nanda201项护理诊断与155项护理诊断讲解学习.docx

1、nanda201项护理诊断与155项护理诊断讲解学习155项护理诊断-览表(20012002)(按NANDA分类法U 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.

2、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

3、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(Percepti on /cog niti on)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

4、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 toleranee)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

5、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11

6、7.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、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

7、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（ 20092011 ）领域 1 :健康促进(Health Promotion )1.健康维护能力低下(In effective Health Maintenance )2.自我健康管理无效(In effectiv

8、e Self Health Man ageme nt)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(Readi ness for En ha need Nutriti on )7.家庭执行治疗方案无效 In effective Family Therapeutic Regime n Man ageme nt)8.有自我健康管理改善的趋势( Readi ness for En ha need

9、 Self Health Man ageme nt)领域 2：营养(Nutrition )9.无效性婴儿喂养型态(In effective Infant Feedi ng Pattern )10.营养失调：低于机体需要量(Imbalaneed Nutrition: Less Than Body Requirements )11.营养失调：高于机体需要量(Imbalaneed Nutrition: More Than Body Requirements )12.有营养失调的危险：高于机体需要量(Risk for Imbalaneed Nutrition: More Than Body Requi

10、rements )13.吞咽障碍(Impaired Swallowing )14.有血糖不稳定的危险(Risk for Un stable Glucose Level )15.新生儿黄疸(Neo natal Jaun dice )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 Imbalanee )18.有体液平衡改善的趋势(Readi ness for En ha need Fluid Bala nee)19.体液不足(Deficient Fluid Volume )21.有体液

11、不足的危险（Risk forDeficie nt FluidVolume )22.有体液失衡的危险（Risk forImbala need FluidVolume )领域 3:排泄(Elimination andExchange)23.排尿障碍（ImpairedUrinaryElimi natio n )24.功能性尿失禁（Functional Urinary Incon ti nence )25.溢出性尿失禁（Overflow UrinaryIncon ti nence )26.反射性尿失禁（ReflexUrinaryIncon ti nence )27.压力性尿失禁（StressUrina

12、ryIncon ti nence )28.急迫性尿失禁（UrgeUrinary 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(Readi ness for En ha need Urinary Elimi nation32.排便失禁(Bowel In co ntinence )33.便秘(Constipation )34.感知性便秘(Perceived Constipation )35.有便秘的危险(Risk for Constipa

13、tion )36.腹泻(Diarrhea )37.胃肠动力失调(Dysfunctional Gastrointestinal Motility )38.Motility )有胃肠动力失调的危险(Risk for Dysfunctional Gastrointestinal39.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(Readi ness for En

14、 ha need Sleep )44.有废用综合征的危险（Risk for Disuse Syndrome）45.45.缺乏娱乐活动（Deficie nt Divers ional Activity )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)54.疲乏(Fatigue )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(Dy

15、sfunctional Ventilatory Weaning Response)68.有自理能力增强的趋势( Readi ness for En ha need 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(Dress in g/groomi ng 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/Co

16、gnition )73 单侧身体忽视(Uni lateral 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 Sen sory Percepti on Specify : Visual , Auditory , Kin esthetic , Gustatory ，Tactile ， Olfactory )77.急性意识障碍(Acute Con fusion )78 .慢性意识障碍(C

17、hro nic Con fusion )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(Readi ness for En ha need Kno wledge)82.记忆功能障碍(Impaired Memory)83.有决策能力增强的趋势(Readi ness for En ha need Decisi on-Maki ng )84.活动计划无效(In effective Activity Pla nning )85.语言沟通障碍(Impaired Verbal Communica

18、tion )86.有沟通增进的趋势(Readi ness for En ha need Commu ni catio n )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(Readi ness for En ha need Power)92.无能为力感(Powerlessness )9

19、3.有无能为力感的危险(Risk for Powerlessness )94.有自我概念改善的趋势( Readi ness for En ha need Self-Co ncept )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-Esteem98.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 Ro

20、le 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(Readi ness for En ha need Pare nting )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/lnfant/Child Attachment )105.家庭运作过程失常(Dysfunctional Family Processes )106

21、.家庭运作过程改变(Interrupted Family Processes )107.有家庭运作过程改善的趋势（Readi ness for Enhanced Family108.母乳喂养有效（EffectiveBreastfeedi ng )109.母乳喂养无效（In effectiveBreastfeedi ng )110.母乳喂养中断（InterruptedBreastfeedi ng )111.父母角色冲突（ParentalRole Conflict )Processes )Enhanced Childbearing Process)Dyad)124.焦虑(Anxiety )125.

22、对死亡的焦虑（Death Anxiety128.无能性家庭应对(Disabled Family Coping)129.防卫性应对(Defensive Coping )130.应对无效(In effective Copi ng)114.社会交往障碍(Impaired Social Interaction ) 领域& 性(Sexuality )115.性功能障碍(Sexual Dysfunction )116 .性生活型态无效(In effective Sexuality Patterns )117.有生育进程改善的趋势（Readiness for 118.有母体与胎儿双方受干扰的危险(Risk

23、for Disturbed Maternal/Fetal132.有应对增强的趋势(Read in ess for En ha need Cop ing)134.有家庭应对增强的趋势(Readi ness for En ha need Family Copi ng )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 In dividual Resilie nee )141.有恢复能力受损的危险

24、（Risk for Compromised Resilie nee )142.有恢复能力增强的趋势（Readi ness for Enhanced Resilie nee )143.持续性悲伤（ChronicSorrow)144.压力负何过重（StressOverload )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

25、 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(Readi ness for En ha need Hope)152.有精神安适增进的趋势(Readi ness for En ha need Spiritual Well-bei ng )153.抉择冲突(Decisional Conf

26、lict )154.道德困扰(Moral Distress )155.不依从行为(Noncomplianee )156.宗教信仰减弱(Impaired 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(In effective Airw

27、ay Cleara nee )163.有误吸的危险(Risk for Aspiration )164.Syn drome )Injury )有婴儿猝死综合症的危险(Risk for Sudden Infant Death165.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-Positioning169.口腔黏膜受损(Impaired Oral Mucous Membran170.有外周神经血管功能障碍

28、的危险(Risk for Peripheral Neurovascular Dysfu nction )171.防护能力低下(In effective Protectio n )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 Integrity174.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 Vascu

29、lar 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 Violenee )182.有对自己施行暴力的危险( Risk for Self-Directed Violenee )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

30、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 Imbalaneed Body Temperature )189.体温过高(Hyperthermia )190.体温过低(Hypothermia )191.体温调节无效(In effective Thermoregulation )领域12：舒适(Comfort )192.有舒适增进的趋势(Read in ess for En ha need 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(Chro nic Pa in)197.社交孤立(Social Isolation )领域 13:生长 / 发展(Gro