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护理诊断

来源:知库网
?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(decreased cardiac output) 气体交换受损(impaired gas exchange) 清理呼吸道无效(Ineffecthe Airway Clearance)

低效性呼吸型态(Ineffective Breathing Pattern)呼吸机依赖(Dysfunctional ventilatory weaning response DVWR) 有受伤的危险(Risk for Injury) 有窒息的危险(Risk for Suffocation) 有外伤的危险(Risk for Trauma) 有误吸的危险(Risk for Aspiration) 组织完整性受损(ImPaired Tissue Integrity) 口腔粘膜改变(Altered Oral Mucous Membrance) 皮肤完整性受损(ImPaired Skin Integrity) 语言沟通障碍(impaired VerbalCommunlcatlon)

(6)活动(Moving) 躯体移动障碍(ImPaired Physical Mobility) 活动无耐力(Activity Intolerance) 疲乏(Fatigue)

睡眠状态紊乱(SleepPattern Disturbance) 娱乐活动缺乏(Diversional Activity Deficit) 持家能力障碍(Impaired Home Maintenance Management) 保持健康的能力改变(Altered Health Maintenance) 进食自理缺陷(Feeding Self Care Deficit) 吞咽障碍(Impaired Swallowing)

沐浴/卫生自理缺陷(Bathing/Hygiene Self Care Deficit) 穿戴/修饰自理障碍(Dressing/Grooming Self Care Deficit) 入厕自理缺陷(Toileting Self Care Deficit) 环境改变应激综合征(Relocation Stress Syndrome) (9)感觉(Feeling) 疼痛(Pain)

慢性疼痛(Chronic Pain)

功能障碍性悲哀(Dysfunctional Crievins) 预感性悲哀(AnticiPatory Crieving)

有暴力行为的危险:对自己或对他人(Risk for Violence: Self-Directed or drected at Others)

有自伤的危险(Risk for Self-Mutilation) 创伤后反应(Post-Trauma Response) 焦虑(Anxiety)

恐惧(Fear)???????(7)感知(Perceiving) 自我形象紊乱(Body Imagse Disturbance) 自尊紊乱(SolfEsteem disturbance) 长期自我贬低(Chronic Low Self Esteem) 情境性自我贬低(Situational Low Self Esteem) 自我认同紊乱(Personal Identity disturbance)

感知改变(特定的)(视、听、运动、味、触、嗅)(Sensory/PerceptualAlterations)(specify)(Visual,Auditory,Kinesthetlc,Gustatory,Taotile,Olfactory) 单侧感觉丧失(Unilateral Neglect) 绝望(Honelessness) 无能为力(Powerlessness)

(8)认知(Knowing)

知识缺乏(特定的)(Knowledge Deficit)(Specify) 定向力障碍(Impaired Environmental Interpretation) 突发性意识模糊(Acute Confusion) 渐进性意识模糊(Chronic Confusion) 思维过程改变(Altered Thought Processes) 记忆力障碍(ImPaired Memoryy) ????

个人应对无效(Ineffctive Individual Coping)家庭应对无效:失去能力( Ineffective Family Coping:Disabling)

家庭应对无效:妥协性 (Ineffectiv Family Coping:Compromised) 家庭应对:潜能性(Family CoPing: Potential for Growth)

遵守治疗方案无效(个人的)(Ineffective Management of Therapeutic Regimen)(Individual)

不合作(特定的)(Noncompliance)(Specitfy)

遵守治疗方案无效(家庭的)(Ineffective Management of Therapeutic Regimen: ( (Families)

遵守治疗方案无效(社区的)(Ineffective Management of Therapeutic Regimen: Community)

遵守治疗方案有效(个人的)(Effective Management of Therapeutic Regimen:Individual)寻求健康行为???? ????

社会障碍(Impaired Soial Interatlon) 社交孤立(Social Isolition) 角色紊乱(Altered Role Performance) 父母不称职(Altered Parenting)

有父母不称职的危险(Risk for Altered Parenting)

有父母亲子依恋改变的危险(Risk for Altered Parent/Infant/Child Att8Chffi6llt) 性功能障碍(Sexual Dysfunction) 家庭作用改变(Altered Family Process) 照顾者角色障碍(Caresiver Role Strain)

有照顾者角色障碍的危险(Risk for Caregiver Role Strain) 家庭作用改变:酗酒(Altered Family Process: Alcoholism) 父母角色冲突(Parental Role Conflict) 性生活型态改变(Altered SexualityPatterns)

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