护理诊断2

Ⅱ 护理诊断(按功能性健康型态分类)

1健康感知—健康管理型态 Health PerceptionHealth Management 

* 生长发育异常 Growth and Development, Altered(155)

* 成人缺乏生命活力Failure to Thrive，Adult(164)

* 有生长异常的危险 Growth, Risk for Altered(163)

* 有发育异常的危险 Development, Risk for Altered(163)

健康维护能力改变 Health Maintenance, Altered(165)

* 外科手术后恢复延迟 Surgical Recovery, Delayed(376)

寻求健康行为(特定的) HealthSeeking Behaviors，Specify(173)

有受伤的危险 Injury, Risk for(200)

有窒息的危险 Risk for Suffocation(208)

有中毒的危险 Risk for Poisoning(207)

有外伤的危险 Risk for Trauma(208)

有围手术期体位性损伤的危险

Injury, Risk for Perioperative Positioning(208)

个人处理治疗计划有效 Management of Therapeutic Regimen, Effective: In dividual(220)

处理治疗计划不当/无效 Management of Therapeutic Regimen, Ineffective(222)

社区处理治疗计划不当/无效 Management of Therapeutic Regimen,Ineffective: Community(228)

·功能性健康型态是戈登（Gordon·M.1982）提出的，护理诊断：程序和应用，纽约：McGrawHill，作者有较小的修改。

·*为1998年被NANDA接受认可的护理诊断。

·**为尚未列入NANDA目录，但已被明确包括并应用的护理诊断。

家庭处理治疗计划不当/无效 Management of Therapeutic Regimen,Ineffec tive: Families(227) 

不合作 Noncompliance(244)

2营养/代谢型态 NutritionalMetabolic

颅内适应能力下降 Adaptive Capacity, IntracranialDecreased(8)

有体温改变的危险 Body Temperature, Risk for Altered(19)

体温过低 Hypothermia(20)

体温过高 Hyperthermia(23)

体温调节无效 Thermoregulation, Ineffective(25)

体液不足 Fluid Volume Deficit(140)

体液过多 Fluid Volume Excess(143)

* 有体液失衡的危险 Fluid Volume Imbalance, Risk for(146) 

营养失调：低于机体需要量

Nutrition, Altered: Less Than Body Requirements(247)

* 牙齿异常 Dentition, Altered(252)

婴幼儿喂养不当/无效 Feeding Pattern, IneffectiveInfant(255)

吞咽能力受损 Swallowing, Impaired(252)

营养失调：高于机体需要量

Nutrition, Altered: More Than Requirements(258)

营养失调：潜在的高于机体需要量

Nutrition, Altered: Potential for More Than Body Requirements(262)

母乳喂养有效 Breastfeeding, Effective(30)

母乳喂养不当/无效 Breastfeeding, Ineffective(33)

母乳喂养中断 Breastfeeding, Interrupted(36)

有感染的危险 Infection, Risk for(194)

**有传播感染的危险 Infection Transmission, Risk for(198)

* 乳胶过敏反应 Latex Allergy(212)

* 有乳胶过敏反应的危险 Latex Allergy , Risk for(215)

保护能力改变 Protection, Altered(286)

组织完整性受损 Tissue Integrity, Impaired(385)

口腔粘膜改变 Oral Mucous Membrane， Altered(392)

皮肤完整性受损 Skin Integrity, Impaired(388)

有皮肤完整性受损的危险 Skin Integrity, Impaired，Risk for(390)

3排泄型态 Elimination

便秘 Constipation(74)

*有便秘的危险 Constipation, Risk for(80)

感知性便秘 Perceived Constipation(79)

腹泻 Diarrhea(107)

排便失禁 Bowel Incontinence(27)

排尿型态异常 Urinary Elimination, Altered Patterns of(404)

尿潴留 Urinary Retention(422)

完全性尿失禁 Total Incontinence(416)

功能性尿失禁 Functional Incontinence(410)

反射性尿失禁 Reflex Incontinence(412)

急迫性尿失禁 Urge Incontinence(419)

*有急迫性尿失禁的危险 Urge Incontinence, Risk for(421)

压力性尿失禁 Stress Incontinence(414)

**成熟性遗尿 Maturational Enuresis(408)

4活动—运动型态 ActivityExercise

活动无耐力 Activity Intolerance(3)

心输出量减少 Cardiac Output, Decreased(37)

废用综合征 Disuse Syndrome(110)

娱乐活动缺乏 Diversional Activity Deficit(114)

持家能力障碍 Home Maintenance Management, Impaired(176) 

婴儿行为紊乱 Infant Behavior, Disorganized(183)

婴幼儿有行为紊乱的危险 Infant Behavior, Risk for Disorganized(189)

婴幼儿有行为能力增强的潜力 Infant Behavior, Potential for Enhanc ed Organized(189)

躯体移动障碍 Mobility, Impaired Physical(231)

*床上活动障碍 Bed Mobility, Impaired(236)

*行走障碍 Walking, Impaired(237)

*借助轮椅活动障碍 Wheelchair Mobility, Impaired(238) 

*轮椅转移能力障碍 Wheelchair Transfer Ability, Impaired（239)

有周围神经血管功能障碍的危险Neurovascular

Dysfunction, Risk for Peripheral(241)

**有呼吸功能异常的危险 Respiratory Function, Risk for Altered(291)

功能障碍性脱离呼吸机反应Dysfunctional Ventilatory Weaning Res ponse(294)

清理呼吸道无效 Ineffective Airway Clearance(301)

低效性呼吸型态 Ineffective Breathing Pattern(302)

气体交换受损 Impaired Gas Exchange(304)

不能维持自主呼吸 Ventilation, Inability to SustainSpontaneous(305)

**自理能力缺陷：特定的（进食、沐浴/卫生、穿衣/修饰、如厕、使用器具）SelfCare Deficit Syndrome ( Specify ):

Instrumental)(307)

组织灌注量改变：特定的 Tissue Perfusion, Altered (Specify)(396)

5睡眠—休息型态 SleepRest

睡眠型态紊乱 Sleep Pattern Disturbance(359)

*睡眠剥夺 Sleep Deprivation(363)

6认知—感知型态 CognitivePerceptual

不舒适 Comfort, Altered(45)

急性疼痛 Acute Pain(48)

慢性疼痛 Chronic Pain(54)

* 恶心 Nausea(56)

意识模糊/混乱 Confusion(65)

急性意识模糊/混乱 Acute Confusion(66)

慢性意识模糊/混乱 Chronic Confusion(71)

决策冲突 Decisional Conflict(103)

反射失调 Dysreflexia(116)

* 有反射失调的危险 Dysreflexia, Risk for(119)

环境解析障碍综合征 Environmental InterpretationSyndrome, Impaired(123)

知识缺乏 Knowledge Deficit(211)

有误吸的危险 Risk for Aspiration(205)

感知改变(特定的)：（视、听、味、嗅、触、动觉） (Feeding, Bathing/Hygiene, Dressing /Grooming, Toileting，

SensoryPerceptual Alterations(Specify ):(Visual, Auditory, Kinesthetic, Gustatory,Tactile, Olfactory)( 348) 思维过程异常 Thought Processes, Altered(377)

记忆受损 Memory, Impaired(382)

忽略单侧身体 Unilateral Neglect(402)

能量场紊乱 Energy Field Disturbance(120)

7自我感知型态 SelfPerception

焦虑 Anxiety(10)

* 对死亡的焦虑 Death Anxiety(16)

疲乏 Fatigue(131)

恐惧 Fear(136)

绝望 Hopelessness(178)

无能为力感 Powerlessness(283)

**自我概念紊乱 SelfConcept Disturbance(322)

自我形象紊乱 Body Image Disturbance(326)

自我认同紊乱 Personal Identity Disturbance(330)

自尊紊乱 SelfEsteem Disturbance(330)

长期自尊低下 Chronic Low SelfEsteem(334)

情境性自尊低下 Situational Low SelfEsteem(336)

8角色/关系型态 RoleRelationship

**沟通障碍 Communication, Impaired(58)

语言沟通障碍 Communication, Impaired Verbal(63)

家庭运作改变 Family Processes, Altered(124)

家庭运作改变：酗酒Family Processes, Altered: Alcoholism(127) **悲伤 Grieving(147)

预期性悲伤 Grieving, Anticipatory(151)

功能障碍性悲伤 Grieving, Dysfunctional(153)

*长期悲伤 Chronic Sorrow(369)

有孤独的危险 Loneliness, Risk for(216)

有亲子依附关系改变的危险 ParentInfant Attachment,Risk for Altered(267) 父母不称职 Parenting, Altered(263)

父母角色冲突 Parental Role Conflict(271)

角色紊乱 Role Performance, Altered(306)

社交障碍 Social Interaction, Impaired(363)

社交隔离 Social Isolation(367)

9性/生殖型态 SexualityReproductive

性功能障碍 Sexual Dysfunction(358)

性生活型态改变 Sexuality Patterns, Altered(351)

10压力/应激耐受型态 CopingStress Tolerance

调节障碍 Adjustment, Impaired(9)

照顾者角色紧张 Caregiver Role Strain(38)

个人应对能力失调 Coping, Ineffective Individual(81)

防御性应对 Defensive Coping(86)

无效性否认 Ineffective Denial(88)

家庭失能性应对能力失调 Coping: Disabling, IneffectiveFamily(98)

家庭妥协性应对能力失调 Coping: Compromised,Ineffective Family(97) 家庭有应对能力增强的潜力 Coping: Potential for Growth, Family(96) 社区应对能力失调 Coping, Ineffective Community(91)

社区有应对能力增强的潜力 Coping, Potential for Enhanced Community(93) 创伤后反应 PostTrauma Response(275)

* 有创伤后反应的危险 PostTrauma Response,Risk for (279)

强暴创伤综合征 RapeTrauma Syndrome(280)

迁移压力(综合征) Relocation Stress (Syndrome)(287)

**有自我伤害的危险 SelfHarm, Risk for(338)

有自虐的危险 SelfAbuse, Risk for(342)

有自残的危险 SelfMutilation, Risk for(343)

**有自杀的危险 Suicide, Risk for(344)

有暴力行为的危险 Violence, Risk for(345)

11价值—信念型态 ValueBelief

精神困扰 Spiritual Distress(371)

*有精神困扰的危险 Spiritual Distress, Risk for(374)

有精神健康增强的潜力 Spiritual WellBeing, Potentialfor Enhanced(375)