔Ris for Neonatal Jaundice〕〔00230〕48. 领域4:活动∕休息〔Activit y∕Rest〕49. 类别4:心血管/肺部反响〔Cardiovascular/onary Res50. 有慢性低自尊的危险〔Ris for Chronic LowSelf-Esteem〕〔00224〕51. 领域7:角色关系〔Role Relationshiance〕52. 无效的关系〔Ineffective Relationshial Injury〕〔0022021类别5:防御过程〔Defensive fort〕〔00214〕53. 有感染的危险〔Ris for Infection〕〔00004〕54. 新生儿黄疸〔Neonatal Jaundice〕〔00194〕55. 恶心〔Nausea〕〔00134〕56. 无能为力〔ent〕〔00162〕有皮肤完整性受损的危险〔Ris for Immunication〕57.感觉知觉紊乱〔特定的:视觉、听觉、方位感、味觉、触觉、嗅觉〕〔Disturbed Sensory Perception〕〔00122〕。

NANDA确定的128个护理诊断

NANDA确定的128个护理诊断

NANDA确定的128个护理诊断NANDA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个护理诊断分列如下: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 Nutrition: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)便秘(Constipation)感知性便秘(Perceived Consttipation)结肠性便秘(Colonic Constipation)腹泻(Diarrhea)大便失禁(Bowel Inconttinence)排尿异常(Altered Urinary Elimination)压迫性尿失禁(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,Peripheral))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。

新版216个护理诊断NANDA护理诊断

新版216个护理诊断NANDA护理诊断

新版216个护理诊断NANDA护理诊断NANDA-I护理诊断2012~2014(共216页)1. 领域1:健康促进(Health Promotion)2. 类别1:健康意识(Health Awareness)3. 娱乐活动缺乏(Deficient Diversional Activity)(00097)4. 静态的生活方式(Sedentary Lifestyle)(00168)5. 类别2:健康管理(Health Management)6. 缺乏公共卫生(Deficient Community Health)(00215)7. 有危险倾向的健康行为(Risk-Prone Health Behavior)(00188)8. 健康维持无效(Ineffective Health Maintenance)(00099)9. 有增强免疫状态的愿望(Readiness for Enhanced Immunization Status)(00186)10. 防护无效(Ineffective Protection)(00043)11. 自我健康维持无效(Ineffective Self-Health Management)(00078)12. 有增强自我健康管理的愿望(Readiness for Enhanced Self-HealthManagement)(00162)家庭执行治疗方案无效(Ineffective FamilyTherapeutic Regimen Management)(00080)13. 领域2:营养(Nutrition)14. 类别1:摄入(Ingestion)15. 母乳不足(Insufficient Breast Milk)(00216)16. 婴儿喂养无效(Ineffective Infant Feeding Pattern)(00107)17. 营养失调:低于机体需要量(Imbalanced Nutrition:Less Than BodyRequirements)(00002)营养失调:高于机体需要量(Imbalanced Nutrition:More Than Body Requirements)(00001)有增强营养的愿望(Readiness for Enhanced Nutrition)(00163)18. 有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition:MoreThan Body Requirements)(00003)19. 吞咽能力受损(Impaired Swallowing)(00103)20. 类别2:消化(Digestion)21. 类别3:吸收(Absorption)22. 类别4:代谢(Metabolism)23. 有血糖不稳定的危险(Risk for Unstable Blood Glucose Level)(00179)24. 新生儿黄疸(Neonatal Jaundice)(00194)25. 有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)26. 有肝功能受损的危险(Risk for Impaired Liver Function)(00178)27. 类别5:水化28. 有电解质失衡的危险(Risk for Electrolyte Imbalance)(00195)29. 有维持体液平衡的愿望(Readiness for Enhanced Fluid Balance)(00160)30. 体液不足(Deficient Fluid Volume)(00027)31. 体液过多(Excess Fluid Volume)(00026)32. 有体液不足的危险(Risk for Deficient Fluid Volume)(00028)33. 有体液失衡的危险(Risk for Imbalanced Fluid Volume)(00025)34. 领域3:排泄(Elimination and Exchange)35. 类别1:排尿功能(Urinary Function)36. 功能性尿失禁(Functional Urinary Incontinence)(00020)37. 充溢性尿失禁(Overflow Urinary Incontinence)(00176)38. 反射性尿失禁(Reflex Urinary Incontinence)(00018)39. 压力性尿失禁(Stress Urinary Incontinence)(00017)40. 急迫性尿失禁(Urge Urinary Incontinence)(00019)41. 有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)(00022)42. 排尿形态改变(Impaired Urinary Elimination)(00016)43. 有排尿形态恢复正常的愿望(Readiness for Enhanced Urinary Elimination)(00166)尿潴留(Urinary Retention)(00023)44. 类别2:胃肠功能(Gastrointestinal Function)45. 便秘(Constipation)(00011)46. 感知性便秘(Perceived Constipation)(00012)47. 有便秘的危险(Risk for Constipation)(00015)48. 腹泻(Diarrhea)(00013)49. 胃肠动力紊乱(Dysfunctional Gastrointestinal Motility)(00196)50. 有胃肠动力紊乱的危险(Risk for Dysfunctional Gastrointestinal Motility)(00197)排便失禁(Bowel Incontinence)(00014)51. 类别3:皮肤功能(Integumentary Function)52. 类别4:呼吸功能(Respiratory Function)53. 气体交换受损(Impaired Gas Exchange)(00030)54. 领域4:活动∕休息(Activit y∕Rest)55. 类别1:睡眠/休息(Sleep/Rest)56. 失眠(Insomnia)(00095)57. 睡眠剥夺(Sleep Deprivation)(00096)58. 有睡眠形态增进的愿望(Readiness for Enhanced Sleep)(00165)59. 睡眠形态紊乱(Disturbed Sleep Pattern)(00198)60. 类别2:活动/运动(Activity/Exercise)61. 有废用综合征的危险(Risk for Disuse Syndrome)(00040)62. 床上活动障碍(Impaired Bed Mobility)(00091)63. 躯体移动障碍(Impaired Physical Mobility)(00085)64. 借助轮椅活动障碍(Impaired Wheelchair Mobility)(00089)65. 移位能力障碍(Impaired Transfer Ability)(00090)66. 行走障碍(Impaired Walking)(00088)67. 类别3:能量平衡(Energy Balance)68. 能量场紊乱(Disturbed Energy Field)(00050)69. 疲乏(Fatigue)(00093)70. 漫游(Wandering)(00154)71. 类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)72. 活动无耐力(Activity Intolerance)(00092)73. 有活动无耐力的危险(Risk for Activity Intolerance)(00094)74. 低效性呼吸形态(Ineffective Breathing Pattern)(00032)75. 心输出量减少(Decreased Cardiac Output)(00029)76. 有胃肠灌注不足的危险(Risk for Ineffective Gastrointestinal Perfusion)(00202)77. 有肾脏灌注不足的危险(Risk for Ineffective Renal Perfusion)(00203)78. 不能维持自主呼吸(Impaired Spontaneous Ventilation)(00033)79. 周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)80. 有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)(00200)有脑组织灌注不足的危险(Risk for Ineffective Cerebral Tissue Perfusion)(00201)有周围组织灌注不足的危险(Risk for IneffectivePeripheral Tissue Perfusion)(00228)呼吸机依赖(Dysfunctional Ventilatory Weaning Response)(00034)类别5:自我照顾(Self-Care)81. 持家能力障碍(Impaired Home Maintenance)(00098)82. 有增强自理的愿望(Readiness for Enhanced Self-Care)(00182)83. 沐浴自理缺陷(Bathing Self-Care Deficit)(00108)84. 穿衣自理缺陷(Dressing Self-Care Deficit)(00109)85. 进食自理缺陷(Feeding Self-Care Deficit)(00102)86. 如厕自理缺陷(Toileting Self-Care Deficit)(00110)87. 忽视自我健康管理(Self-Neglect)(00193)88. 领域5:知觉∕认知(Perception∕Cognition)89. 类别1:注意力(Attention)90. 忽视单侧身体(Unilateral Neglect)(00123)91. 类别2:定向力(Orientation)92. 环境解析障碍综合征(Impaired Environmental Interpretation Syndrome)(00127)类别3:感觉/知觉(Sensation/Perception)93. 类别4:认知(Cognition)94. 急性意识障碍(Acute Confusion)(00128)95. 慢性意识障碍(Chronic Confusion)(00129)96. 有急性意识障碍的危险(Risk for Acute Confusion)(00173)97. 自我控制无效(Ineffective Impulse Control)(00222)98. 知识缺乏(Deficient Knowledge)(00126)99. 有增加知识的愿望(Readiness for Enhanced Knowledge)(00161)100. 记忆受损(Impaired Memory)(00131)101. 类别5:沟通(Communication)102. 有加强沟通的愿望(Readiness for Enhanced Communication)(00157)103. 语言沟通障碍(Impaired Verbal Communication)(00051)104. 领域6:自我知觉(Self-Perception)105. 类别1:自我概念(Self-Concept)106. 绝望(Hopelessness)(00124)107. 有危及个人尊严的危险(Risk for Compromised Human Dignity)(00174)108. 有孤独的危险(Risk for Loneliness)(00054)109. 自我认同紊乱(Disturbed Personal Identity)(00121)110. 有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)111. 有增强自我概念的愿望(Readiness for Enhanced Self-Concept)(00167)类别2:自尊Self-Esteem112. 慢性低自尊(Chronic Low Self-Esteem)(00119)113. 情境性低自尊(Situational Low Self-Esteem)(00120)114. 有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)115. 有情境性低自尊的危险(Risk for Situational Low Self-Esteem)(00153)类别3:自我形象(Body Image)116. 自我形象紊乱(Disturbed Body Image)(00118)117. 领域7:角色关系(Role Relationships)118. 类别1:照顾者角色(Caregiving Roles)119. 母乳喂养无效(Ineffective Breastfeeding)(00104)120. 母乳喂养中断(Interrupted Breastfeeding)(00105)121. 有增强母乳喂养的愿望(Readiness for Enhanced Breastfeeding)(00106)122. 照顾者角色紧张(Caregiver Role Strain)(00061)123. 有照顾者角色紧张的危险(Risk for Caregiver Role Strain)(00062)124. 抚养障碍(Impaired Parenting)(00056)125. 有增进抚养能力的愿望(Readiness for Enhanced Parenting)(00164)126. 有抚养障碍的危险(Risk for Impaired Parenting)(00057)127. 类别2:家庭关系(Family Relationships)128. 有依附关系障碍的危险(Risk for Impaired Attachment)(00058)129. 家庭运作紊乱(Dysfunctional Family Processes)(00063)130. 家庭运作中断(Interrupted Family Processes)(00060)131. 有家庭运作稳定的愿望(Readiness for Enhanced Family Processes)(00159)类别3:角色表现(Role Performance)132. 无效的关系(Ineffective Relationship)(00223)133. 有增进关系的愿望(Readiness for Enhanced Relationship)(00207)134. 有关系无效的危险(Risk for Ineffective Relationship)(00229)135. 父母角色冲突(Parental Role Conflict)(00064)136. 角色紊乱(Ineffective Role Performance)(00055)137. 社交障碍(Impaired Social Interaction)(00052)138. 领域8:性学(Sexuality)139. 类别1:性别认同(Sexual Identity)140. 类别2:性功能(Sexual Function)141. 性功能障碍(Sexual Dysfunction)(00059)142. 性生活形态改变(Ineffective Sexuality Pattern)(00065)143. 类别3:生殖(Reproduction)144. 分娩过程无效(Ineffective Childbearing Process)(00221)145. 有增进分娩过程的愿望(Readiness for Enhanced Childbearing Process)(00208)有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)有母体-胎儿受干扰的危险(Risk for Disturbed Maternal-FetalDyad)(00209)146. 领域9:调适∕压力耐受(Coping∕Stress Tolerance)147. 类别1:创伤后反应(Post-Trauma Responses)148. 创伤后综合征(Post-Trauma Syndrome)(00141)149. 有创伤后综合征的危险(Risk for Post-Trauma Syndrome)(00145)150. 强暴创伤综合征(Rape-Trauma Syndrome)(00142)151. 迁移应激综合征(Relocation Stress Syndrome)(00114)152. 有迁移应激综合征的危险(Risk for Relocation Stress Syndrome)(00149)类别2:应对反应(Coping Responses)153. 活动计划无效(Ineffective Activity Planning)(00199)154. 有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)155. 焦虑(Anxiety)(00146)156. 防御性应对(Defensive Coping)(00071)157. 应对无效(Ineffective Coping)(00069)158. 有增强应对的愿望(Readiness for Enhanced Coping)(00158)159. 社区应对无效(Ineffective Community Coping)(00077)160. 社区有增强应对的愿望(Readiness for Enhanced Community Coping)(00076)161. 家庭妥协性应对(Compromised Family Coping)(00074)162. 家庭应对缺陷(Disabled Family Coping)(00073)163. 家庭有增强应对的愿望(Readiness for Enhanced Family Coping)(00075)164. 死亡焦虑(Death Anxiety)(00147)165. 无效性否认(Ineffective Denial)(00072)166. 成人生存功能衰退(Adult Failure to Thrive)(00101)167. 恐惧(Fear)(00148)168. 悲痛(Grieving)(00136)169. 复杂性哀伤(Complicated Grieving)(00135)170. 有复杂性哀伤的危险(Risk for Complicated Grieving)(00172)171. 有增强能力的愿望(Readiness for Enhanced Power)(00187)172. 无能为力(Powerlessness)(00125)173. 有无能为力的危险(Risk for Powerlessness)(00152)174. 个人复原能力受损(Impaired Individual Resilience)(00210)175. 有增强复原能力的愿望(Readiness for Enhanced Resilience)(00212)176. 有危及复原的危险(Risk for Compromised Resilience)(00211)177. 长期悲伤(Chronic Sorrow)(00137)178. 超负荷压力(Stress Overload)(00177)179. 类别3:神经行为压力(Neurobehavioral Stress)180. 自主性反射障碍(Autonomic Dysreflexia)(00009)181. 有自主反射障碍的危险(Risk for Autonomic Dysreflexia)(00010)182. 婴儿行为紊乱(Disorganized Infant Behavior)(00116)183. 婴儿有行为能力增强的潜力(Readiness for Enhanced Organized Infant Behavior)(00117)有婴儿行为紊乱的危险(Risk for Disorganized Infant Behavior)(00115)184. 颅内调试能力下降(Decreased Intracranial Adaptive Capacity)(00049)185. 领域10:生命原则(Life Principles)186. 类别1:价值观(Values)187. 有增进希望的愿望(Readiness for Enhanced Hope)(00185)188. 类别2:信念(Beliefs)189. 有促进精神健康增强的愿望(Readiness for Enhanced Spiritual Well-Being)(00068)190. 类别3:价值/信念/行动一致(Value/Belief/Action Congruence)191. 有增强决策的愿望(Readiness for Enhanced Decision-Making)(00184)192. 决策冲突(Decisional Conflict)(00083)193. 道德困扰(Moral Distress)(00175)194. 不合作(Noncompliance)(00079)195. 虔信受损(Impaired Religiosity)(00169)196. 有增进虔信的愿望(Readiness for Enhanced Religiosity)(00171)197. 有虔信受损的危险(Risk for Impaired Religiosity)(00170)198. 精神困扰(Spiritual Distress)(00066)199. 有精神困扰的危险(Risk for Spiritual Distress)(00067)200. 领域11:安全∕保护(Safety∕Protection)201. 类别1:感染(Infection)202. 有感染的危险(Risk for Infection)(00004)203. 类别2:身体伤害(Physical Injury)204. 清理呼吸道无效(Ineffective Airway Clearance)(00031)205. 有误吸的危险(Risk for Aspiration)(00039)206. 有出血的危险(Risk for Bleeding)(00206)207. 牙齿受损(Impaired Dentition)(00048)208. 有干眼症的危险(Risk for Dry Eye)(00219)209. 有跌倒的危险(Risk for Falls)(00155)210. 有受伤的危险(Risk for Injury)(00035)211. 口腔黏膜受损(Impaired Oral Mucous Membrane)(00045)212. 有围手术期体位性损伤的危险(Risk for Perioperative Positioning Injury)(00087)213. 有周围神经血管功能障碍的危险(Risk for Peripheral Neurovascular Dysfunction)(00086)有休克的危险(Risk for Shock)(00205)214. 皮肤完整性受损(Impaired Skin Integrity)(00046)215. 有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)216. 有婴儿猝死综合征的危险(Risk for Sudden Infant Death Syndrome)(00156)217. 有窒息的危险(Risk for Suffocation)(00036)218. 术后恢复延迟(Delayed Surgical Recovery)(00100)219. 有烫伤的危险(Risk for Thermal Injury)(00220)220. 组织完整性受损(Impaired Tissue Integrity)(00044)221. 有外伤的危险(Risk for Trauma)(00038)222. 有血管受损的危险(Risk for Vascular Trauma)(00213)223. 类别3:暴力(Violence)224. 有虐待他人的危险(Risk for Other-Directed Violence)(00138)225. 有自虐的危险(Risk for Self-Directed Violence)(00140)226. 自残(Self-Mutilation)(00151)227. 有自残的危险(Risk for Self-Mutilation)(00139)228. 有自杀的危险(Risk for Suicide)(00150)229. 类别4:环境危害(Environmental Hazards)230. 污染(Contamination)(00181)231. 有污染的危险(Risk for Contamination)(00180)232. 有中毒的危险(Risk for Poisoning)(00037)233. 类别5:防御过程(Defensive Processes)234. 有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)乳胶过敏反应(Latex Allergy Response)(00041)235. 有过敏反应的危险(Risk for Allergy Response)(00217)236. 有乳胶过敏反应的危险(Risk for Latex Allergy Response)(00042)237. 类别6:体温调节(Thermoregulation)238. 有体温平衡失调的危险(Risk for Imbalanced Body Temperature)(00005)239. 体温过高(Hyperthermia)(00007)240. 体温过低(Hypothermia)(00006)241. 体温调节无效(Ineffective Thermoregulation)(00008)242. 领域12:舒适(Comfort)243. 类别1:身体舒适(Physical Comfort)244. 类别2:环境舒适(Environmental Comfort)245. 类别3:社交舒适(Social Comfort)246. 舒适的改变(Impaired Comfort)(00214)247. 有增加舒适的愿望(Readiness for Enhanced Comfort)(00183)248. 恶心(Nausea)(00134)249. 急性疼痛(Acute Pain)(00132)250. 慢性疼痛(Chronic Pain)(00133)251. 社交隔离(Social Isolation)(00053)252. 领域13:生长∕发育(Growth∕Development)253. 类别1:生长(Growth)254. 有生长不成比例的危险(Risk for Disproportionate Growth)(00113)255. 类别2:发育(Development)256. 生长发育迟缓(Delayed Growth and Development)(00111)257. 有发育迟缓的危险(Risk for Delayed Development)(00112)258. 一、新增诊断(16项):259. 领域1:健康促进(Health Promotion)260. 类别2:健康管理(Health Management)261. 缺乏公共卫生(Deficient Community Health)(00215)262. 领域2:营养(Nutrition)263. 类别1:摄入(Ingestion)264. 母乳不足(Insufficient Breast Milk)(00216)265. 类别4:代谢(Metabolism)266. 有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)267. 领域4:活动∕休息(Activit y∕Rest)268. 类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)269. 有周围组织灌注不足的危险(Risk for Ineffective Peripheral Tissue Perfusion)(00228)领域5:知觉∕认知(Perception∕Cognition)270. 类别3:感觉/知觉(Sensation/Perception)271. 类别4:认知(Cognition)272. 自我控制无效(Ineffective Impulse Control)(00222)273. 领域6:自我知觉(Self-Perception)274. 类别1:自我概念(Self-Concept)275. 有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)类别2:自尊Self-Esteem276. 有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)277. 领域7:角色关系(Role Relationships)278. 类别3:角色表现(Role Performance)279. 无效的关系(Ineffective Relationship)(00223)280. 有关系无效的危险(Risk for Ineffective Relationship)(00229)281. 领域8:性学(Sexuality)282. 类别3:生殖(Reproduction)283. 分娩过程无效(Ineffective Childbearing Process)(00221)284. 有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)285. 领域9:调适∕压力耐受(Coping∕Stress Tolerance)286. 类别2:应对反应(Coping Responses)287. 有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)288. 领域11:安全∕保护(Safety∕Protection)289. 类别2:身体伤害(Physical Injury)290. 有干眼症的危险(Risk for Dry Eye)(00219)291. 有烫伤的危险(Risk for Thermal Injury)(00220)292. 类别5:防御过程(Defensive Processes)293. 有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)有过敏反应的危险(Risk for Allergy Response)(00217)294. 二、修改诊断(11项):295. 有增强母乳喂养的愿望(Readiness for Enhanced Breastfeeding)(00106)296. 低效性呼吸形态(Ineffective Breathing Pattern)(00032)297. 舒适的改变(Impaired Comfort)(00214)298. 有感染的危险(Risk for Infection)(00004)299. 新生儿黄疸(Neonatal Jaundice)(00194)300. 恶心(Nausea)(00134)301. 无能为力(Powerlessness)(00125)302. 有无能为力的危险(Risk for Powerlessness)(00152)303. 有增强自我健康管理的愿望(Readiness for Enhanced Self-Health Management)(00162)有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)304. 周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)305. 三、退出诊断(1项):306. 领域5:知觉∕认知(Perception∕Cognition)307. 类别5:沟通(Communication)308.感觉知觉紊乱(特定的:视觉、听觉、方位感、味觉、触觉、嗅觉)(Disturbed Sensory Perception)(00122)。

新版216个护理诊断

新版216个护理诊断

新版216个护理诊断护士出国- NANDA(北美护理诊断协会)128个护理诊断NANDA(北美护理诊断协会)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个护理诊断分列如下:(1)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 Nutrition: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)便秘(Constipation)感知性便秘(Perceived Consttipation)结肠性便秘(Colonic Constipation)腹泻(Diarrhea)大便失禁(Bowel Inconttinence)排尿异常(Altered Urinary Elimination)压迫性尿失禁(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(T otal Incontlnencd尿储留(Urinary Retentron)组织灌注量改变(肾、脑、心肺、胃肠、周围血管)(Altered TissuePerfuslorl(Renal,Cereral,Cardlopulmonary Gastrolntestlnal,Peripheral)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。

北美护理协会 最新155个护理诊断

北美护理协会  最新155个护理诊断

北美护理协会最新155个护理诊断( 按 NANDA 分类法排列〉NANDA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155个护理诊断分列如下:一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection)121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险。

NANDA201项护理诊断(2009-2011)与155项护理诊断

NANDA201项护理诊断(2009-2011)与155项护理诊断

155 项护理诊断 -览表 (2001~2002)( 按 NANDA 分类法Ⅱ排列〉一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection) 121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险201项护理诊断一览表(2009~2011)领域1:健康促进(Health Promotion)1.健康维护能力低下(Ineffective Health Maintenance)2.自我健康管理无效(Ineffective Self Health Management)3.持家能力障碍(Impaired Home Maintenance)4.有免疫状态改善的趋势(Readiness for Enhanced Immunization Status)5.忽视自我健康管理(Self Neglect)6.有营养改善的趋势(Readiness for Enhanced Nutrition)7.家庭执行治疗方案无效Ineffective Family Therapeutic Regimen Management)8.有自我健康管理改善的趋势(Readiness for Enhanced Self Health Management)领域2:营养(Nutrition)9.无效性婴儿喂养型态(Ineffective Infant Feeding Pattern)10.营养失调:低于机体需要量(Imbalanced Nutrition: Less Than Body Requirements)11.营养失调:高于机体需要量(Imbalanced Nutrition: More Than Body Requirements)12.有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition: More Than Body Requirements)13.吞咽障碍(Impaired Swallowing)14.有血糖不稳定的危险(Risk for Unstable Glucose Level)15.新生儿黄疸(Neonatal Jaundice)16.有肝功能受损的危险(Risk for Impaired Liver Function)17.有电解质失衡的危险(Risk for Electrolyte Imbalance)18.有体液平衡改善的趋势(Readiness for Enhanced Fluid Balance)19.体液不足(Deficient Fluid Volume)20.体液过多(Excess Fluid Volume)21.有体液不足的危险(Risk for Deficient Fluid Volume)22.有体液失衡的危险(Risk for Imbalanced Fluid Volume)领域3:排泄(Elimination and Exchange)23.排尿障碍(Impaired Urinary Elimination)24.功能性尿失禁(Functional Urinary Incontinence)25.溢出性尿失禁(Overflow Urinary Incontinence)26.反射性尿失禁(Reflex Urinary Incontinence)27.压力性尿失禁(Stress Urinary Incontinence)28.急迫性尿失禁(Urge Urinary Incontinence)29.有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)30.尿潴留(Urinary Retention)31.有排尿功能改善的趋势(Readiness for Enhanced Urinary Elimination)32.排便失禁(Bowel Incontinence)33.便秘(Constipation)34.感知性便秘(Perceived Constipation)35.有便秘的危险(Risk for Constipation)36.腹泻(Diarrhea)37.胃肠动力失调(Dysfunctional Gastrointestinal Motility)38.有胃肠动力失调的危险(Risk for Dysfunctional Gastrointestinal Motility)39.气体交换障碍(Impaired Gas Exchange)领域4:活动/休息(Activity/Rest)40失眠(Insomnia)41.睡眠型态紊乱(Disturbed Sleep Pattern)42.睡眠剥夺(Sleep Deprivation)43.有睡眠改善的趋势(Readiness for Enhanced Sleep)44.有废用综合征的危险(Risk for Disuse Syndrome)45.缺乏娱乐活动(Deficient Diversional Activity)46.久坐的生活方式(Sedentary Lifestyle)47.床上活动障碍(Impaired Bed Mobility)48.躯体活动障碍(Impaired Physical Mobility)49.借助轮椅活动障碍(Impaired wheelchair Mobility)50.移动能力障碍(Impaired Transfer Ability)51.行走障碍(Impaired Walking)52.术后康复迟缓(Delayed Surgical Recovery)53.能量场紊乱(Disturbed Energy Field)54.疲乏(Fatigue)55.活动无耐力(Activity Intolerance)56.有活动无耐力的危险(Risk for Activity Intolerance)57.有出血的危险(Risk for Bleeding)58.低效性呼吸型态(Ineffective Breathing Pattern)59.心输出量减少(Decreased Cardiac Output)60.外周组织灌注无效(Ineffective Peripheral Tissue Perfusion)61.有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)62.有脑组织灌注无效的危险(Risk for Ineffective Cerebral Tissue Perfusion)63.有胃肠道灌注无效的危险(Risk for Ineffective Gastrointestinal Tissue Perfusion)64.有肾脏灌注无效的危险(Risk for Ineffective Renal Perfusion)65.有休克的危险(Risk for Shock)66.自主呼吸障碍(Impaired Spontaneous Ventilation)67.呼吸机依赖(Dysfunctional Ventilatory Weaning Response)68.有自理能力增强的趋势(Readiness for Enhanced Self-Care)69.沐浴/卫生自理缺陷(Bathing/Hygiene Self-Care Deficit))70.穿着/修饰自理缺陷(Dressing/grooming Self-Care Deficit)71.进食自理缺陷(Feeding Self-Care Deficit)72.如厕自理缺陷(Toileting Self-Care Deficit)领域5:感知/认知(Perception/Cognition)73单侧身体忽视(Unilateral Neglect)74.环境认知障碍综合征(Impaired Environmental Interpretation Syndrome)75.漫游状态(Wandering)76.感知觉紊乱(具体说明:视觉、听觉、方位感、味觉、触觉、嗅觉)(Disturbed Sensory Perception〔Specify:Visual,Auditory,Kinesthetic,Gustatory,Tactile,Olfactory)77.急性意识障碍(Acute Confusion)78.慢性意识障碍(Chronic Confusion)79.有急性意识障碍的危险(Risk for Acute Confusion)80.知识缺乏(Deficient Knowledge)81.有知识增进的趋势(Readiness for Enhanced Knowledge)82.记忆功能障碍(Impaired Memory)83.有决策能力增强的趋势(Readiness for Enhanced Decision-Making)84.活动计划无效(Ineffective Activity Planning)85.语言沟通障碍(Impaired Verbal Communication)86.有沟通增进的趋势(Readiness for Enhanced Communication)领域6:自我感知(Self-Perception)87.有个人尊严受损的危险(Risk for Compromised Human Dignity)88.无望感(Hopelessness)89.自我认同紊乱(Disturbed Personal Identity)90.有孤独的危险(Risk for Loneliness)91.有能力增强的趋势(Readiness for Enhanced Power)92.无能为力感(Powerlessness)93.有无能为力感的危险(Risk for Powerlessness)94.有自我概念改善的趋势(Readiness for Enhanced Self-Concept)95.情境性低自尊(Situational low Self-Esteem)96.长期性低自尊(Chronic Low Self-Esteem)97.有情境性低自尊的危险(Risk for Situational Low Self-Esteem)98.体像紊乱(Disturbed Body Image)领域7:角色关系(Role Relationships)99.照顾者角色紧张(Caregiver Role Strain)100.有照顾者角色紧张的危险(Risk for Caregiver Role Strain)101.养育功能障碍(Impaired Parenting)102.有养育功能改善的趋势(Readiness for Enhanced Parenting)103.有养育功能障碍的危险(Risk for Impaired Parenting)104.有依附关系受损的危险(Risk for Impaired Parent/Infant/Child Attachment)105.家庭运作过程失常(Dysfunctional Family Processes)106.家庭运作过程改变(Interrupted Family Processes)107.有家庭运作过程改善的趋势(Readiness for Enhanced Family Processes)108.母乳喂养有效(Effective Breastfeeding)109.母乳喂养无效(Ineffective Breastfeeding)110.母乳喂养中断(Interrupted Breastfeeding)111.父母角色冲突(Parental Role Conflict)112.有关系改善的趋势(Readiness for Enhanced Relationship)113.无效性角色行为(Ineffective Role Performance)114.社会交往障碍(Impaired Social Interaction)领域8:性(Sexuality)115.性功能障碍(Sexual Dysfunction)116.性生活型态无效(Ineffective Sexuality Patterns)117.有生育进程改善的趋势(Readiness for Enhanced Childbearing Process)118.有母体与胎儿双方受干扰的危险(Risk for Disturbed Maternal/Fetal Dyad)领域9:应对/应激耐受性(Coping/ Stress Tolerance)119.创伤后综合征(Post Trauma Syndrome)120.有创伤后综合征的危险(Risk for Post Trauma Syndrome)121.强暴创伤综合征(Rape-Trauma Syndrome)122.迁移应激综合征(Relocation Stress Syndrome)123.有迁移应激综合征的危险(Risk for Relocation Stress Syndrome)124.焦虑(Anxiety)125.对死亡的焦虑(Death Anxiety)126.有威胁健康的行为(Risk-Prone Health Behavior)127.妥协性家庭应对(Compromised Family Coping)128.无能性家庭应对(Disabled Family Coping)129.防卫性应对(Defensive Coping)130.应对无效(Ineffective Coping)131.社区应对无效(Ineffective Community Coping)132.有应对增强的趋势(Readiness for Enhanced Coping)133.有社区应对增强的趋势(Readiness for Enhanced Community Coping)134.有家庭应对增强的趋势(Readiness for Enhanced Family Coping)135.无效性否认(Ineffective Denial)136.恐惧(Fear)137.悲伤(Grieving)138.复杂性悲伤(Complicated Grieving)139.有复杂性悲伤的危险(Risk for Complicated Grieving)140.个人恢复能力障碍(Impaired Individual Resilience)141.有恢复能力受损的危险(Risk for Compromised Resilience)142.有恢复能力增强的趋势(Readiness for Enhanced Resilience)143.持续性悲伤(Chronic Sorrow)144.压力负荷过重(Stress Overload)145.自主性反射失调(Autonomic Dysreflexia)146.有自主性反射失调的危险(Risk for Autonomic Dysreflexia)147.婴儿行为紊乱(Disorganized Infant Behavior)148.有婴儿行为紊乱的危险(Risk for Disorganized Infant Behavior)149.有婴儿行为调节改善的趋势(Readiness for Enhanced Organized Infant Behavior)150.颅内调适能力降低(Decreased Intracranial Adaptive Capacity)领域10:生活准则(Life Principles)151.有希望增强的趋势(Readiness for Enhanced Hope)152.有精神安适增进的趋势(Readiness for Enhanced Spiritual Well-being)153.抉择冲突(Decisional Conflict)154.道德困扰(Moral Distress)155.不依从行为(Noncompliance)156.宗教信仰减弱(Impaired Religiosity)157.有宗教信仰增强的趋势(Readiness for Enhanced Religiosity)158.有宗教信仰减弱的危险(Risk for Impaired Religiosity)159.精神困扰(Spiritual Distress)160.有精神困扰的危险(Risk for Spiritual Distress)领域11:安全/防护(Safety/Protection)161.有感染的危险(Risk for Infect ion)162.清理呼吸道无效(Ineffective Airway Clearance)163.有误吸的危险(Risk for Aspiration)164.有婴儿猝死综合症的危险(Risk for Sudden Infant Death Syndrome)165.牙齿受损(Impaired Dentition)166.有跌倒的危险(Risk for Falls)167.有受伤害的危险(Risk for Injury)168.有手术期体位性损伤的危险(Risk for Perioperative-Positioning Injury)169.口腔黏膜受损(Impaired Oral Mucous Membrane)170.有外周神经血管功能障碍的危险(Risk for Peripheral Neurovascular Dysfunction)171.防护能力低下(Ineffective Protection)172.皮肤完整性受损(Impaired Skin Integrity)173.有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)174.有窒息的危险(Risk for Suffocation)175.组织完整性受损(Impaired Tissue Integrity)176.有外伤的危险(Risk for Trauma)177.有血管损伤的危险(Risk for Vascular Trauma)178.自伤(Self-Mutilation)179.有自伤的危险(Risk for Self-Mutilation)180.有自杀的危险(Risk for Suicide)181.有对他人施行暴力的危险(Risk for Other-Directed Violence)182.有对自己施行暴力的危险(Risk for Self-Directed Violence)183.受污染(Contamination)184.有受污染的危险(Risk for Contamination)185.有中毒的危险(Risk for Poisoning)186.乳胶过敏反应(Latex Allergy Response)187.有乳胶过敏反应的危险(Risk for Latex Allergy Response)188.有体温失调的危险(Risk for Imbalanced Body Temperature)189.体温过高(Hyperthermia)190.体温过低(Hypothermia)191.体温调节无效(Ineffective Thermoregulation)领域12:舒适(Comfort)192.有舒适增进的趋势(Readiness for Enhanced Comfort)193.舒适度减弱(Impaired Comfort)194.恶心(Nausea)195.急性疼痛(Acute Pain)196.慢性疼痛(Chronic Pain)197.社交孤立(Social Isolation)领域13:生长/发展(Growth/Development)198.成人身心功能衰退(Adult Failure to Thrive)199.生长发展迟缓(Delayed Growth and Development)200.有发展迟缓的危险(Risk for Delayed Development)201.有生长比例失调的危险(Risk for Disproportionate Growth)。

NANDA护理诊断一览表(2018-2020)中英文对照版

NANDA护理诊断一览表(2018-2020)中英文对照版

NANDA 护理诊断一览表(2018-2020)领域 1:健康促进(Health Promotion)类别1:健康觉察(Health awareness)∙娱乐活动参与减少(Decreased diversional activity engagement)∙增进健康管理的准备度(Readiness for enhanced health literacy)∙久坐的生活方式(Sedentary lifestyle)类别2:健康管理(Health management)∙老年综合征(Frail elderly syndrome)∙有老年综合征的危险(Risk for frail elderly syndrome)∙缺乏社区保健(Deficient community health)∙风险倾向的健康行为(Risk-prone health behavior)∙健康维持无效(Ineffective health maintenance)∙健康管理无效(Ineffective Health Management)∙有健康管理改善的趋势(Readiness for Enhanced Health Management) ∙家庭健康管理无效(Ineffective Family Health Management)∙防护无效(Ineffective Protection)领域 2:营养(Nutrition)类别1:摄食(Ingestion)∙营养失调:低于机体需要量(Imbalanced nutrition: less than body requirements)∙有营养改善的趋势 (Readiness for enhanced nutrition)∙母乳泌乳不足(Insufficient breast milk production)∙母乳喂养无效(Ineffective breastfeeding)∙母乳喂养中断(Readiness for enhanced breastfeeding)∙有母乳喂养改善的趋势(Ineffective breastfeeding)∙青少年进食动力不足(Ineffective adolescent eating dynamics)∙儿童进食动力不足(Ineffective child eating dynamics)∙婴儿受哺养动力不足(Ineffective infant feeding dynamics)∙无效性婴儿喂养型态(Ineffective Infant Feeding Pattern)∙肥胖(Obesity)∙超重(Overweight)∙有超重的危险(Risk for overweight)∙吞咽障碍(Impaired Swallowing)类别2:消化(Digestion)类别3:吸收(Absorption)类别4:代谢(Metabolism)∙有血糖不稳定的危险(Risk for Unstable Blood Glucose Level)∙新生儿高胆红素血症 (Neonatal hyperbilirubinemia)∙有新生儿高胆红素血症的危险(Risk for neonatal hyperbilirubinemia) ∙有肝功能受损的危险(Risk for Impaired Liver Function)∙有电解质失衡的危险(Risk for Electrolyte Imbalance)类别5:水化(Hydration)∙有电解质失衡的危险(Risk for electrolyte imbalance)∙有体液失衡的危险(Risk for imbalanced fluid volume)∙体液不足(Deficient fluid volume)∙有体液不足的危险(Risk for deficient fluid volume)∙体液过多(Risk for deficient fluid volume)领域 3:排泄(Elimination and Exchange)类别1:泌尿功能(Urinary function)∙排尿障碍(Impaired Urinary Elimination)∙功能性尿失禁(Functional Urinary Incontinence)∙溢出性尿失禁(Overflow Urinary Incontinence)∙反射性尿失禁(Reflex Urinary Incontinence)∙压力性尿失禁(Stress Urinary Incontinence)∙急迫性尿失禁(Urge Urinary Incontinence)∙有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)∙尿潴留(Urinary Retention)类别2:胃肠功能(Gastrointestinal function)∙便秘(Constipation)∙有便秘的危险(Risk for Constipation)∙感知性便秘(Perceived Constipation)∙慢性功能性便秘(Chronic Functional Constipation)∙有慢性功能性便秘的危险(Risk for Chronic Functional Constipation) ∙腹泻(Diarrhea)∙胃肠动力失调(Dysfunctional Gastrointestinal Motility)∙有胃肠动力失调的危险(Risk for Dysfunctional Gastrointestinal Motility)∙排便失禁(Bowel Incontinence)类别3:皮肤功能(Integumentary function)类别4:呼吸功能( Respiratory function)∙气体交换受损(Impaired Gas Exchange)领域 4:活动/休息(Activity/Rest)类别1:睡眠/休息(Sleep/rest)∙失眠(Insomnia)∙睡眠剥夺(Sleep deprivation)∙有睡眠改善的趋势(Disturbed sleep pattern)∙睡眠型态紊乱(Disturbed sleep pattern)类别2:活动/运动(Activity/exercise)∙有失用综合征的危险(Risk for disuse syndrome)∙床上活动障碍(Impaired bed mobility)∙躯体活动障碍(Impaired bed mobility)∙借助轮椅活动障碍(Impaired wheelchair mobility)∙坐起障碍(Impaired sitting)∙站立障碍(Impaired standing)∙移动能力障碍(Impaired transfer ability)∙行走障碍(Impaired walking)类别3:能量平衡(Energy balance)∙能量失衡(Imbalanced energy field)∙疲乏(Fatigue)∙游走状态(Wandering)类别4:心血管/肺部反应(Cardiovascular/pulmonary responses)∙活动无耐力(Activity intolerance)∙有活动无耐力的危险(Risk for activity intolerance)∙低效性呼吸型态(Risk for activity intolerance)∙心输出量减少(Decreased cardiac output)∙有心输出量减少的危险(Risk for decreased cardiac output)∙自主呼吸障碍(Decreased cardiac output)∙潜在危险性血压不稳定(Risk for unstable blood pressure)∙有心脏组织灌注不足的危险(Risk for decreased cardiac tissue perfusion)∙有脑组织灌注无效的危险(Risk for ineffective cerebral tissue perfusion)∙外周组织灌注无效(Ineffective peripheral tissue perfusion)∙有外周组织灌注无效的危险(Risk for ineffective peripheral tissue perfusion)∙呼吸机依赖(Dysfunctional ventilatory weaning response)类别5:自我照顾(Self-care)∙持家能力障碍(Impaired home maintenance)∙沐浴自理缺陷(Bathing self-care deficit)∙穿着自理缺陷(Dressing self-care deficit)∙进食自理陷(Feeding self-care deficit)∙如厕自理缺陷(Toileting self-care deficit)∙有自理能力改善的趋势(Readiness for enhanced self-care)∙自我忽视(Self-neglect)领域 5:感知/认知(Perception/Cognition)类别1:注意力(Attention)∙单侧身体忽视(Unilateral Neglect)类别2:定向力类别3:感觉/知觉类别4:认知∙急性意识障碍(Acute confusion)∙有急性意识障碍的危险(Acute confusion)∙慢性意识障碍(Acute confusion)∙情绪控制失调(Labile emotional control)∙冲动控制无效(Labile emotional control)∙知识缺乏(Deficient knowledge)∙有知识增进的趋势(Readiness for enhanced knowledge)∙记忆功能障碍(Impaired memory)类别5:沟通∙有沟通增进的趋势(Readiness for enhanced communication)∙语言沟通障碍(Impaired verbal communication)领域 6:自我感知(Self-Perception)类别1:自我概念(Self-concept)∙无望感(Hopelessness)∙有希望增强的趋势(Readiness for enhanced hope)∙有个人尊严受损的危险(Risk for compromised human dignity)∙自我认同紊乱(Disturbed personal identity)∙有自我认同紊乱的危险(Risk for disturbed personal identity)∙有自我概念改善的趋势(Readiness for enhanced self-concept)类别2:自尊(Self-esteem)∙长期低自尊(Chronic low self-esteem)∙有长期低自尊的危险(Risk for chronic low self-esteem)∙情境性低自尊(Situational low self-esteem)∙有情境性低自尊的危险(Risk for situational low self-esteem)类别3:身体形象(Body image)∙体像紊乱(Disturbed body image)领域 7:角色关系(Role Relationships)类别1:照顾者角色(Caregiving roles)∙照顾者角色紧张(Caregiving roles)∙有照顾者角色紧张的危险(Risk for caregiver role strain)∙养育功能障碍(Impaired parenting)∙有养育功能障碍的危险(Risk for impaired parenting)∙有养育功能改善的趋势(Readiness for enhanced parenting)类别2:家庭关系(Family relationships)∙有依附关系受损的危险(Risk for impaired attachment)∙家庭运作过程失常(Dysfunctional family processes)∙家庭运作过程改变(Interrupted family processes)∙有家庭运作过程改善的趋势(Readiness for enhanced family processes) 类别3:角色扮演(Role performance)∙关系无效(Ineffective relationship)∙有关系无效的危险(Risk for ineffective relationship)∙有关系改善的趋势(Readiness for enhanced relationship)∙父母角色冲突(Parental role conflict)∙无效性角色行为(Ineffective role performance)∙社会交往障碍(Impaired social interaction)领域 8:性(Sexuality)类别1:性认同(Sexual identity)类别2:性功能(Sexual function)∙性功能障碍(Sexual dysfunction)∙性生活型态无效(Ineffective sexuality pattern)类型3:生殖(Reproduction)∙生育进程无效(Ineffective childbearing process)∙有生育进程无效的危险(Risk for ineffective childbearing process)∙有生育进程改善的趋势(Readiness for enhanced childbearing process)∙有母体与胎儿双方受干扰的危险(Risk for disturbed maternal-fetal dyad)领域 9:应对/应激耐受性(Coping/Stress Tolerance)类别1:创伤后反应(Post-trauma responses)∙有复杂性移民的危险(Risk for complicated immigration transition)∙创伤后综合征(Post-trauma syndrome)∙有创伤后综合征的危险(Risk for post-trauma syndrome)∙强暴创伤综合征(Rape-trauma syndrome)∙迁移应激综合征(Relocation stress syndrome)有迁移应激综合征的危险(Risk for relocation stress syndrome)类别2:应对反应(Coping responses)∙活动计划无效(Ineffective activity planning)∙有活动计划无效的危险(Risk for ineffective activity planning)∙焦虑(Anxiety)∙防卫性应对(Defensive coping)∙应对无效(Ineffective coping)∙有应对改善的趋势(Readiness for enhanced coping)∙社区应对无效(Ineffective community coping)∙有社区应对改善的趋势(Readiness for enhanced community coping)∙妥协性家庭应对(Compromised family coping)∙无能性家庭应对(Disabled family coping)∙有家庭应对改善的趋势(Readiness for enhanced family coping)∙对死亡的焦虑(Death anxiety)∙无效性否认(Ineffective denial)∙恐惧(Fear)∙悲伤(Grieving)∙复杂性悲伤(Complicated grieving)∙有复杂性悲伤的危险(Risk for complicated grieving)∙情绪调控受损(Impaired mood regulation)∙无能为力感(Powerlessness)∙有无能为力感的危险(Risk for powerlessness)∙有能力增强的趋势(Readiness for enhanced power)∙恢复能力障碍(Impaired resilience)∙有恢复能力障碍的危险(Risk for impaired resilience)∙有恢复能力增强的趋势(Readiness for enhanced resilience)∙持续性悲伤(Chronic sorrow)∙压力负荷过重(Stress overload)类别3:神经行为压力(Neurobehavioral stress)∙急性成瘾物质戒断综合征(Acute substance withdrawal syndrome)∙有急性成瘾物质戒断综合征的危险(Risk for acute substance withdrawal syndrome)∙自主反射失调(Autonomic dysreflexia)∙有自主反射失调的危险(Risk for autonomic dysreflexia)∙颅内调适能力降低(Decreased intracranial adaptive capacity)∙新生儿戒断综合征(Neonatal abstinence syndrome)∙婴儿行为紊乱(Disorganized infant behaviour)∙有婴儿行为紊乱的危险(Risk for disorganized infant behaviour)∙有婴儿行为调节改善的趋势(Readiness for enhanced organized infant behavior)领域 10:生活准则(Life Principles)类别1:价值(Values)类别2:信念(Beliefs)∙有精神安适增进的趋势(Readiness for enhanced spiritual well-being)类别3:价值/信念/行动一致性(Value/belief/action congruence)∙有决策能力增强的趋势(Readiness for enhanced decision-making)∙抉择冲突(Decisional conflict)∙独立决策能力减弱(Impaired emancipated decision-making)∙有独立决策能力减弱的危险(Risk for impaired emancipated decision-making)∙有独立决策能力增强的趋势(Readiness for enhanced emancipated decision-making)∙道德困扰(Moral distress)∙宗教信仰减弱(Impaired religiosity)∙有宗教信仰减弱的危险(Risk for impaired religiosity)∙有宗教信仰增强的趋势(Readiness for enhanced religiosity)∙精神困扰(Spiritual distress)∙有精神困扰的危险(Risk for spiritual distress)领域 11:安全/防护(Safety/Protection)类别1:感染(Infection)∙有感染的危险(Risk for infection)∙有手术部位感染的危险(Risk for surgical site infection)类别2:身体伤害(Physical injury)∙清理呼吸道无效(Ineffective airway clearance)∙有误吸的危险(Risk for aspiration)∙有出血的危险(Risk for bleeding)∙牙齿受损(Impaired dentition)∙有干眼症的危险(Risk for dry eye)∙有口干症的危险(Risk for dry mouth)∙有跌倒的危险(Risk for falls)∙有角膜受损的危险(Risk for corneal injury)∙有受伤的危险(Risk for injury)∙有尿道损伤的危险(Risk for urinary tract injury)∙有手术期体位性损伤危险(Risk for perioperative positioning injury)∙有热损伤的危险(Risk for thermal injury)∙口腔黏膜完整性受损(Impaired oral mucous membrane integrity)∙有口腔黏膜完整性受损的危险(Risk for impaired oral mucous membrane integrity)∙有外周神经血管功能障碍的危险(Risk for peripheral neurovascular dysfunction)∙有身体创伤的危险(Risk for physical trauma)∙有血管损伤的危险(Risk for vascular trauma)∙有压疮的危险(Risk for pressure ulcer)∙有休克的危险(Risk for shock)∙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 integrity)∙有婴儿猝死的危险(Risk for sudden infant death)∙有窒息的危险(Risk for suffocation)∙术后康复迟缓(Delayed surgical recovery)∙有术后康复迟缓的危险(Risk for delayed surgical recovery)∙组织完整性 (Impaired tissue integrity)∙有组织完整性受损的危险(Risk for impaired tissue integrity)∙有静脉栓塞的危险(Risk for venous thromboembolism)类别3:暴力(Violence)∙有女性割礼的危险(Risk for female genital mutilation)∙有对他人施行暴力的危险(Risk for other-directed violence)∙有对自己施行暴力的危险(Risk for self-directed violence)∙自残(Self-mutilation)∙有自残的危险(Risk for self-mutilation)∙有自杀的危险(Risk for suicide)类别4:环境伤害(Environmental hazards)∙受污染(Contamination)∙有受污染的危险(Risk for contamination)∙有职业伤害的危险(Risk for occupational injury)∙有中毒的危险(Risk for poisoning)类别5:防卫过程(Defensive processes)∙有碘造影剂不良反应的危险(Risk for adverse reaction to iodinated contrast media)∙有过敏反应的危险(Risk for allergy reaction)∙乳胶过敏反应(Latex allergy reaction)∙有乳胶过敏反应的危险(Risk for latex allergy reaction)类别6:体温调节(Thermoregulation)∙体温过高(Hyperthermia)∙体温过低(Hypothermia)∙有体温过低的危险(Risk for hypothermia)∙有手术期体温过低的危险(Risk for perioperative hypothermia)∙体温调节无效(Ineffective thermoregulation)∙有体温调节无效的危险(Risk for ineffective thermoregulation)领域 12:舒适(Comfort)类别1:身体舒适(Physical comfort)∙舒适度减弱(Impaired comfort)∙有舒适增进的趋势(Readiness for enhanced comfort)∙恶心(Nausea)∙急性疼痛(Acute pain)∙慢性疼痛(Chronic pain)∙慢性疼痛综合征(Chronic pain syndrome)∙分娩疼痛(Labor pain)类别2:环境舒适(Environmental comfort)类别3:社会舒适(Social comfort)∙有孤独的危险(Risk for loneliness)∙社交孤立(Social isolation)领域 13:生长/发展(Growth/Development)类别1:生长类别2:发展有发育迟缓的危险(Risk for delayed development)。

北美护理协会 最新155个护理诊断

北美护理协会  最新155个护理诊断

北美护理协会最新155个护理诊断( 按 NANDA 分类法排列〉NANDA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155个护理诊断分列如下:一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection)121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险。

新版216个护理诊断NANDA护理诊断

新版216个护理诊断NANDA护理诊断

新版216个护理诊断NANDA护理诊断2012~2014(共216项)领域1:健康促进(Health Promotion)类别1:健康意识(Health Awareness)1.娱乐活动缺乏(Deficient Diversional Activity)(00097)2.静态的生活方式(Sedentary Lifestyle)(00168)类别2:健康管理(Health Management)1.缺乏公共卫生(Deficient Community Health)(00215)2.有危险倾向的健康行为(Risk-Prone Health Behavior)(00188)3.健康维持无效(Ineffective Health Maintenance)(00099)4.有增强免疫状态的愿望(Readiness for EnhancedImmunization Status)(00186)5.防护无效(Ineffective Protection)(00043)6.自我健康维持无效(Ineffective Self-Health Management)(00078)7.有增强自我健康管理的愿望(Readiness for EnhancedSelf-Health Management)(00162)家庭执行治疗方案无效(Ineffective Family Therapeutic Regimen Management)(00080)领域2:营养(Nutrition)类别1:摄入(Ingestion)1.母乳不足(Insufficient Breast Milk)(00216)2.婴儿喂养无效(Ineffective Infant Feeding Pattern)(00107)3.营养失调:低于机体需要量(Imbalanced Nutrition:Less ThanBody Requirement(00002)营养失调:高于机体需要量(Imbalanced Nutrition:More Than Body Requirements(00001)有增强营养的愿望(Readiness for Enhanced Nutrition)(00163)4.有营养失调的危险:高于机体需要量(Risk for ImbalancedNutrition:More Than Body Requirements)(00003)5.吞咽能力受损(Impaired Swallowing)(00103)类别2:消化(Digestion)类别3:吸收(Absorption)类别4:代谢(Metabolism)1.有血糖不稳定的危险(Risk for Unstable Blood Glucose Level)(00179)2.新生儿黄疸(Neonatal Jaundice)(00194)3.有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)4.有肝功能受损的危险(Risk for Impaired Liver Function)(00178)类别5:水化1.有电解质失衡的危险(Risk for Electrolyte Imbalance)(00195)2.有维持体液平衡的愿望(Readiness for Enhanced FluidBalance)(00160)3.体液不足(Deficient Fluid Volume)(00027)4.体液过多(Excess Fluid Volume)(00026)5.有体液不足的危险(Risk for Deficient Fluid Volume)(00028)6.有体液失衡的危险(Risk for Imbalanced Fluid Volume)(00025)领域3:排泄(Elimination and Exchange)类别1:排尿功能(Urinary Function)1.功能性尿失禁(Functional Urinary Incontinence)(00020)2.充溢性尿失禁(Overflow Urinary Incontinence)(00176)3.反射性尿失禁(Reflex Urinary Incontinence)(00018)4.压力性尿失禁(Stress Urinary Incontinence)(00017)5.急迫性尿失禁(Urge Urinary Incontinence)(00019)6.有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)(00022)7.排尿形态改变(Impaired Urinary Elimination)(00016)8.有排尿形态恢复正常的愿望(Readiness for Enhanced UrinaryElimination)(00166)9.尿潴留(Urinary Retention)(00023)类别2:胃肠功能(Gastrointestinal Function)1.便秘(Constipation)(00011)2.感知性便秘(Perceived Constipation)(00012)3.有便秘的危险(Risk for Constipation)(00015)4.腹泻(Diarrhea)(00013)5.胃肠动力紊乱(Dysfunctional Gastrointestinal Motility)(00196)6.有胃肠动力紊乱的危险(Risk for DysfunctionalGastrointestinal Motility)(00197)7.排便失禁(Bowel Incontinence)(00014)类别3:皮肤功能(Integumentary Function)类别4:呼吸功能(Respiratory Function)1.气体交换受损(Impaired Gas Exchange)(00030)领域4:活动∕休息(Activit y∕Rest)类别1:睡眠/休息(Sleep/Rest)1.失眠(Insomnia)(00095)2.睡眠剥夺(Sleep Deprivation)(00096)3.有睡眠形态增进的愿望(Readiness for Enhanced Sleep)(00165)4.睡眠形态紊乱(Disturbed Sleep Pattern)(00198)类别2:活动/运动(Activity/Exercise)1.有废用综合征的危险(Risk for Disuse Syndrome)(00040)2.床上活动障碍(Impaired Bed Mobility)(00091)3.躯体移动障碍(Impaired Physical Mobility)(00085)4.借助轮椅活动障碍(Impaired Wheelchair Mobility)(00089)5.移位能力障碍(Impaired Transfer Ability)(00090)6.行走障碍(Impaired Walking)(00088)类别3:能量平衡(Energy Balance)1.能量场紊乱(Disturbed Energy Field)(00050)2.疲乏(Fatigue)(00093)3.漫游(Wandering)(00154)类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)1.活动无耐力(Activity Intolerance)(00092)2.有活动无耐力的危险(Risk for Activity Intolerance)(00094)3.低效性呼吸形态(Ineffective Breathing Pattern)(00032)4.心输出量减少(Decreased Cardiac Output)(00029)5.有胃肠灌注不足的危险(Risk for Ineffective GastrointestinalPerfusion)(00202)6.有肾脏灌注不足的危险(Risk for Ineffective Renal Perfusion)(00203)7.不能维持自主呼吸(Impaired Spontaneous Ventilation)(00033)8.周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)9.有心脏组织灌注不足的危险(Risk for Decreased CardiacTissue Perfusion)(00200)有脑组织灌注不足的危险(Risk for Ineffective Cerebral Tissue Perfusion)(00201)有周围组织灌注不足的危险(Risk for IneffectivePeripheral Tissue Perfusion)(00228)呼吸机依赖(Dysfunctional Ventilatory Weaning Response)(00034)类别5:自我照顾(Self-Care)1.持家能力障碍(Impaired Home Maintenance)(00098)2.有增强自理的愿望(Readiness for Enhanced Self-Care)(00182)3.沐浴自理缺陷(Bathing Self-Care Deficit)(00108)4.穿衣自理缺陷(Dressing Self-Care Deficit)(00109)5.进食自理缺陷(Feeding Self-Care Deficit)(00102)6.如厕自理缺陷(Toileting Self-Care Deficit)(00110)7.忽视自我健康管理(Self-Neglect)(00193)领域5:知觉∕认知(Perception∕Cognition)类别1:注意力(Attention)1.忽视单侧身体(Unilateral Neglect)(00123)类别2:定向力(Orientation)1.环境解析障碍综合征(Impaired Environmental InterpretationSyndrome)(00127)类别3:感觉/知觉(Sensation/Perception)类别4:认知(Cognition)1.急性意识障碍(Acute Confusion)(00128)2.慢性意识障碍(Chronic Confusion)(00129)3.有急性意识障碍的危险(Risk for Acute Confusion)(00173)4.自我控制无效(Ineffective Impulse Control)(00222)5.知识缺乏(Deficient Knowledge)(00126)6.有增加知识的愿望(Readiness for Enhanced Knowledge)(00161)7.记忆受损(Impaired Memory)(00131)类别5:沟通(Communication)1.有加强沟通的愿望(Readiness for Enhanced Communication)(00157)2.语言沟通障碍(Impaired Verbal Communication)(00051)领域6:自我知觉(Self-Perception)类别1:自我概念(Self-Concept)1.绝望(Hopelessness)(00124)2.有危及个人尊严的危险(Risk for Compromised HumanDignity)(00174)3.有孤独的危险(Risk for Loneliness)(00054)4.自我认同紊乱(Disturbed Personal Identity)(00121)5.有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)6.有增强自我概念的愿望(Readiness for EnhancedSelf-Concept)(00167)类别2:自尊Self-Esteem1.慢性低自尊(Chronic Low Self-Esteem)(00119)2.情境性低自尊(Situational Low Self-Esteem)(00120)3.有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)4.有情境性低自尊的危险(Risk for Situational Low Self-Esteem)(00153)类别3:自我形象(Body Image)1.自我形象紊乱(Disturbed Body Image)(00118)领域7:角色关系(Role Relationships)类别1:照顾者角色(Caregiving Roles)1.母乳喂养无效(Ineffective Breastfeeding)(00104)2.母乳喂养中断(Interrupted Breastfeeding)(00105)3.有增强母乳喂养的愿望(Readiness for EnhancedBreastfeeding)(00106)4.照顾者角色紧张(Caregiver Role Strain)(00061)5.有照顾者角色紧张的危险(Risk for Caregiver Role Strain)(00062)6.抚养障碍(Impaired Parenting)(00056)7.有增进抚养能力的愿望(Readiness for Enhanced Parenting)(00164)8.有抚养障碍的危险(Risk for Impaired Parenting)(00057)类别2:家庭关系(Family Relationships)1.有依附关系障碍的危险(Risk for Impaired Attachment)(00058)2.家庭运作紊乱(Dysfunctional Family Processes)(00063)3.家庭运作中断(Interrupted Family Processes)(00060)4.有家庭运作稳定的愿望(Readiness for Enhanced FamilyProcesses)(00159)类别3:角色表现(Role Performance)1.无效的关系(Ineffective Relationship)(00223)2.有增进关系的愿望(Readiness for Enhanced Relationship)(00207)3.有关系无效的危险(Risk for Ineffective Relationship)(00229)4.父母角色冲突(Parental Role Conflict)(00064)5.角色紊乱(Ineffective Role Performance)(00055)6.社交障碍(Impaired Social Interaction)(00052)领域8:性学(Sexuality)类别1:性别认同(Sexual Identity)类别2:性功能(Sexual Function)1.性功能障碍(Sexual Dysfunction)(00059)2.性生活形态改变(Ineffective Sexuality Pattern)(00065)类别3:生殖(Reproduction)1.分娩过程无效(Ineffective Childbearing Process)(00221)2.有增进分娩过程的愿望(Readiness for Enhanced ChildbearingProcess)(00208)有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)有母体-胎儿受干扰的危险(Risk for Disturbed Maternal-Fetal Dyad)(00209)领域9:调适∕压力耐受(Coping∕Stress Tolerance)类别1:创伤后反应(Post-Trauma Responses)1.创伤后综合征(Post-Trauma Syndrome)(00141)2.有创伤后综合征的危险(Risk for Post-Trauma Syndrome)(00145)3.强暴创伤综合征(Rape-Trauma Syndrome)(00142)4.迁移应激综合征(Relocation Stress Syndrome)(00114)5.有迁移应激综合征的危险(Risk for Relocation StressSyndrome)(00149)类别2:应对反应(Coping Responses)1.活动计划无效(Ineffective Activity Planning)(00199)2.有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)3.焦虑(Anxiety)(00146)4.防御性应对(Defensive Coping)(00071)5.应对无效(Ineffective Coping)(00069)6.有增强应对的愿望(Readiness for Enhanced Coping)(00158)7.社区应对无效(Ineffective Community Coping)(00077)8.社区有增强应对的愿望(Readiness for Enhanced CommunityCoping)(00076)9.家庭妥协性应对(Compromised Family Coping)(00074)10.家庭应对缺陷(Disabled Family Coping)(00073)11.家庭有增强应对的愿望(Readiness for Enhanced FamilyCoping)(00075)12.死亡焦虑(Death Anxiety)(00147)13.无效性否认(Ineffective Denial)(00072)14.人生存功能衰退(Adult Failure to Thrive)(00101)15.恐惧(Fear)(00148)16.悲痛(Grieving)(00136)17.复杂性哀伤(Complicated Grieving)(00135)18.有复杂性哀伤的危险(Risk for Complicated Grieving)(00172)19.有增强能力的愿望(Readiness for Enhanced Power)(00187)20.无能为力(Powerlessness)(00125)21.有无能为力的危险(Risk for Powerlessness)(00152)22.个人复原能力受损(Impaired Individual Resilience)(00210)23.有增强复原能力的愿望(Readiness for Enhanced Resilience)(00212)24.有危及复原的危险(Risk for Compromised Resilience)(00211)25.长期悲伤(Chronic Sorrow)(00137)26.超负荷压力(Stress Overload)(00177)类别3:神经行为压力(Neurobehavioral Stress)1.自主性反射障碍(Autonomic Dysreflexia)(00009)2.有自主反射障碍的危险(Risk for Autonomic Dysreflexia)(00010)3.婴儿行为紊乱(Disorganized Infant Behavior)(00116)4.婴儿有行为能力增强的潜力(Readiness for EnhancedOrganized Infant Behavior)(00117)5.有婴儿行为紊乱的危险(Risk for Disorganized InfantBehavior)(00115)6.颅内调试能力下降(Decreased Intracranial AdaptiveCapacity)(00049)领域10:生命原则(Life Principles)类别1:价值观(Values)1.有增进希望的愿望(Readiness for Enhanced Hope)(00185)类别2:信念(Beliefs)1.有促进精神健康增强的愿望(Readiness for Enhanced SpiritualWell-Being)(00068)类别3:价值/信念/行动一致(Value/Belief/Action Congruence)1.有增强决策的愿望(Readiness for EnhancedDecision-Making)(00184)2.决策冲突(Decisional Conflict)(00083)3.道德困扰(Moral Distress)(00175)4.不合作(Noncompliance)(00079)5.虔信受损(Impaired Religiosity)(00169)6.有增进虔信的愿望(Readiness for Enhanced Religiosity)(00171)7.有虔信受损的危险(Risk for Impaired Religiosity)(00170)8.精神困扰(Spiritual Distress)(00066)9.有精神困扰的危险(Risk for Spiritual Distress)(00067)领域11:安全∕保护(Safety∕Protection)类别1:感染(Infection)1.有感染的危险(Risk for Infection)(00004)类别2:身体伤害(Physical Injury)1.清理呼吸道无效(Ineffective Airway Clearance)(00031)2.有误吸的危险(Risk for Aspiration)(00039)3.有出血的危险(Risk for Bleeding)(00206)4.牙齿受损(Impaired Dentition)(00048)5.有干眼症的危险(Risk for Dry Eye)(00219)6.有跌倒的危险(Risk for Falls)(00155)7.有受伤的危险(Risk for Injury)(00035)8.口腔黏膜受损(Impaired Oral Mucous Membrane)(00045)9.有围手术期体位性损伤的危险(Risk for PerioperativePositioning Injury)(00087)10.有周围神经血管功能障碍的危险(Risk for PeripheralNeurovascular Dysfunction)(00086)有休克的危险(Risk for Shock)(00205)11.皮肤完整性受损(Impaired Skin Integrity)(00046)12.有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)13.有婴儿猝死综合征的危险(Risk for Sudden Infant DeathSyndrome)(00156)14.有窒息的危险(Risk for Suffocation)(00036)15.术后恢复延迟(Delayed Surgical Recovery)(00100)16.有烫伤的危险(Risk for Thermal Injury)(00220)17.组织完整性受损(Impaired Tissue Integrity)(00044)18.有外伤的危险(Risk for Trauma)(00038)19.有血管受损的危险(Risk for Vascular Trauma)(00213)类别3:暴力(Violence)1.有虐待他人的危险(Risk for Other-Directed Violence)(00138)2.有自虐的危险(Risk for Self-Directed Violence)(00140)3.自残(Self-Mutilation)(00151)4.有自残的危险(Risk for Self-Mutilation)(00139)5.有自杀的危险(Risk for Suicide)(00150)类别4:环境危害(Environmental Hazards)1.污染(Contamination)(00181)2.有污染的危险(Risk for Contamination)(00180)3.有中毒的危险(Risk for Poisoning)(00037)类别5:防御过程(Defensive Processes)1.有碘造影剂不良反应的危险(Risk for Adverse Reaction toIodinated Contrast Media)(000218)2.乳胶过敏反应(Latex Allergy Response)(00041)3.有过敏反应的危险(Risk for Allergy Response)(00217)4.有乳胶过敏反应的危险(Risk for Latex Allergy Response)(00042)类别6:体温调节(Thermoregulation)1.有体温平衡失调的危险(Risk for Imbalanced BodyTemperature)(00005)2.体温过高(Hyperthermia)(00007)3.体温过低(Hypothermia)(00006)4.体温调节无效(Ineffective Thermoregulation)(00008)领域12:舒适(Comfort)类别1:身体舒适(Physical Comfort)类别2:环境舒适(Environmental Comfort)类别3:社交舒适(Social Comfort)1.舒适的改变(Impaired Comfort)(00214)2.有增加舒适的愿望(Readiness for Enhanced Comfort)(00183)3.恶心(Nausea)(00134)4.急性疼痛(Acute Pain)(00132)5.慢性疼痛(Chronic Pain)(00133)6. 社交隔离(Social Isolation)(00053)领域13:生长∕发育(Growth∕Development)类别1:生长(Growth)1.有生长不成比例的危险(Risk for Disproportionate Growth)(00113)类别2:发育(Development)1.生长发育迟缓(Delayed Growth and Development)(00111)2. 有发育迟缓的危险(Risk for Delayed Development)(00112)一、新增诊断(16项):领域1:健康促进(Health Promotion)类别2:健康管理(Health Management)缺乏公共卫生(Deficient Community Health)(00215)领域2:营养(Nutrition)类别1:摄入(Ingestion)母乳不足(Insufficient Breast Milk)(00216)类别4:代谢(Metabolism)有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)领域4:活动∕休息(Activit y∕Rest)类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)有周围组织灌注不足的危险(Risk for Ineffective Peripheral Tissue Perfusion)(00228)领域5:知觉∕认知(Perception∕Cognition)类别3:感觉/知觉(Sensation/Perception)类别4:认知(Cognition)自我控制无效(Ineffective Impulse Control)(00222)领域6:自我知觉(Self-Perception)类别1:自我概念(Self-Concept)有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)类别2:自尊Self-Esteem有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)领域7:角色关系(Role Relationships)类别3:角色表现(Role Performance)无效的关系(Ineffective Relationship)(00223)有关系无效的危险(Risk for Ineffective Relationship)(00229)领域8:性学(Sexuality)类别3:生殖(Reproduction)分娩过程无效(Ineffective Childbearing Process)(00221)有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)领域9:调适∕压力耐受(Coping∕Stress Tolerance)类别2:应对反应(Coping Responses)有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)领域11:安全∕保护(Safety∕Protection)类别2:身体伤害(Physical Injury)有干眼症的危险(Risk for Dry Eye)(00219)有烫伤的危险(Risk for Thermal Injury)(00220)类别5:防御过程(Defensive Processes)有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)有过敏反应的危险(Risk for Allergy Response)(00217)二、修改诊断(11项):1.有增强母乳喂养的愿望(Readiness for EnhancedBreastfeeding)(00106)2.低效性呼吸形态(Ineffective Breathing Pattern)(00032)3.舒适的改变(Impaired Comfort)(00214)4.有感染的危险(Risk for Infection)(00004)5.新生儿黄疸(Neonatal Jaundice)(00194)6.恶心(Nausea)(00134)7.无能为力(Powerlessness)(00125)8.有无能为力的危险(Risk for Powerlessness)(00152)9.有增强自我健康管理的愿望(Readiness for EnhancedSelf-Health Management)(00162)有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)10.周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)三、退出诊断(1项):领域5:知觉∕认知(Perception∕Cognition)类别5:沟通(Communication)感觉知觉紊乱(特定的:视觉、听觉、方位感、味觉、触觉、嗅觉)(Disturbed Sensory Perception)(00122)。

北美护理协会 最新155个护理诊断

北美护理协会  最新155个护理诊断

北美护理协会最新155个护理诊断( 按 NANDA 分类法排列〉NANDA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155个护理诊断分列如下:一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection)121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险。

NANDA确定的128个护理诊断

NANDA确定的128个护理诊断

NANDA确定的128个护理诊断NANDA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个护理诊断分列如下: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 Nutrition: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)便秘(Constipation)感知性便秘(Perceived Consttipation)结肠性便秘(Colonic Constipation)腹泻(Diarrhea)大便失禁(Bowel Inconttinence)排尿异常(Altered Urinary Elimination)压迫性尿失禁(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,Peripheral))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。

北美护理协会__最新155个护理诊断

北美护理协会__最新155个护理诊断

北美护理协会最新155个护理诊断( 按 NANDA 分类法排列〉NANDA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155个护理诊断分列如下:一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉)58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance)88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection)121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险。

介绍北美护理诊断协会1998年通过的21个新护理诊断

介绍北美护理诊断协会1998年通过的21个新护理诊断

介绍北美护理诊断协会1998年通过的21个新护理诊断北美护理诊断协会(NANDA)于1998年召开了第13次护理诊断会议,在原有128个护理诊断的基础上删除了1个“结肠性便秘”的护理诊断,同时增加了21个新的护理诊断。

因此,目前被NANDA正式通过的护理诊断数目已达148个[1]。

本文以NANDA的护理诊断分类法Ⅰ的排列顺序为序逐一介绍这21个护理诊断的名称、定义、诊断依据、相关因素或危险因素[1]。

限于篇幅,笔者将后3者做了归纳,并对部分新护理诊断产生的背景、必要性,新护理诊断与原有护理诊断之间的关系,以及新护理诊断适用于哪类病人等作了简要介绍,以使我国广大临床护理、教学和科研人员尽快了解和掌握这些新护理诊断的信息,以便在各自的领域内推广使用。

123 2 有自主反射失调的危险(Risk for autonomic dysreflexia):对于患有胸8或胸8以上脊髓段损伤或损害的个体以及脊髓休克恢复期的个体终生可能受到一种无法抑制的交感神经反应的威胁。

该诊断用于高位脊髓损伤病人可能会出现脊髓损伤段水平以下疼痛、便秘、腹胀、尿潴留、深静脉血栓、活动范围受限、褥疮等一系列问题。

131 4 有便秘的危险(Risk for constipation):个体有排便次数减少伴有排便困难或排便不完全和/或排便干、硬的危险。

危险因素包括所有容易引起便秘的生理因素(纤维素摄入量不足,液体入量不足,饮食改变,胃肠蠕动功能减弱)、心理因素(情绪紧张、抑郁)、功能性因素(有便意时不去排便,环境改变,入厕方式改变,活动量减少,腹肌无力)以及药物的不良作用等。

1321 6 有急迫性尿失禁的危险(Risk for urinary urge incontinence):与一种突然、强烈或急迫的尿意有关而有发生不自主排尿的危险。

危险因素包括:药物、咖啡因、酒精的作用;由于膀胱炎、尿道炎、肿瘤、肾结石引起的逼尿肌反射亢进;逼尿肌不稳定伴有收缩障碍;不随意的括约肌松弛,不良的入厕习惯(如尿急时才去厕所);膀胱容量小。

NANDA 心理问题护理诊断学生版

NANDA 心理问题护理诊断学生版

NANDA 心理护理诊断(部分)NO. 1语言沟通障碍(impaired verbal communication)【定义】个人在与人交往中,使用和理解语言的能力低下甚或丧失的状态。

NO 2.社交障碍impaired social interaction【定义】个人参加的社会交往,有不足、过多或无效的情况。

【诊断依据】主要依据:1.口述或观察到在社交场合的不舒适感。

2.口述或观察到无法沟通或获得满意的归属感,照顾和分享的感觉。

次要依据:1.家庭成员诉说其交往方式有改变。

2.缺乏动力、丧失自尊、自理能力差、较严重的焦虑,没有固定职业等情况。

【病因和促成因素】1.病理生理方面身体活动受限制,有慢性疾病或肢体缺失等。

有智力迟滞、听觉、视觉缺陷或语言障碍,自我概念紊乱和思维障碍等。

2.情境方面缺乏能促进融洽的知识和技巧。

缺乏可依靠的亲属和朋友。

治疗性隔离。

环境的障碍,如交通不方便。

社会,文化的不协调。

NO.3 社交孤立social isolation【定义】个人经受到了孤独,并感到是被人强加予的消极或威胁的状态。

【诊断依据】主要依据:1.表示有不可解释的恐惧或被遗弃感。

2.希望与人更多的接触。

由于社交孤立是主观感觉的情况,因此有关孤独的感觉都必须经过证实,其表现的方式也有很多,以下可供参考。

主观依据:1.与他人相处时,表现出孤独感和有被拒绝的感觉。

2.在公共场合没有安全感客观依据:1.没有起支持作用的重要成员,如家属、朋友和组织团体。

2.表情悲伤而呆滞。

3.表现与其发展年龄不符合的或不成熟的兴趣和活动。

4.无法沟通、退缩、无眼神接触。

5.寻求孤独或生活在次要文化群体中。

6.有身体或精神缺陷及健康状况有改变的证据。

NO.4 角色紊乱altered role performance【定义】个人感受自己的角色扮演方面受到干扰。

【诊断依据】1.对角色的感知有所改变。

2.否认角色。

3.对他人的角色感受也有所改变。

新版216个护理诊断

新版216个护理诊断

新版216个护理诊断1. 娱乐活动缺乏(Deficient Diversional Activity)(00097)2. 静态的生活方式(Sedentary Lifestyle)(00168)3. 缺乏公共卫生(Deficient Community Health)(00215)4. 有危险倾向的健康行为(Risk-Prone Health Behavior)(00188)5. 健康维持无效(Ineffective Health Maintenance)(00099)6. 有增强免疫状态的愿望(Readiness for Enhanced Immunization Status)(00186)7. 防护无效(Ineffective Protection)(00043)8. 自我健康维持无效(Ineffective Self-Health Management)(00078)9. 有增强自我健康管理的愿望(Readiness for Enhanced Self-HealthManagement)(00162)10.家庭执行治疗方案无效(Ineffective Famil Therapeutic Regimen Management)(00080)11. 母乳不足(Insufficient Breast Milk)(00216)12. 婴儿喂养无效(Ineffective Infant Feeding Pattern)(00107)13. 营养失调:低于机体需要量(Imbalanced Nutrition:Less Than BodyRequirements)(00002)14.营养失调:高于机体需要量(Imbalanced Nutrition:More Than Body Requirements)15.(00001)有增强营养的愿望(Readiness for Enhanced Nutrition)(00163)16. 有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition:MoreThan Body Requirements)(00003)17. 吞咽能力受损(Impaired Swallowing)(00103)18. 有血糖不稳定的危险(Risk for Unstable Blood Glucose Level)(00179)19. 新生儿黄疸(Neonatal Jaundice)(00194)20. 有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)21. 有肝功能受损的危险(Risk for Impaired Liver Function)(00178)22. 有电解质失衡的危险(Risk for Electrolyte Imbalance)(00195)23. 有维持体液平衡的愿望(Readiness for Enhanced Fluid Balance)(00160)24. 体液不足(Deficient Fluid Volume)(00027)25. 体液过多(Excess Fluid Volume)(00026)26. 有体液不足的危险(Risk for Deficient Fluid Volume)(00028)27. 有体液失衡的危险(Risk for Imbalanced Fluid Volume)(00025)28. 功能性尿失禁(Functional Urinary Incontinence)(00020)29. 充溢性尿失禁(Overflow Urinary Incontinence)(00176)30. 反射性尿失禁(Reflex Urinary Incontinence)(00018)31. 压力性尿失禁(Stress Urinary Incontinence)(00017)32. 急迫性尿失禁(Urge Urinary Incontinence)(00019)33. 有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)(00022)34. 排尿形态改变(Impaired Urinary Elimination)(00016)35. 有排尿形态恢复正常的愿望(Readiness for Enhanced Urinary Elimination)(00166)尿潴留(Urinary Retention)(00023)36. 便秘(Constipation)(00011)37. 感知性便秘(Perceived Constipation)(00012)38. 有便秘的危险(Risk for Constipation)(00015)39. 腹泻(Diarrhea)(00013)40. 胃肠动力紊乱(Dysfunctional Gastrointestinal Motility)(00196)41. 有胃肠动力紊乱的危险(Risk for Dysfunctional Gastrointestinal Motility)(00197)42.排便失禁(Bowel Incontinence)(00014)43. 气体交换受损(Impaired Gas Exchange)(00030)44. 失眠(Insomnia)(00095)45. 睡眠剥夺(Sleep Deprivation)(00096)46. 有睡眠形态增进的愿望(Readiness for Enhanced Sleep)(00165)47. 睡眠形态紊乱(Disturbed Sleep Pattern)(00198)48. 有废用综合征的危险(Risk for Disuse Syndrome)(00040)49. 床上活动障碍(Impaired Bed Mobility)(00091)50. 躯体移动障碍(Impaired Physical Mobility)(00085)51. 借助轮椅活动障碍(Impaired Wheelchair Mobility)(00089)52. 移位能力障碍(Impaired Transfer Ability)(00090)53. 行走障碍(Impaired Walking)(00088)54. 能量场紊乱(Disturbed Energy Field)(00050)55. 疲乏(Fatigue)(00093)56. 漫游(Wandering)(00154)57. 活动无耐力(Activity Intolerance)(00092)58. 有活动无耐力的危险(Risk for Activity Intolerance)(00094)59. 低效性呼吸形态(Ineffective Breathing Pattern)(00032)60. 心输出量减少(Decreased Cardiac Output)(00029)61. 有胃肠灌注不足的危险(Risk for Ineffective Gastrointestinal Perfusion)00202)62. 有肾脏灌注不足的危险(Risk for Ineffective Renal Perfusion)(00203)63. 不能维持自主呼吸(Impaired Spontaneous Ventilation)(00033)64. 周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)65. 有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)00200)66.有脑组织灌注不足的危险(Risk for Ineffective Cerebral Tissue Perfusion)(00201)67. 周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)68. 有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)(00200)69.有脑组织灌注不足的危险(Risk for Ineffective Cerebral Tissue Perfusion)(00201)70..有周围组织灌注不足的危险(Risk for Ineffective Peripheral Tissue Perfusion)(00228)71.呼吸机依赖(Dysfunctional Ventilatory Weaning Response)(00034)72. 持家能力障碍(Impaired Home Maintenance)(00098)73. 有增强自理的愿望(Readiness for Enhanced Self-Care)(00182)74. 沐浴自理缺陷(Bathing Self-Care Deficit)(00108)75. 穿衣自理缺陷(Dressing Self-Care Deficit)(00109)76. 进食自理缺陷(Feeding Self-Care Deficit)(00102)77. 如厕自理缺陷(Toileting Self-Care Deficit)(00110)78. 忽视自我健康管理(Self-Neglect)(00193)79.. 忽视单侧身体(Unilateral Neglect)(00123)80. 环境解析障碍综合征(Impaired Environmental Interpretation Syndrome)(00127)81. 急性意识障碍(Acute Confusion)(00128)82. 慢性意识障碍(Chronic Confusion)(00129)83. 有急性意识障碍的危险(Risk for Acute Confusion)(00173)84. 自我控制无效(Ineffective Impulse Control)(00222)85. 知识缺乏(Deficient Knowledge)(00126)86. 有增加知识的愿望(Readiness for Enhanced Knowledge)(00161)87. 记忆受损(Impaired Memory)(00131)88. 有加强沟通的愿望(Readiness for Enhanced Communication)(00157)89. 语言沟通障碍(Impaired Verbal Communication)(00051)90. 绝望(Hopelessness)(00124)91. 有危及个人尊严的危险(Risk for Compromised Human Dignity)(00174)92. 有孤有分娩过程无效的危险(Risk for Ineffective Childbearing Process)93.有母体-胎儿受干扰的危险(Risk for Disturbed Maternal-Fetal Dyad)(00209)94.有婴儿行为紊乱的危险(Risk for Disorganized Infant Behavior)(00115)95.有休克的危险(Risk for Shock)(00205)96. 自我认同紊乱(Disturbed Personal Identity)(00121)97. 有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)98. 有增强自我概念的愿望(Readiness for Enhanced Self-Concept)(00167)99. 慢性低自尊(Chronic Low Self-Esteem)(00119)100. 情境性低自尊(Situational Low Self-Esteem)(00120)101. 有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)102. 有情境性低自尊的危险(Risk for Situational Low Self-Esteem)(00153)103. 自我形象紊乱(Disturbed Body Image)(00118)104. 母乳喂养无效(Ineffective Breastfeeding)(00104)105. 母乳喂养中断(Interrupted Breastfeeding)(00105)106. 有增强母乳喂养的愿望(Readiness for Enhanced Breastfeeding)(00106)107. 照顾者角色紧张(Caregiver Role Strain)(00061)108. 有照顾者角色紧张的危险(Risk for Caregiver Role Strain)(00062)109. 抚养障碍(Impaired Parenting)(00056)110. 有增进抚养能力的愿望(Readiness for Enhanced Parenting)(00164)111. 有抚养障碍的危险(Risk for Impaired Parenting)(00057)112. 有依附关系障碍的危险(Risk for Impaired Attachment)(00058)113. 家庭运作紊乱(Dysfunctional Family Processes)(00063)114. 家庭运作中断(Interrupted Family Processes)(00060)115. 有家庭运作稳定的愿望(Readiness for Enhanced Family Processes)(00159)116. 无效的关系(Ineffective Relationship)(00223)117. 有增进关系的愿望(Readiness for Enhanced Relationship)(00207)118. 有关系无效的危险(Risk for Ineffective Relationship)(00229)119. 父母角色冲突(Parental Role Conflict)(00064)120. 角色紊乱(Ineffective Role Performance)(00055)121.有孤独的危险(Risk for Loneliness)(00054)122. 社交障碍(Impaired Social Interaction)(00052)123. 性功能障碍(Sexual Dysfunction)(00059)124. 性生活形态改变(Ineffective Sexuality Pattern)(00065)125. 分娩过程无效(Ineffective Childbearing Process)(00221)126. 有增进分娩过程的愿望(Readiness for Enhanced Childbearing Process)(00208)127. 创伤后综合征(Post-Trauma Syndrome)(00141)128. 有创伤后综合征的危险(Risk for Post-Trauma Syndrome)(00145)129. 强暴创伤综合征(Rape-Trauma Syndrome)(00142)130. 迁移应激综合征(Relocation Stress Syndrome)(00114)131. 有迁移应激综合征的危险(Risk for Relocation Stress Syndrome)(00149)类别2:应对反应(Coping Responses)132. 活动计划无效(Ineffective Activity Planning)(00199)133. 有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)134. 焦虑(Anxiety)(00146)135. 防御性应对(Defensive Coping)(00071)136. 应对无效(Ineffective Coping)(00069)137. 有增强应对的愿望(Readiness for Enhanced Coping)(00158)138. 社区应对无效(Ineffective Community Coping)(00077)139. 社区有增强应对的愿望(Readiness for Enhanced Community Coping)(00076)140. 家庭妥协性应对(Compromised Family Coping)(00074)141. 家庭应对缺陷(Disabled Family Coping)(00073)142. 家庭有增强应对的愿望(Readiness for Enhanced Family Coping)(00075)143. 死亡焦虑(Death Anxiety)(00147)144. 无效性否认(Ineffective Denial)(00072)145. 成人生存功能衰退(Adult Failure to Thrive)(00101)146. 恐惧(Fear)(00148)147. 悲痛(Grieving)(00136)148. 复杂性哀伤(Complicated Grieving)(00135)149. 有复杂性哀伤的危险(Risk for Complicated Grieving)(00172)150. 有增强能力的愿望(Readiness for Enhanced Power)(00187)151. 无能为力(Powerlessness)(00125)152. 有无能为力的危险(Risk for Powerlessness)(00152)153. 个人复原能力受损(Impaired Individual Resilience)(00210)154. 有增强复原能力的愿望(Readiness for Enhanced Resilience)(00212)155. 有危及复原的危险(Risk for Compromised Resilience)(00211)156. 长期悲伤(Chronic Sorrow)(00137)157. 超负荷压力(Stress Overload)(00177)158. 自主性反射障碍(Autonomic Dysreflexia)(00009)159. 有自主反射障碍的危险(Risk for Autonomic Dysreflexia)(00010)160. 婴儿行为紊乱(Disorganized Infant Behavior)(00116)161. 婴儿有行为能力增强的潜力(Readiness for Enhanced Organized Infant Behavior)(00117)162. 颅内调试能力下降(Decreased Intracranial Adaptive Capacity)(00049)163. 有增进希望的愿望(Readiness for Enhanced Hope)(00185)164. 有促进精神健康增强的愿望(Readiness for Enhanced Spiritual Well-Being)(00068)165. 决策冲突(Decisional Conflict)(00083)166. 道德困扰(Moral Distress)(00175)167. 不合作(Noncompliance)(00079)168. 虔信受损(Impaired Religiosity)(00169)169. 有增进虔信的愿望(Readiness for Enhanced Religiosity)(00171)170. 有虔信受损的危险(Risk for Impaired Religiosity)(00170)171. 精神困扰(Spiritual Distress)(00066)172. 有精神困扰的危险(Risk for Spiritual Distress)(00067)173. 有感染的危险(Risk for Infection)(00004)174. 清理呼吸道无效(Ineffective Airway Clearance)(00031)175. 有误吸的危险(Risk for Aspiration)(00039)176. 有出血的危险(Risk for Bleeding)(00206)177. 牙齿受损(Impaired Dentition)(00048)178. 有干眼症的危险(Risk for Dry Eye)(00219)179. 有跌倒的危险(Risk for Falls)(00155)180. 有受伤的危险(Risk for Injury)(00035)181. 口腔黏膜受损(Impaired Oral Mucous Membrane)(00045)182. 有围手术期体位性损伤的危险(Risk for Perioperative Positioning Injury)(00087)183. 有周围神经血管功能障碍的危险(Risk for Peripheral Neurovascular Dysfunction)(00086)184. 皮肤完整性受损(Impaired Skin Integrity)(00046)185. 有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)186. 有婴儿猝死综合征的危险(Risk for Sudden Infant Death Syndrome)(00156)187. 有窒息的危险(Risk for Suffocation)(00036)188. 术后恢复延迟(Delayed Surgical Recovery)(00100)189. 有烫伤的危险(Risk for Thermal Injury)(00220)190. 组织完整性受损(Impaired Tissue Integrity)(00044)191. 有外伤的危险(Risk for Trauma)(00038)192. 有血管受损的危险(Risk for Vascular Trauma)(00213)193. 有虐待他人的危险(Risk for Other-Directed Violence)(00138)194. 有自虐的危险(Risk for Self-Directed Violence)(00140)195. 自残(Self-Mutilation)(00151)196. 有自残的危险(Risk for Self-Mutilation)(00139)197. 有自杀的危险(Risk for Suicide)(00150)198. 污染(Contamination)(00181)199. 有污染的危险(Risk for Contamination)(00180)200. 有中毒的危险(Risk for Poisoning)(00037)201. 有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)乳胶过敏反应(Latex Allergy Response)(00041)202. 有过敏反应的危险(Risk for Allergy Response)(00217)203. 有乳胶过敏反应的危险(Risk for Latex Allergy Response)(00042)204. 有体温平衡失调的危险(Risk for Imbalanced Body Temperature)(00005)205. 体温过高(Hyperthermia)(00007)206. 体温过低(Hypothermia)(00006)207. 体温调节无效(Ineffective Thermoregulation)(00008)208. 舒适的改变(Impaired Comfort)(00214)209. 有增加舒适的愿望(Readiness for Enhanced Comfort)(00183)210. 恶心(Nausea)(00134)211. 急性疼痛(Acute Pain)(00132)212. 慢性疼痛(Chronic Pain)(00133)213. 社交隔离(Social Isolation)(00053)214. 有生长不成比例的危险(Risk for Disproportionate Growth)(00113)215. 生长发育迟缓(Delayed Growth and Development)(00111)216. 有发育迟缓的危险(Risk for Delayed Development)(00112)。

NANDA201项护理诊断(2009-2011)与155项护理诊断

NANDA201项护理诊断(2009-2011)与155项护理诊断

155 项护理诊断 -览表 (2001~2002)( 按 NANDA 分类法Ⅱ排列〉一、健康促进(Health promotion)1.执行治疗方案有效2.执行治疗方案无效3.家庭执行治疗方案无效4.社区执行治疗方案无效5.寻求健康行为(具体说明)6.保持健康无效7.持家能力障碍二、营养(Nutrition)8.无效性婴儿喂养型态9.吞咽障碍10.营养失调:低于机体需要量11.营养失调:高于机体需要量12.有营养失调的危险:高于机体需要量13.体液不足14.有体液不足的危险15.体液过多16.有体液失衡的危险三、排泄(Elimination )17.排尿障碍18.尿潴留19.完全性尿失禁20.功能性尿失禁21.压力性尿失禁22.急迫性尿失禁23.反射性尿失禁24.有急迫性尿失禁的危险25.排便失禁26.腹泻27.便秘28.有便秘的危险29.感知性便秘30.气体交换受损四、活动/休息(Activity/rest)31.睡眠型态紊乱32.睡眠剥夺33.有废用综合征的危险34.躯体活动障碍35.床上活动障碍36.借助轮椅活动障碍37.转移能力障碍38.行走障碍39.缺乏娱乐活动40.漫游状态41.穿着/修饰自理缺陷42.沐浴/卫生自理缺陷43.进食自理缺陷44.如厕自理缺陷45.术后康复延缓46.能量场紊乱47.疲乏48.心输出量减少49.自主呼吸受损50.低效性呼吸型态51.活动无耐力52.有活动无耐力的危险53.功能障碍性撤离呼吸机反应54.组织灌注无效(具体说明类型:肾脏、大脑、心、肺、胃肠道、外周)五、感知/认识(Perception/cognition)55.单侧性忽视56.认识环境障碍综合征57.感知紊乱(具体说明:视觉、听觉、运动觉、味觉、触觉、嗅觉) 58.知识缺乏59.急性意识障碍60.慢性意识障碍61.记忆受损62.思维过程紊乱63.语言沟通障碍六、自我感知(Self-perception)64.自我认可紊乱65.无能为力感66.有无能为力感的危险67.无望感68.有孤独的危险69.长期自尊低下70.情境性自尊低下71.有情境性自尊低下的危险72.体像紊乱七、角色关系(Role relationship)73.照顾者角色紧张74.有照顾者角色紧张的危险75.父母不称职76.有父母不称职的危险77.家庭运作中断78.家庭运作功能不全(酗酒)79.有亲子依恋受损的危险80.母乳喂养有效81.母乳喂养无效82.母乳喂养中断83.无效性角色行为84.父母角色冲突85.社交障碍八、性(Sexuality)86.性功能障碍87.无效性性生活型态九、应对/应激耐受性(Coping/stress tolerance) 88.迁居应激综合征89.有迁居应激综合征的危险90.强暴创伤综合征91.强暴创伤综合征:隐匿性反应92.强暴创伤综合征:复合性反应93.创伤后反应94.有创伤后反应的危险95.恐惧96.焦虑97.对死亡的焦虑98.长期悲伤99.无效性否认100.预感性悲哀101.功能障碍性悲哀102.调节障碍103.应对无效104.无能性家庭应对105.妥协性家庭应对106.防卫性应对107.社区应对无效108.有增强家庭应对趋势109.有增强社区应对趋势110.自主性反射失调111.有自主性反射失调的危险112.婴儿行为紊乱113.有婴儿行为紊乱的危险114.有增强调节婴儿行为的趋势 115.颅内适应能力下降十、生活准则(Life principles)116.有增强精神健康的趋势117.精神困扰118.有精神困扰的危险119.抉择冲突120.不依从行为十一、安全/防御(Safety/protection) 121.有感染的危险122.口腔黏膜受损123.有受伤的危险124.有围手术期体位性损伤的危险 125.有摔倒的危险126.有外伤的危险127.皮肤完整性受损128.有皮肤完整性受损的危险129.组织完整性受损130.牙齿受损131.有窒息的危险132.有误息的危险133.清理呼吸道无效134.有外周神经血管功能障碍的危险 135.防护无效136.自伤137.有自伤的危险138.有对他人施行暴力的危险139.有对自己施行暴力的危险140.有自杀的危险141.有中毒的危险142.乳胶过敏反应143.有乳胶过敏反应的危险144.有体温失调的危险145.体温调节无效146.体温过低147.体温过高十二、舒适(Comfort)148.急性疼痛149.慢性疼痛150.恶心151.社交孤立十三、成长/发展(Growth/development) 152.成长发展延缓153.成人身心衰竭154.有发展迟滞的危险155.有成长比例失调的危险精品文档201项护理诊断一览表(2009~2011)领域1:健康促进(Health Promotion)1.健康维护能力低下(Ineffective Health Maintenance)2.自我健康管理无效(Ineffective Self Health Management)3.持家能力障碍(Impaired Home Maintenance)4.有免疫状态改善的趋势(Readiness for Enhanced Immunization Status)5.忽视自我健康管理(Self Neglect)6.有营养改善的趋势(Readiness for Enhanced Nutrition)7.家庭执行治疗方案无效Ineffective Family Therapeutic Regimen Management)8.有自我健康管理改善的趋势(Readiness for Enhanced Self Health Management)领域2:营养(Nutrition)9.无效性婴儿喂养型态(Ineffective Infant Feeding Pattern)10.营养失调:低于机体需要量(Imbalanced Nutrition:Less Than Body Requirements)11.营养失调:高于机体需要量(Imbalanced Nutrition:More Than Body Requirements)12.有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition:More Than Body Requirements)13.吞咽障碍(Impaired Swallowing)14.有血糖不稳定的危险(Risk for Unstable Glucose Level)15.新生儿黄疸(Neonatal Jaundice)16.有肝功能受损的危险(Risk for Impaired Liver Function)17.有电解质失衡的危险(Risk for Electrolyte Imbalance)18.有体液平衡改善的趋势(Readiness for Enhanced Fluid Balance)19.体液不足(Deficient Fluid Volume)20.体液过多(Excess Fluid Volume)21.有体液不足的危险(Risk for Deficient Fluid Volume)22.有体液失衡的危险(Risk for Imbalanced Fluid Volume)领域3:排泄(Elimination and Exchange)23.排尿障碍(Impaired Urinary Elimination)24.功能性尿失禁(Functional Urinary Incontinence)25.溢出性尿失禁(Overflow Urinary Incontinence)26.反射性尿失禁(Reflex Urinary Incontinence)27.压力性尿失禁(Stress Urinary Incontinence)28.急迫性尿失禁(Urge Urinary Incontinence)29.有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)30.尿潴留(Urinary Retention)31.有排尿功能改善的趋势(Readiness for Enhanced Urinary Elimination)32.排便失禁(Bowel Incontinence)33.便秘(Constipation)34.感知性便秘(Perceived Constipation)35.有便秘的危险(Risk for Constipation)36.腹泻(Diarrhea)37.胃肠动力失调(Dysfunctional Gastrointestinal Motility)38.有胃肠动力失调的危险(Risk for Dysfunctional Gastrointestinal Motility)39.气体交换障碍(Impaired Gas Exchange)领域4:活动/休息(Activity/Rest)40失眠(Insomnia)41.睡眠型态紊乱(Disturbed Sleep Pattern)42.睡眠剥夺(Sleep Deprivation)43.有睡眠改善的趋势(Readiness for Enhanced Sleep)44.有废用综合征的危险(Risk for Disuse Syndrome)45.缺乏娱乐活动(Deficient Diversional Activity)46.久坐的生活方式(Sedentary Lifestyle)47.床上活动障碍(Impaired Bed Mobility)48.躯体活动障碍(Impaired Physical Mobility)49.借助轮椅活动障碍(Impaired wheelchair Mobility)50.移动能力障碍(Impaired Transfer Ability)51.行走障碍(Impaired Walking)52.术后康复迟缓(Delayed Surgical Recovery)53.能量场紊乱(Disturbed Energy Field)54.疲乏(Fatigue)55.活动无耐力(Activity Intolerance)56.有活动无耐力的危险(Risk for Activity Intolerance)57.有出血的危险(Risk for Bleeding)58.低效性呼吸型态(Ineffective Breathing Pattern)59.心输出量减少(Decreased Cardiac Output)60.外周组织灌注无效(Ineffective Peripheral Tissue Perfusion)61.有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)62.有脑组织灌注无效的危险(Risk for Ineffective Cerebral Tissue Perfusion)63.有胃肠道灌注无效的危险(Risk for Ineffective Gastrointestinal Tissue Perfusion)64.有肾脏灌注无效的危险(Risk for Ineffective Renal Perfusion)65.有休克的危险(Risk for Shock)66.自主呼吸障碍(Impaired Spontaneous Ventilation)67.呼吸机依赖(Dysfunctional Ventilatory Weaning Response)68.有自理能力增强的趋势(Readiness for Enhanced Self-Care)69.沐浴/卫生自理缺陷(Bathing/Hygiene Self-Care Deficit))70.穿着/修饰自理缺陷(Dressing/grooming Self-Care Deficit)71.进食自理缺陷(Feeding Self-Care Deficit)72.如厕自理缺陷(Toileting Self-Care Deficit)领域5:感知/认知(Perception/Cognition)73单侧身体忽视(Unilateral Neglect)74.环境认知障碍综合征(Impaired Environmental Interpretation Syndrome)75.漫游状态(Wandering)76.感知觉紊乱(具体说明:视觉、听觉、方位感、味觉、触觉、嗅觉)(Disturbed Sensory Perception〔Specify:Visual,Auditory,Kinesthetic,Gustatory,Tactile,Olfactory)77.急性意识障碍(Acute Confusion)78.慢性意识障碍(Chronic Confusion)79.有急性意识障碍的危险(Risk for Acute Confusion)80.知识缺乏(Deficient Knowledge)81.有知识增进的趋势(Readiness for Enhanced Knowledge)82.记忆功能障碍(Impaired Memory)83.有决策能力增强的趋势(Readiness for Enhanced Decision-Making)84.活动计划无效(Ineffective Activity Planning)85.语言沟通障碍(Impaired Verbal Communication)86.有沟通增进的趋势(Readiness for Enhanced Communication)领域6:自我感知(Self-Perception)87.有个人尊严受损的危险(Risk for Compromised Human Dignity)88.无望感(Hopelessness)89.自我认同紊乱(Disturbed Personal Identity)90.有孤独的危险(Risk for Loneliness)91.有能力增强的趋势(Readiness for Enhanced Power)92.无能为力感(Powerlessness)93.有无能为力感的危险(Risk for Powerlessness)94.有自我概念改善的趋势(Readiness for Enhanced Self-Concept)95.情境性低自尊(Situational low Self-Esteem)96.长期性低自尊(Chronic Low Self-Esteem)97.有情境性低自尊的危险(Risk for Situational Low Self-Esteem)98.体像紊乱(Disturbed Body Image)领域7:角色关系(Role Relationships)99.照顾者角色紧张(Caregiver Role Strain)100.有照顾者角色紧张的危险(Risk for Caregiver Role Strain)101.养育功能障碍(Impaired Parenting)102.有养育功能改善的趋势(Readiness for Enhanced Parenting)103.有养育功能障碍的危险(Risk for Impaired Parenting)104.有依附关系受损的危险(Risk for Impaired Parent/Infant/Child Attachment)105.家庭运作过程失常(Dysfunctional Family Processes)106.家庭运作过程改变(Interrupted Family Processes)107.有家庭运作过程改善的趋势(Readiness for Enhanced Family Processes)108.母乳喂养有效(Effective Breastfeeding)109.母乳喂养无效(Ineffective Breastfeeding)110.母乳喂养中断(Interrupted Breastfeeding)111.父母角色冲突(Parental Role Conflict)112.有关系改善的趋势(Readiness for Enhanced Relationship)113.无效性角色行为(Ineffective Role Performance)114.社会交往障碍(Impaired Social Interaction)领域8:性(Sexuality)115.性功能障碍(Sexual Dysfunction)116.性生活型态无效(Ineffective Sexuality Patterns)117.有生育进程改善的趋势(Readiness for Enhanced Childbearing Process)118.有母体与胎儿双方受干扰的危险(Risk for Disturbed Maternal/Fetal Dyad)领域9:应对/应激耐受性(Coping/Stress Tolerance)119.创伤后综合征(Post Trauma Syndrome)120.有创伤后综合征的危险(Risk for Post Trauma Syndrome)121.强暴创伤综合征(Rape-Trauma Syndrome)122.迁移应激综合征(Relocation Stress Syndrome)123.有迁移应激综合征的危险(Risk for Relocation Stress Syndrome)124.焦虑(Anxiety)125.对死亡的焦虑(Death Anxiety)126.有威胁健康的行为(Risk-Prone Health Behavior)127.妥协性家庭应对(Compromised Family Coping)128.无能性家庭应对(Disabled Family Coping)129.防卫性应对(Defensive Coping)130.应对无效(Ineffective Coping)131.社区应对无效(Ineffective Community Coping)132.有应对增强的趋势(Readiness for Enhanced Coping)133.有社区应对增强的趋势(Readiness for Enhanced Community Coping)134.有家庭应对增强的趋势(Readiness for Enhanced Family Coping)135.无效性否认(Ineffective Denial)136.恐惧(Fear)137.悲伤(Grieving)138.复杂性悲伤(Complicated Grieving)139.有复杂性悲伤的危险(Risk for Complicated Grieving)140.个人恢复能力障碍(Impaired Individual Resilience)141.有恢复能力受损的危险(Risk for Compromised Resilience)142.有恢复能力增强的趋势(Readiness for Enhanced Resilience)143.持续性悲伤(Chronic Sorrow)144.压力负荷过重(Stress Overload)145.自主性反射失调(Autonomic Dysreflexia)146.有自主性反射失调的危险(Risk for Autonomic Dysreflexia)147.婴儿行为紊乱(Disorganized Infant Behavior)148.有婴儿行为紊乱的危险(Risk for Disorganized Infant Behavior)149.有婴儿行为调节改善的趋势(Readiness for Enhanced Organized Infant Behavior)150.颅内调适能力降低(Decreased Intracranial Adaptive Capacity)领域10:生活准则(Life Principles)151.有希望增强的趋势(Readiness for Enhanced Hope)152.有精神安适增进的趋势(Readiness for Enhanced Spiritual Well-being)153.抉择冲突(Decisional Conflict)154.道德困扰(Moral Distress)155.不依从行为(Noncompliance)156.宗教信仰减弱(Impaired Religiosity)157.有宗教信仰增强的趋势(Readiness for Enhanced Religiosity)158.有宗教信仰减弱的危险(Risk for Impaired Religiosity)159.精神困扰(Spiritual Distress)160.有精神困扰的危险(Risk for Spiritual Distress)领域11:安全/防护(Safety/Protection)161.有感染的危险(Risk for Infect ion)162.清理呼吸道无效(Ineffective Airway Clearance)163.有误吸的危险(Risk for Aspiration)164.有婴儿猝死综合症的危险(Risk for Sudden Infant Death Syndrome)165.牙齿受损(Impaired Dentition)166.有跌倒的危险(Risk for Falls)167.有受伤害的危险(Risk for Injury)168.有手术期体位性损伤的危险(Risk for Perioperative-Positioning Injury)169.口腔黏膜受损(Impaired Oral Mucous Membrane)170.有外周神经血管功能障碍的危险(Risk for Peripheral Neurovascular Dysfunction)171.防护能力低下(Ineffective Protection)172.皮肤完整性受损(Impaired Skin Integrity)173.有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)174.有窒息的危险(Risk for Suffocation)175.组织完整性受损(Impaired Tissue Integrity)176.有外伤的危险(Risk for Trauma)177.有血管损伤的危险(Risk for Vascular Trauma)178.自伤(Self-Mutilation)179.有自伤的危险(Risk for Self-Mutilation)180.有自杀的危险(Risk for Suicide)181.有对他人施行暴力的危险(Risk for Other-Directed Violence)182.有对自己施行暴力的危险(Risk for Self-Directed Violence)183.受污染(Contamination)184.有受污染的危险(Risk for Contamination)185.有中毒的危险(Risk for Poisoning)186.乳胶过敏反应(Latex Allergy Response)187.有乳胶过敏反应的危险(Risk for Latex Allergy Response)188.有体温失调的危险(Risk for Imbalanced Body Temperature)189.体温过高(Hyperthermia)190.体温过低(Hypothermia)191.体温调节无效(Ineffective Thermoregulation)领域12:舒适(Comfort)192.有舒适增进的趋势(Readiness for Enhanced Comfort)193.舒适度减弱(Impaired Comfort)194.恶心(Nausea)195.急性疼痛(Acute Pain)196.慢性疼痛(Chronic Pain)197.社交孤立(Social Isolation)领域13:生长/发展(Growth/Development)198.成人身心功能衰退(Adult Failure to Thrive)199.生长发展迟缓(Delayed Growth and Development)200.有发展迟缓的危险(Risk for Delayed Development)201.有生长比例失调的危险(Risk for Disproportionate Growth)。

新版216个护理问题NANDA护理问题

新版216个护理问题NANDA护理问题

新版216个护理问题NANDA护理问题
NANDA护理问题分类是由国际护理诊断协会(Nursing Diagnoses Association)制定的一套标准化的护理问题分类系统。


个分类系统包含了大量的护理问题,帮助护士快速准确地评估、诊
断和规划患者护理。

最近,NANDA发布了新版的216个护理问题,进一步完善了这一分类系统。

这份文档将介绍新版216个护理问题NANDA护理问题的内容,让护士了解这些护理问题的定义和特征。

通过了解这些护理问题,
护士可以更好地进行护理评估和护理干预,提高护理质量。

文档内容将按照NANDA护理问题分类的结构组织,将每个护
理问题的名称、定义、特征和相关参考文献进行介绍。

这样的组织
结构使得文档易于阅读和查找需要的信息。

为了确保文档的准确性和可靠性,所有内容将以确凿的来源为
基础。

引用的内容都会注明引用来源,确保内容可追溯。

同时,文
档将以简洁明了的语言进行撰写,避免复杂的法律问题和术语,专
注于护理问题的介绍和说明。

总结而言,这份文档将为护士提供关于新版216个护理问题NANDA护理问题的详细信息,帮助护士评估和诊断患者,并规划相应的护理干预。

这将有助于提高护理质量,确保患者获得最佳的护理服务。

NANDA护理诊断一览表(2018-2020)中英文对照版

NANDA护理诊断一览表(2018-2020)中英文对照版

NANDA护理诊断一览表(2018-2020)中英文对照版NANDA护理诊断一览表(2018-2020)领域1:健康促进(Health n)类别1:健康觉察(Health awareness)减少娱乐活动参与(Decreased XXX)增强健康素养的准备(XXX)久坐的生活方式(Sedentary lifestyle)类别2:健康管理(Health management)衰弱老年综合征(Frail elderly syndrome)衰弱老年综合征的危险(Risk for frail elderly syndrome)缺乏社区保健(Deficient community health)风险倾向的健康行为(Risk-prone health r)无效的健康维护(Ineffective health maintenance)无效的健康管理(Ineffective Health Management)准备改善健康管理(Readiness for Enhanced Health Management)无效的家庭健康管理(Ineffective Family Health Management)无效的防护(XXX)领域2:营养(n)类别1:摄食(n)营养失调:低于机体需要量(Imbalanced n: less than body requirements)准备改善营养(Readiness for XXX)母乳泌乳不足(Insufficient breast milk n)无效的母乳喂养(Ineffective breastfeeding)准备改善母乳喂养(Readiness for XXX)准备改善母乳喂养(Readiness for XXX)XXX。

Children。

and Infants:Many young people are not XXX。

This can lead to obesity and other health problems。

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新版216个护理诊断NANDA护理诊断NANDA-I护理诊断2012~2014(共216页)1.领域1:健康促进(Health Promotion)2.类别1:健康意识(Health Awareness)3.娱乐活动缺乏(Deficient Diversional Activity)(00097)4.静态的生活方式(Sedentary Lifestyle)(00168)5.类别2:健康管理(Health Management)6.缺乏公共卫生(Deficient Community Health)(00215)7.有危险倾向的健康行为(Risk-Prone Health Behavior)(00188)8.健康维持无效(Ineffective Health Maintenance)(00099)9.有增强免疫状态的愿望(Readiness for Enhanced Immunization Status)(00186)10.防护无效(Ineffective Protection)(00043)11.自我健康维持无效(Ineffective Self-Health Management)(00078)12.有增强自我健康管理的愿望(Readiness for Enhanced Self-Health Management)(00162)家庭执行治疗方案无效(Ineffective Family Therapeutic Regimen Management)(00080)13.领域2:营养(Nutrition)14.类别1:摄入(Ingestion)15.母乳不足(Insufficient Breast Milk)(00216)16.婴儿喂养无效(Ineffective Infant Feeding Pattern)(00107)17.营养失调:低于机体需要量(Imbalanced Nutrition:Less Than BodyRequirements)(00002)营养失调:高于机体需要量(Imbalanced Nutrition:More Than Body Requirements)(00001)有增强营养的愿望(Readiness for Enhanced Nutrition)(00163)18.有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition:More ThanBody Requirements)(00003)19.吞咽能力受损(Impaired Swallowing)(00103)20.类别2:消化(Digestion)21.类别3:吸收(Absorption)22.类别4:代谢(Metabolism)23.有血糖不稳定的危险(Risk for Unstable Blood Glucose Level)(00179)24.新生儿黄疸(Neonatal Jaundice)(00194)25.有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)26.有肝功能受损的危险(Risk for Impaired Liver Function)(00178)27.类别5:水化28.有电解质失衡的危险(Risk for Electrolyte Imbalance)(00195)29.有维持体液平衡的愿望(Readiness for Enhanced Fluid Balance)(00160)30.体液不足(Deficient Fluid Volume)(00027)31.体液过多(Excess Fluid Volume)(00026)32.有体液不足的危险(Risk for Deficient Fluid Volume)(00028)33.有体液失衡的危险(Risk for Imbalanced Fluid Volume)(00025)34.领域3:排泄(Elimination and Exchange)35.类别1:排尿功能(Urinary Function)36.功能性尿失禁(Functional Urinary Incontinence)(00020)37.充溢性尿失禁(Overflow Urinary Incontinence)(00176)38.反射性尿失禁(Reflex Urinary Incontinence)(00018)39.压力性尿失禁(Stress Urinary Incontinence)(00017)40.急迫性尿失禁(Urge Urinary Incontinence)(00019)41.有急迫性尿失禁的危险(Risk for Urge Urinary Incontinence)(00022)42.排尿形态改变(Impaired Urinary Elimination)(00016)43.有排尿形态恢复正常的愿望(Readiness for Enhanced Urinary Elimination)(00166)尿潴留(Urinary Retention)(00023)44.类别2:胃肠功能(Gastrointestinal Function)45.便秘(Constipation)(00011)46.感知性便秘(Perceived Constipation)(00012)47.有便秘的危险(Risk for Constipation)(00015)48.腹泻(Diarrhea)(00013)49.胃肠动力紊乱(Dysfunctional Gastrointestinal Motility)(00196)50.有胃肠动力紊乱的危险(Risk for Dysfunctional Gastrointestinal Motility)(00197)排便失禁(Bowel Incontinence)(00014)51.类别3:皮肤功能(Integumentary Function)52.类别4:呼吸功能(Respiratory Function)53.气体交换受损(Impaired Gas Exchange)(00030)54.领域4:活动∕休息(Activit y∕Rest)55.类别1:睡眠/休息(Sleep/Rest)56.失眠(Insomnia)(00095)57.睡眠剥夺(Sleep Deprivation)(00096)58.有睡眠形态增进的愿望(Readiness for Enhanced Sleep)(00165)59.睡眠形态紊乱(Disturbed Sleep Pattern)(00198)60.类别2:活动/运动(Activity/Exercise)61.有废用综合征的危险(Risk for Disuse Syndrome)(00040)62.床上活动障碍(Impaired Bed Mobility)(00091)63.躯体移动障碍(Impaired Physical Mobility)(00085)64.借助轮椅活动障碍(Impaired Wheelchair Mobility)(00089)65.移位能力障碍(Impaired Transfer Ability)(00090)66.行走障碍(Impaired Walking)(00088)67.类别3:能量平衡(Energy Balance)68.能量场紊乱(Disturbed Energy Field)(00050)69.疲乏(Fatigue)(00093)70.漫游(Wandering)(00154)71.类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)72.活动无耐力(Activity Intolerance)(00092)73.有活动无耐力的危险(Risk for Activity Intolerance)(00094)74.低效性呼吸形态(Ineffective Breathing Pattern)(00032)75.心输出量减少(Decreased Cardiac Output)(00029)76.有胃肠灌注不足的危险(Risk for Ineffective Gastrointestinal Perfusion)(00202)77.有肾脏灌注不足的危险(Risk for Ineffective Renal Perfusion)(00203)78.不能维持自主呼吸(Impaired Spontaneous Ventilation)(00033)79.周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)80.有心脏组织灌注不足的危险(Risk for Decreased Cardiac Tissue Perfusion)(00200)有脑组织灌注不足的危险(Risk for Ineffective Cerebral Tissue Perfusion)(00201)有周围组织灌注不足的危险(Risk for IneffectivePeripheral Tissue Perfusion)(00228)呼吸机依赖(Dysfunctional Ventilatory Weaning Response)(00034)类别5:自我照顾(Self-Care)81.持家能力障碍(Impaired Home Maintenance)(00098)82.有增强自理的愿望(Readiness for Enhanced Self-Care)(00182)83.沐浴自理缺陷(Bathing Self-Care Deficit)(00108)84.穿衣自理缺陷(Dressing Self-Care Deficit)(00109)85.进食自理缺陷(Feeding Self-Care Deficit)(00102)86.如厕自理缺陷(Toileting Self-Care Deficit)(00110)87.忽视自我健康管理(Self-Neglect)(00193)88.领域5:知觉∕认知(Perception∕Cognition)89.类别1:注意力(Attention)90.忽视单侧身体(Unilateral Neglect)(00123)91.类别2:定向力(Orientation)92.环境解析障碍综合征(Impaired Environmental Interpretation Syndrome)(00127)类别3:感觉/知觉(Sensation/Perception)93.类别4:认知(Cognition)94.急性意识障碍(Acute Confusion)(00128)95.慢性意识障碍(Chronic Confusion)(00129)96.有急性意识障碍的危险(Risk for Acute Confusion)(00173)97.自我控制无效(Ineffective Impulse Control)(00222)98.知识缺乏(Deficient Knowledge)(00126)99.有增加知识的愿望(Readiness for Enhanced Knowledge)(00161)100.记忆受损(Impaired Memory)(00131)101.类别5:沟通(Communication)102.有加强沟通的愿望(Readiness for Enhanced Communication)(00157)103.语言沟通障碍(Impaired Verbal Communication)(00051)104.领域6:自我知觉(Self-Perception)105.类别1:自我概念(Self-Concept)106.绝望(Hopelessness)(00124)107.有危及个人尊严的危险(Risk for Compromised Human Dignity)(00174)108.有孤独的危险(Risk for Loneliness)(00054)109.自我认同紊乱(Disturbed Personal Identity)(00121)110.有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)111.有增强自我概念的愿望(Readiness for Enhanced Self-Concept)(00167)类别2:自尊Self-Esteem112.慢性低自尊(Chronic Low Self-Esteem)(00119)113.情境性低自尊(Situational Low Self-Esteem)(00120)114.有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)115.有情境性低自尊的危险(Risk for Situational Low Self-Esteem)(00153)类别3:自我形象(Body Image)116.自我形象紊乱(Disturbed Body Image)(00118)117.领域7:角色关系(Role Relationships)118.类别1:照顾者角色(Caregiving Roles)119.母乳喂养无效(Ineffective Breastfeeding)(00104)120.母乳喂养中断(Interrupted Breastfeeding)(00105)121.有增强母乳喂养的愿望(Readiness for Enhanced Breastfeeding)(00106)122.照顾者角色紧张(Caregiver Role Strain)(00061)123.有照顾者角色紧张的危险(Risk for Caregiver Role Strain)(00062)124.抚养障碍(Impaired Parenting)(00056)125.有增进抚养能力的愿望(Readiness for Enhanced Parenting)(00164)126.有抚养障碍的危险(Risk for Impaired Parenting)(00057)127.类别2:家庭关系(Family Relationships)128.有依附关系障碍的危险(Risk for Impaired Attachment)(00058)129.家庭运作紊乱(Dysfunctional Family Processes)(00063)130.家庭运作中断(Interrupted Family Processes)(00060)131.有家庭运作稳定的愿望(Readiness for Enhanced Family Processes)(00159)类别3:角色表现(Role Performance)132.无效的关系(Ineffective Relationship)(00223)133.有增进关系的愿望(Readiness for Enhanced Relationship)(00207)134.有关系无效的危险(Risk for Ineffective Relationship)(00229)135.父母角色冲突(Parental Role Conflict)(00064)136.角色紊乱(Ineffective Role Performance)(00055)137.社交障碍(Impaired Social Interaction)(00052)138.领域8:性学(Sexuality)139.类别1:性别认同(Sexual Identity)140.类别2:性功能(Sexual Function)141.性功能障碍(Sexual Dysfunction)(00059)142.性生活形态改变(Ineffective Sexuality Pattern)(00065)143.类别3:生殖(Reproduction)144.分娩过程无效(Ineffective Childbearing Process)(00221)145.有增进分娩过程的愿望(Readiness for Enhanced Childbearing Process)(00208)有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)有母体-胎儿受干扰的危险(Risk for Disturbed Maternal-Fetal Dyad)(00209)146.领域9:调适∕压力耐受(Coping∕Stress Tolerance)147.类别1:创伤后反应(Post-Trauma Responses)148.创伤后综合征(Post-Trauma Syndrome)(00141)149.有创伤后综合征的危险(Risk for Post-Trauma Syndrome)(00145)150.强暴创伤综合征(Rape-Trauma Syndrome)(00142)151.迁移应激综合征(Relocation Stress Syndrome)(00114)152.有迁移应激综合征的危险(Risk for Relocation Stress Syndrome)(00149)类别2:应对反应(Coping Responses)153.活动计划无效(Ineffective Activity Planning)(00199)154.有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)155.焦虑(Anxiety)(00146)156.防御性应对(Defensive Coping)(00071)157.应对无效(Ineffective Coping)(00069)158.有增强应对的愿望(Readiness for Enhanced Coping)(00158)159.社区应对无效(Ineffective Community Coping)(00077)160.社区有增强应对的愿望(Readiness for Enhanced Community Coping)(00076)161.家庭妥协性应对(Compromised Family Coping)(00074)162.家庭应对缺陷(Disabled Family Coping)(00073)163.家庭有增强应对的愿望(Readiness for Enhanced Family Coping)(00075)164.死亡焦虑(Death Anxiety)(00147)165.无效性否认(Ineffective Denial)(00072)166.成人生存功能衰退(Adult Failure to Thrive)(00101)167.恐惧(Fear)(00148)168.悲痛(Grieving)(00136)169.复杂性哀伤(Complicated Grieving)(00135)170.有复杂性哀伤的危险(Risk for Complicated Grieving)(00172)171.有增强能力的愿望(Readiness for Enhanced Power)(00187)172.无能为力(Powerlessness)(00125)173.有无能为力的危险(Risk for Powerlessness)(00152)174.个人复原能力受损(Impaired Individual Resilience)(00210)175.有增强复原能力的愿望(Readiness for Enhanced Resilience)(00212)176.有危及复原的危险(Risk for Compromised Resilience)(00211)177.长期悲伤(Chronic Sorrow)(00137)178.超负荷压力(Stress Overload)(00177)179.类别3:神经行为压力(Neurobehavioral Stress)180.自主性反射障碍(Autonomic Dysreflexia)(00009)181.有自主反射障碍的危险(Risk for Autonomic Dysreflexia)(00010)182.婴儿行为紊乱(Disorganized Infant Behavior)(00116)183.婴儿有行为能力增强的潜力(Readiness for Enhanced Organized Infant Behavior)(00117)有婴儿行为紊乱的危险(Risk for Disorganized Infant Behavior)(00115)184.颅内调试能力下降(Decreased Intracranial Adaptive Capacity)(00049)185.领域10:生命原则(Life Principles)186.类别1:价值观(Values)187.有增进希望的愿望(Readiness for Enhanced Hope)(00185)188.类别2:信念(Beliefs)189.有促进精神健康增强的愿望(Readiness for Enhanced Spiritual Well-Being)(00068)190.类别3:价值/信念/行动一致(Value/Belief/Action Congruence)191.有增强决策的愿望(Readiness for Enhanced Decision-Making)(00184)192.决策冲突(Decisional Conflict)(00083)193.道德困扰(Moral Distress)(00175)194.不合作(Noncompliance)(00079)195.虔信受损(Impaired Religiosity)(00169)196.有增进虔信的愿望(Readiness for Enhanced Religiosity)(00171)197.有虔信受损的危险(Risk for Impaired Religiosity)(00170)198.精神困扰(Spiritual Distress)(00066)199.有精神困扰的危险(Risk for Spiritual Distress)(00067)200.领域11:安全∕保护(Safety∕Protection)201.类别1:感染(Infection)202.有感染的危险(Risk for Infection)(00004)203.类别2:身体伤害(Physical Injury)204.清理呼吸道无效(Ineffective Airway Clearance)(00031)205.有误吸的危险(Risk for Aspiration)(00039)206.有出血的危险(Risk for Bleeding)(00206)207.牙齿受损(Impaired Dentition)(00048)208.有干眼症的危险(Risk for Dry Eye)(00219)209.有跌倒的危险(Risk for Falls)(00155)210.有受伤的危险(Risk for Injury)(00035)211.口腔黏膜受损(Impaired Oral Mucous Membrane)(00045)212.有围手术期体位性损伤的危险(Risk for Perioperative Positioning Injury)(00087)213.有周围神经血管功能障碍的危险(Risk for Peripheral Neurovascular Dysfunction)(00086)有休克的危险(Risk for Shock)(00205)214.皮肤完整性受损(Impaired Skin Integrity)(00046)215.有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)216.有婴儿猝死综合征的危险(Risk for Sudden Infant Death Syndrome)(00156)217.有窒息的危险(Risk for Suffocation)(00036)218.术后恢复延迟(Delayed Surgical Recovery)(00100)219.有烫伤的危险(Risk for Thermal Injury)(00220)220.组织完整性受损(Impaired Tissue Integrity)(00044)221.有外伤的危险(Risk for Trauma)(00038)222.有血管受损的危险(Risk for Vascular Trauma)(00213)223.类别3:暴力(Violence)224.有虐待他人的危险(Risk for Other-Directed Violence)(00138)225.有自虐的危险(Risk for Self-Directed Violence)(00140)226.自残(Self-Mutilation)(00151)227.有自残的危险(Risk for Self-Mutilation)(00139)228.有自杀的危险(Risk for Suicide)(00150)229.类别4:环境危害(Environmental Hazards)230.污染(Contamination)(00181)231.有污染的危险(Risk for Contamination)(00180)232.有中毒的危险(Risk for Poisoning)(00037)233.类别5:防御过程(Defensive Processes)234.有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)乳胶过敏反应(Latex Allergy Response)(00041)235.有过敏反应的危险(Risk for Allergy Response)(00217)236.有乳胶过敏反应的危险(Risk for Latex Allergy Response)(00042)237.类别6:体温调节(Thermoregulation)238.有体温平衡失调的危险(Risk for Imbalanced Body Temperature)(00005)239.体温过高(Hyperthermia)(00007)240.体温过低(Hypothermia)(00006)241.体温调节无效(Ineffective Thermoregulation)(00008)242.领域12:舒适(Comfort)243.类别1:身体舒适(Physical Comfort)244.类别2:环境舒适(Environmental Comfort)245.类别3:社交舒适(Social Comfort)246.舒适的改变(Impaired Comfort)(00214)247.有增加舒适的愿望(Readiness for Enhanced Comfort)(00183)248.恶心(Nausea)(00134)249.急性疼痛(Acute Pain)(00132)250.慢性疼痛(Chronic Pain)(00133)251.社交隔离(Social Isolation)(00053)252.领域13:生长∕发育(Growth∕Development)253.类别1:生长(Growth)254.有生长不成比例的危险(Risk for Disproportionate Growth)(00113)255.类别2:发育(Development)256.生长发育迟缓(Delayed Growth and Development)(00111)257.有发育迟缓的危险(Risk for Delayed Development)(00112)258.一、新增诊断(16项):259.领域1:健康促进(Health Promotion)260.类别2:健康管理(Health Management)261.缺乏公共卫生(Deficient Community Health)(00215)262.领域2:营养(Nutrition)263.类别1:摄入(Ingestion)264.母乳不足(Insufficient Breast Milk)(00216)265.类别4:代谢(Metabolism)266.有新生儿黄疸的危险(Risk for Neonatal Jaundice)(00230)267.领域4:活动∕休息(Activit y∕Rest)268.类别4:心血管/肺部反应(Cardiovascular/Pulmonary Responses)269.有周围组织灌注不足的危险(Risk for Ineffective Peripheral Tissue Perfusion)(00228)领域5:知觉∕认知(Perception∕Cognition)270.类别3:感觉/知觉(Sensation/Perception)271.类别4:认知(Cognition)272.自我控制无效(Ineffective Impulse Control)(00222)273.领域6:自我知觉(Self-Perception)274.类别1:自我概念(Self-Concept)275.有自我认同紊乱的危险(Risk for Disturbed Personal Identity)(00225)类别2:自尊Self-Esteem276.有慢性低自尊的危险(Risk for Chronic Low Self-Esteem)(00224)277.领域7:角色关系(Role Relationships)278.类别3:角色表现(Role Performance)279.无效的关系(Ineffective Relationship)(00223)280.有关系无效的危险(Risk for Ineffective Relationship)(00229)281.领域8:性学(Sexuality)282.类别3:生殖(Reproduction)283.分娩过程无效(Ineffective Childbearing Process)(00221)284.有分娩过程无效的危险(Risk for Ineffective Childbearing Process)(00227)285.领域9:调适∕压力耐受(Coping∕Stress Tolerance)286.类别2:应对反应(Coping Responses)287.有活动计划无效的危险(Risk for Ineffective Activity Planning)(00226)288.领域11:安全∕保护(Safety∕Protection)289.类别2:身体伤害(Physical Injury)290.有干眼症的危险(Risk for Dry Eye)(00219)291.有烫伤的危险(Risk for Thermal Injury)(00220)292.类别5:防御过程(Defensive Processes)293.有碘造影剂不良反应的危险(Risk for Adverse Reaction to Iodinated Contrast Media)(000218)有过敏反应的危险(Risk for Allergy Response)(00217)294.二、修改诊断(11项):295.有增强母乳喂养的愿望(Readiness for Enhanced Breastfeeding)(00106)296.低效性呼吸形态(Ineffective Breathing Pattern)(00032)297.舒适的改变(Impaired Comfort)(00214)298.有感染的危险(Risk for Infection)(00004)299.新生儿黄疸(Neonatal Jaundice)(00194)300.恶心(Nausea)(00134)301.无能为力(Powerlessness)(00125)302.有无能为力的危险(Risk for Powerlessness)(00152)303.有增强自我健康管理的愿望(Readiness for Enhanced Self-Health Management)(00162)有皮肤完整性受损的危险(Risk for Impaired Skin Integrity)(00047)304.周围组织灌注不足(Ineffective Peripheral Tissue Perfusion)(00204)305.三、退出诊断(1项):306.领域5:知觉∕认知(Perception∕Cognition)307.类别5:沟通(Communication)308.感觉知觉紊乱(特定的:视觉、听觉、方位感、味觉、触觉、嗅觉)(Disturbed Sensory Perception)(00122)。

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