NANDA201项护理诊断(2009-2011).doc

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1、 201项护理诊断一览表(20092011)领域1:健康促进(HealthPromotion)1.健康维护能力低下(IneffectiveHealthMaintenance)2.自我健康管理无效(IneffectiveSelfHealthManagement)3.持家能力障碍(ImpairedHomeMaintenance)4.有免疫状态改善的趋势(ReadinessforEnhancedImmunizationStatus)5.忽视自我健康管理(SelfNeglect)6.有营养改善的趋势(ReadinessforEnhancedNutrition)7.家庭执行治疗方案无效Ineffecti

2、veFamilyTherapeuticRegimenManagement)8.有自我健康管理改善的趋势(ReadinessforEnhancedSelfHealthManagement)领域2:营养(Nutrition)9.无效性婴儿喂养型态(IneffectiveInfantFeedingPattern)10.营养失调:低于机体需要量(ImbalancedNutrition:LessThanBodyRequirements)11.营养失调:高于机体需要量(ImbalancedNutrition:MoreThanBodyRequirements)12.有营养失调的危险:高于机体需要量(Risk

3、forImbalancedNutrition:MoreThanBodyRequirements)13.吞咽障碍(ImpairedSwallowing)14.有血糖不稳定的危险(RiskforUnstableGlucoseLevel)15.新生儿黄疸(NeonatalJaundice)16.有肝功能受损的危险(RiskforImpairedLiverFunction)17.有电解质失衡的危险(RiskforElectrolyteImbalance)18.有体液平衡改善的趋势(ReadinessforEnhancedFluidBalance)19.体液不足(DeficientFluidVolume

4、)20.体液过多(ExcessFluidVolume)21.有体液不足的危险(RiskforDeficientFluidVolume)22.有体液失衡的危险(RiskforImbalancedFluidVolume)领域3:排泄(EliminationandExchange)23.排尿障碍(ImpairedUrinaryElimination)24.功能性尿失禁(FunctionalUrinaryIncontinence)25.溢出性尿失禁(OverflowUrinaryIncontinence)26.反射性尿失禁(ReflexUrinaryIncontinence)27.压力性尿失禁(Str

5、essUrinaryIncontinence)28.急迫性尿失禁(UrgeUrinaryIncontinence)29.有急迫性尿失禁的危险(RiskforUrgeUrinaryIncontinence)30.尿潴留(UrinaryRetention)31.有排尿功能改善的趋势(ReadinessforEnhancedUrinaryElimination)32.排便失禁(BowelIncontinence)33.便秘(Constipation)34.感知性便秘(PerceivedConstipation)35.有便秘的危险(RiskforConstipation)36.腹泻(Diarrhea)

6、37.胃肠动力失调(DysfunctionalGastrointestinalMotility)38.有胃肠动力失调的危险(RiskforDysfunctionalGastrointestinalMotility)39.气体交换障碍(ImpairedGasExchange)领域4:活动/休息(Activity/Rest)40失眠(Insomnia)41.睡眠型态紊乱(DisturbedSleepPattern)42.睡眠剥夺(SleepDeprivation)43.有睡眠改善的趋势(ReadinessforEnhancedSleep)44.有废用综合征的危险(RiskforDisuseSynd

7、rome)45.缺乏娱乐活动(DeficientDiversionalActivity)46.久坐的生活方式(SedentaryLifestyle)47.床上活动障碍(ImpairedBedMobility)48.躯体活动障碍(ImpairedPhysicalMobility)49.借助轮椅活动障碍(ImpairedwheelchairMobility)50.移动能力障碍(ImpairedTransferAbility)51.行走障碍(ImpairedWalking)52.术后康复迟缓(DelayedSurgicalRecovery)53.能量场紊乱(DisturbedEnergyField)

8、54.疲乏(Fatigue)55.活动无耐力(ActivityIntolerance)56.有活动无耐力的危险(RiskforActivityIntolerance)57.有出血的危险(RiskforBleeding)58.低效性呼吸型态(IneffectiveBreathingPattern)59.心输出量减少(DecreasedCardiacOutput)60.外周组织灌注无效(IneffectivePeripheralTissuePerfusion)61.有心脏组织灌注不足的危险(RiskforDecreasedCardiacTissuePerfusion)62.有脑组织灌注无效的危险(

9、RiskforIneffectiveCerebralTissuePerfusion)63.有胃肠道灌注无效的危险(RiskforIneffectiveGastrointestinalTissuePerfusion)64.有肾脏灌注无效的危险(RiskforIneffectiveRenalPerfusion)65.有休克的危险(RiskforShock)66.自主呼吸障碍(ImpairedSpontaneousVentilation)67.呼吸机依赖(DysfunctionalVentilatoryWeaningResponse)68.有自理能力增强的趋势(ReadinessforEnhance

10、dSelf-Care)69.沐浴/卫生自理缺陷(Bathing/HygieneSelf-CareDeficit)70.穿着/修饰自理缺陷(Dressing/groomingSelf-CareDeficit)71.进食自理缺陷(FeedingSelf-CareDeficit)72.如厕自理缺陷(ToiletingSelf-CareDeficit)领域5:感知/认知(Perception/Cognition)73单侧身体忽视(UnilateralNeglect)74.环境认知障碍综合征(ImpairedEnvironmentalInterpretationSyndrome)75.漫游状态(Wand

11、ering)76.感知觉紊乱(具体说明:视觉、听觉、方位感、味觉、触觉、嗅觉)(DisturbedSensoryPerceptionSpecify:Visual,Auditory,Kinesthetic,Gustatory,Tactile,Olfactory)77.急性意识障碍(AcuteConfusion)78.慢性意识障碍(ChronicConfusion)79.有急性意识障碍的危险(RiskforAcuteConfusion)80.知识缺乏(DeficientKnowledge)81.有知识增进的趋势(ReadinessforEnhancedKnowledge)82.记忆功能障碍(Imp

12、airedMemory)83.有决策能力增强的趋势(ReadinessforEnhancedDecision-Making)84.活动计划无效(IneffectiveActivityPlanning)85.语言沟通障碍(ImpairedVerbalCommunication)86.有沟通增进的趋势(ReadinessforEnhancedCommunication)领域6:自我感知(Self-Perception)87.有个人尊严受损的危险(RiskforCompromisedHumanDignity)88.无望感(Hopelessness)89.自我认同紊乱(DisturbedPersona

13、lIdentity)90.有孤独的危险(RiskforLoneliness)91.有能力增强的趋势(ReadinessforEnhancedPower)92.无能为力感(Powerlessness)93.有无能为力感的危险(RiskforPowerlessness)94.有自我概念改善的趋势(ReadinessforEnhancedSelf-Concept)95.情境性低自尊(SituationallowSelf-Esteem)96.长期性低自尊(ChronicLowSelf-Esteem)97.有情境性低自尊的危险(RiskforSituationalLowSelf-Esteem)98.体像

14、紊乱(DisturbedBodyImage)领域7:角色关系(RoleRelationships)99.照顾者角色紧张(CaregiverRoleStrain)100.有照顾者角色紧张的危险(RiskforCaregiverRoleStrain)101.养育功能障碍(ImpairedParenting)102.有养育功能改善的趋势(ReadinessforEnhancedParenting)103.有养育功能障碍的危险(RiskforImpairedParenting)104.有依附关系受损的危险(RiskforImpairedParent/Infant/ChildAttachment)105

15、.家庭运作过程失常(DysfunctionalFamilyProcesses)106.家庭运作过程改变(InterruptedFamilyProcesses)107.有家庭运作过程改善的趋势(ReadinessforEnhancedFamilyProcesses)108.母乳喂养有效(EffectiveBreastfeeding)109.母乳喂养无效(IneffectiveBreastfeeding)110.母乳喂养中断(InterruptedBreastfeeding)111.父母角色冲突(ParentalRoleConflict)112.有关系改善的趋势(ReadinessforEnhan

16、cedRelationship)113.无效性角色行为(IneffectiveRolePerformance)114.社会交往障碍(ImpairedSocialInteraction)领域8:性(Sexuality)115.性功能障碍(SexualDysfunction)116.性生活型态无效(IneffectiveSexualityPatterns)117.有生育进程改善的趋势(ReadinessforEnhancedChildbearingProcess)118.有母体与胎儿双方受干扰的危险(RiskforDisturbedMaternal/FetalDyad)领域9:应对/应激耐受性(C

17、oping/StressTolerance)119.创伤后综合征(PostTraumaSyndrome)120.有创伤后综合征的危险(RiskforPostTraumaSyndrome)121.强暴创伤综合征(Rape-TraumaSyndrome)122.迁移应激综合征(RelocationStressSyndrome)123.有迁移应激综合征的危险(RiskforRelocationStressSyndrome)124.焦虑(Anxiety)125.对死亡的焦虑(DeathAnxiety)126.有威胁健康的行为(Risk-ProneHealthBehavior)127.妥协性家庭应对(C

18、ompromisedFamilyCoping)128.无能性家庭应对(DisabledFamilyCoping)129.防卫性应对(DefensiveCoping)130.应对无效(IneffectiveCoping)131.社区应对无效(IneffectiveCommunityCoping)132.有应对增强的趋势(ReadinessforEnhancedCoping)133.有社区应对增强的趋势(ReadinessforEnhancedCommunityCoping)134.有家庭应对增强的趋势(ReadinessforEnhancedFamilyCoping)135.无效性否认(Inef

19、fectiveDenial)136.恐惧(Fear)137.悲伤(Grieving)138.复杂性悲伤(ComplicatedGrieving)139.有复杂性悲伤的危险(RiskforComplicatedGrieving)140.个人恢复能力障碍(ImpairedIndividualResilience)141.有恢复能力受损的危险(RiskforCompromisedResilience)142.有恢复能力增强的趋势(ReadinessforEnhancedResilience)143.持续性悲伤(ChronicSorrow)144.压力负荷过重(StressOverload)145.自

20、主性反射失调(AutonomicDysreflexia)146.有自主性反射失调的危险(RiskforAutonomicDysreflexia)147.婴儿行为紊乱(DisorganizedInfantBehavior)148.有婴儿行为紊乱的危险(RiskforDisorganizedInfantBehavior)149.有婴儿行为调节改善的趋势(ReadinessforEnhancedOrganizedInfantBehavior)150.颅内调适能力降低(DecreasedIntracranialAdaptiveCapacity)领域10:生活准则(LifePrinciples)151.

21、有希望增强的趋势(ReadinessforEnhancedHope)152.有精神安适增进的趋势(ReadinessforEnhancedSpiritualWell-being)153.抉择冲突(DecisionalConflict)154.道德困扰(MoralDistress)155.不依从行为(Noncompliance)156.宗教信仰减弱(ImpairedReligiosity)157.有宗教信仰增强的趋势(ReadinessforEnhancedReligiosity)158.有宗教信仰减弱的危险(RiskforImpairedReligiosity)159.精神困扰(Spiritu

22、alDistress)160.有精神困扰的危险(RiskforSpiritualDistress)领域11:安全/防护(Safety/Protection)161.有感染的危险(RiskforInfection)162.清理呼吸道无效(IneffectiveAirwayClearance)163.有误吸的危险(RiskforAspiration)164.有婴儿猝死综合症的危险(RiskforSuddenInfantDeathSyndrome)165.牙齿受损(ImpairedDentition)166.有跌倒的危险(RiskforFalls)167.有受伤害的危险(RiskforInjury)

23、168.有手术期体位性损伤的危险(RiskforPerioperative-PositioningInjury)169.口腔黏膜受损(ImpairedOralMucousMembrane)170.有外周神经血管功能障碍的危险(RiskforPeripheralNeurovascularDysfunction)171.防护能力低下(IneffectiveProtection)172.皮肤完整性受损(ImpairedSkinIntegrity)173.有皮肤完整性受损的危险(RiskforImpairedSkinIntegrity)174.有窒息的危险(RiskforSuffocation)175

24、.组织完整性受损(ImpairedTissueIntegrity)176.有外伤的危险(RiskforTrauma)177.有血管损伤的危险(RiskforVascularTrauma)178.自伤(Self-Mutilation)179.有自伤的危险(RiskforSelf-Mutilation)180.有自杀的危险(RiskforSuicide)181.有对他人施行暴力的危险(RiskforOther-DirectedViolence)182.有对自己施行暴力的危险(RiskforSelf-DirectedViolence)183.受污染(Contamination)184.有受污染的危险

25、(RiskforContamination)185.有中毒的危险(RiskforPoisoning)186.乳胶过敏反应(LatexAllergyResponse)187.有乳胶过敏反应的危险(RiskforLatexAllergyResponse)188.有体温失调的危险(RiskforImbalancedBodyTemperature)189.体温过高(Hyperthermia)190.体温过低(Hypothermia)191.体温调节无效(IneffectiveThermoregulation)领域12:舒适(Comfort)192.有舒适增进的趋势(ReadinessforEnhanc

26、edComfort)193.舒适度减弱(ImpairedComfort)194.恶心(Nausea)195.急性疼痛(AcutePain)196.慢性疼痛(ChronicPain)197.社交孤立(SocialIsolation)领域13:生长/发展(Growth/Development)198.成人身心功能衰退(AdultFailuretoThrive)199.生长发展迟缓(DelayedGrowthandDevelopment)200.有发展迟缓的危险(RiskforDelayedDevelopment)201.有生长比例失调的危险(RiskforDisproportionateGrowth)

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