附1 人類反應型態(tài)護理診斷
NANDA通過的以人類反應型態(tài)分類方法的128個護理診斷
(1)交換(Exchanging) 營養(yǎng)失調(diào):高于機體需要量(Altered Nutrition:More Than Body Requirements) 營養(yǎng)失調(diào):低于機體需要量(Altered Nutrition: less Than Body Requirements) 營養(yǎng)失調(diào):潛在高于機體需要量(Altered Nutrition:Potential for More Than Body
Requirements) 有感染的危險(Risk for Infection) 有體溫改變的危險(Risk for Altered Body Temperature) 體溫過低(Hypothermia) 體溫過高(Hyperthermia) 體溫調(diào)節(jié)無效(Ineffective Thermoregulation) 反射失調(diào)(Dysre flexia) 便秘(Constipation) 感知性便秘(Perceived Constipation) 結腸性便秘(Colonic Constipation) 腹瀉(Diarrhea) 大便失禁(Bowel Incontinence) 排尿異常(Altered Urinary Elimination) 壓迫性尿失禁(Stress Incontinence) 反射性尿失禁(Reflex Incontinence) 急迫性尿失禁(Unge Incontinence) 功能性尿失禁(Functional Incontinence) 完全性尿失禁(Total Incontinence) 尿儲留(Urinary Retentron) 組織灌注量改變(腎、腦、心肺、胃腸、周圍血管)(Altered Tissue Pefusion( Renal, Cereral, Cardiopulmonary Gastrointestinal,Peripheral)) 體液過多(Fluid Volume Excess) 體液不足(Fluid Volume Deficit) 體液不足的危險(Risk for Fluid Volume Deficit) 心輸出量減少(Decreased Cardiac Output) 氣體交換受損(Impaired Gas Exchanse) 清理呼吸道無效(Ineffective Airway Clearance) 低效性呼吸型態(tài)(Ineffective Breathing Pattern) 不能維持自主呼吸( Inability to Sustain Spontaneous Ventilation) 呼吸機依賴( Dysfunctional Ventilatory Weaning Response,DVWR) 有受傷的危險(Risk for Injury) 有窒息的危險(Risk for Suffocation)
有中毒的危險(Risk for poisoning) 有外傷的危險(Risk for Trauma) 有誤吸的危險(Risk for Aspiration) 自我防護能力改變(Altered Protection)
有廢用綜合征的危險(Risk for di 組織完整性受損(Impaired Tissue Integrity) 口腔粘膜改變(Altered Oral Mucous Membrane) 皮膚完整性受損(Impaired Skin Integrity) 有皮膚完整性受損的危險(Risk for Impaired Skin Integrity) 調(diào)節(jié)顱內(nèi)壓能力下降( Decreased Adaptive Capacity Intracranial) 精力困擾(Energy Field Disturbance) (2)溝通(Communicating) 語言溝通障礙(impaired Verbal Communication) (3)關系(Relating) 社交障礙(Impaired Social Interaction) 社交孤立(Social Isolation) 有孤立的危險(Risk for Loneliness。) 角色紊亂(Altered Role Performance) 父母不稱職(Altered Parenting) 有父母不稱職的危險(Risk for Altered Parenting) 有父母親子依戀改變的危險(Risk for Altered Parent/Infant/Child Att8Chffi6llt) 性功能障礙(Sexual Dysfunction) 家庭作用改變(Altered Family Process) 照顧者角色障礙(Caregiver Role Strain) 有照顧者角色障礙的危險(Risk for Caregiver Role Strain) 家庭作用改變:酗酒(Altered Family Process: Alcoholism) 父母角色沖突(Parental Role Conflict) 性生活型態(tài)改變(Altered Sexuality Patterns) (4)賦予價值(Valuing) 精神困擾(Spiritual Distress) 潛在的精神健康增強(Potential for Enhance Spiritual Well-Being) (5)選擇(Choosing) 個人應對無效(Ineffective Individual Coping) 調(diào)節(jié)障礙(Impaired Adjustment) 防衛(wèi)性應對(Defensive Coping) 防衛(wèi)性否認(Ineffective Denial) 家庭應對無效:失去能力( Ineffective Family Coping:Disabling) 家庭應對無效:妥協(xié)性 (Ineffective Family Coping:Compromised) 潛在的家庭應對增強(Family Coping Potential for Growth) 潛在的社區(qū)應對增強(Potential for Enhanced Community Coping) 社區(qū)應對無效(Ineffective Community Coping) 執(zhí)行治療方案無效(個人的)(Ineffective Management of Therapeutic Regimen)(Individual) 不合作(特定的)(Noncompliance)(Specify) 執(zhí)行治療方案無效(家庭的)(Ineffective Management of Therapeutic Regimen:( (Families) 執(zhí)行治療方案無效(社區(qū)的)(Ineffective Management of Therapeutic Regimen: Community) 執(zhí)行治療方案有效(個人的)(Effective Management of Therapeutic Regimen:Individual) 抉擇沖突(特定的)(Decisional Conflict)(Specify) 尋求健康行為(特定的)(Health Seeking Behaviors)(Specify)
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