护理诊断一览表(NANDA分类法Ⅱ排列)

1

领域1:健康促进

(Health Promotion)

健康维护能力低下(Ineffective Health Maintenance)

2

自我健康管理无效(Ineffective Self Health Management)

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(Readiness for Enhanced Nutrition)

7

家庭执行治疗方案无效

(Ineffective Family Therapeutic Regimen Management)

8

有自我健康管理改善的趋势

(Readiness for Enhanced Self Health Management)

9

领域2:营养(Nutrition)

无效性婴儿喂养型态(Ineffective Infant Feeding Pattern)

10

营养失调:低于机体需要量

(Imbalanced Nutrition: Less Than Body Requirements)

11

营养失调:高于机体需要量

(Imbalanced Nutrition: More Than Body Requirements)

12

有营养失调的危险:高于机体需要量(Risk for Imbalanced Nutrition: More Than Body Requirements)

13

吞咽障碍(Impaired Swallowing)

14

有血糖不稳定的危险(Risk for Unstable Glucose Level)

15

新生儿黄疸(Neonatal Jaundice)

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 Imbalance)

18

有体液平衡改善的趋势

(Readiness for Enhanced Fluid Balance)

19

体液不足(Deficient Fluid Volume)

20

体液过多(Excess Fluid Volume)

21

有体液不足的危险(Risk for Deficient Fluid Volume)

22

有体液失衡的危险(Risk for Imbalanced Fluid Volume)

23

领域3:排泄(Elimination and Exchange)

排尿障碍(Impaired Urinary Elimination)

24

功能性尿失禁(Functional Urinary Incontinence)

25

溢出性尿失禁(Overflow Urinary Incontinence)

26

反射性尿失禁(Reflex Urinary Incontinence)

27

压力性尿失禁(Stress Urinary Incontinence)

28

急迫性尿失禁(Urge Urinary 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

(Readiness for Enhanced Urinary Elimination)

32

排便失禁(Bowel Incontinence)

33

便秘(Constipation)

34

感知性便秘(Perceived Constipation)

35

有便秘的危险(Risk for Constipation)

36

腹泻(Diarrhea)

37

胃肠动力失调(Dysfunctional Gastrointestinal Motility)

38

有胃肠动力失调的危险

(Risk for Dysfunctional Gastrointestinal Motility)

39

气体交换障碍(Impaired Gas Exchange)

40

领域4:活动/休息(Activity/Rest)

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(Readiness for Enhanced Sleep)

44

有废用综合征的危险(Risk for Disuse Syndrome)

45

缺乏娱乐活动(Deficient Diversional Activity)

46

久坐的生活方式(Sedentary Lifestyle)

47

床上活动障碍(Impaired Bed Mobility)

48

躯体活动障碍(Impaired Physical Mobility)

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)

52

术后康复迟缓(Delayed Surgical Recovery)

53

能量场紊乱(Disturbed Energy Field)

54

疲乏(Fatigue)

55

活动无耐力(Activity Intolerance)

56

有活动无耐力的危险(Risk for Activity Intolerance)

57

有出血的危险(Risk for Bleeding)

58

低效性呼吸型态(Ineffective Breathing Pattern)

59

心排出量减少(Decreased Cardiac Output)

60

外周组织灌注无效(Ineffective Peripheral Tissue Perfusion)

61

有心脏组织灌注不足的危险

(Risk for Decreased Cardiac Tissue Perfusion)

62

有脑组织灌注无效的危险

(Risk for Ineffective Cerebral Tissue Perfusion)

63

有胃肠道灌注无效的危险

(Risk for Ineffective Gastrointestinal Tissue Perfusion)

64

有肾脏灌注无效的危险

(Risk for Ineffective Renal Perfusion)

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(Dysfunctional Ventilatory Weaning Response)

68

有自理能力增强的趋势(Readiness for Enhanced 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(Dressing/grooming 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)

73

领域5:感知/认知(Perception/

Cognition)

单侧身体忽视(Unilateral 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 Sensory Perception(Specify:Visual,Auditory,Kinesthetic,Gustatory,Tactile,Olfactory)]

77

急性意识障碍(Acute Confusion)

78

慢性意识障碍(Chronic Confusion)

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(Readiness for Enhanced Knowledge)

82

记忆功能障碍(Impaired Memory)

83

有决策能力增强的趋势

(Readiness for Enhanced Decision-Making)

84

活动计划无效(Ineffective Activity Planning)

85

语言沟通障碍(Impaired Verbal Communication)

86

有沟通增进的趋势(Readiness for Enhanced Communication)

87

领域6:自我感知(Self-Perception)

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(Readiness for Enhanced Power)

92

无能为力感(Powerlessness)

93

有无能为力感的危险(Risk for Powerlessness)

94

有自我概念改善的趋势

(Readiness for Enhanced Self-Concept)

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-Esteem)

98

体像紊乱(Disturbed Body Image)

99

领域7:角色关系

(Role Relationships)

照顾者角色紧张(Caregiver Role 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(Readiness for Enhanced Parenting)

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/Infant/Child Attachment)

105

家庭运作过程失常(Dysfunctional Family Processes)

106

家庭运作过程改变(Interrupted Family Processes)

107

有家庭运作过程改善的趋势

(Readiness for Enhanced Family Processes)

108

母乳喂养有效(Effective Breastfeeding)

109

母乳喂养无效(Ineffective Breastfeeding)

110

母乳喂养中断(Interrupted Breastfeeding)

111

父母角色冲突(Parental Role Conflict)

112

有关系改善的趋势(Readiness for Enhanced Relationship)

113

无效性角色行为(Ineffective Role Performance)

114

社会交往障碍(Impaired Social Interaction)

115

领域8:性(Sexuality)

性功能障碍(Sexual Dysfunction)

116

性生活型态无效(Ineffective Sexuality Patterns)

117

有生育进程改善的趋势

(Readiness for Enhanced Childbearing Process)

118

有母体与胎儿双方受干扰的危险

(Risk for Disturbed Maternal/Fetal Dyad)

119

领域9:

应对/应激耐受性(Coping/ Stress Tolerance)

创伤后综合征(Post Trauma Syndrome)

120

有创伤后综合征的危险(Risk for Post Trauma Syndrome)

121

强暴创伤综合征(Rape-Trauma Syndrome)

122

迁移应激综合征(Relocation Stress Syndrome)

123

有迁移应激综合征的危险

(Risk for Relocation Stress Syndrome)

124

焦虑(Anxiety)

125

对死亡的焦虑(Death Anxiety)

126

有威胁健康的行为(Risk-Prone Health Behavior)

127

妥协性家庭应对(Compromised Family Coping)

128

无能性家庭应对(Disabled Family Coping)

129

防卫性应对(Defensive Coping)

130

应对无效(Ineffective Coping)

131

社区应对无效(Ineffective Community Coping)

132

有应对增强的趋势(Readiness for Enhanced Coping)

133

有社区应对增强的趋势

(Readiness for Enhanced Community Coping)

134

有家庭应对增强的趋势

(Readiness for Enhanced Family Coping)

135

无效性否认(Ineffective Denial)

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 Individual Resilience)

141

有恢复能力受损的危险(Risk for Compromised Resilience)

142

有恢复能力增强的趋势

(Readiness for Enhanced Resilience)

143

持续性悲伤(Chronic Sorrow)

144

压力负荷过重(Stress Overload)

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 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)

151

领域10:生活准则

(Life Principles)

有希望增强的趋势

(Readiness for Enhanced Hope)

152

有精神安适增进的趋势

(Readiness for Enhanced Spiritual Well-being)

153

抉择冲突(Decisional Conflict)

154

道德困扰(Moral Distress)

155

不依从行为(Noncompliance)

156

宗教信仰减弱(Impaired Religiosity)

157

有宗教信仰增强的趋势

(Readiness for Enhanced 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)

161

领域11:安全/防护(Safety/Protection)

有感染的危险(Risk for Infect ion)

162

清理呼吸道无效(Ineffective Airway Clearance)

163

有误吸的危险(Risk for Aspiration)

164

有婴儿猝死综合征的危险

(Risk for Sudden Infant Death Syndrome)

165

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-Positioning Injury)

169

口腔黏膜受损(Impaired Oral Mucous Membrane)

170

有外周神经血管功能障碍的危险

(Risk for Peripheral Neurovascular Dysfunction)

171

防护能力低下(Ineffective Protection)

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 Integrity)

174

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 Vascular 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 Violence)

182

有对自己施行暴力的危险(Risk for Self-Directed Violence)

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 Imbalanced Body Temperature)

189

体温过高(Hyperthermia)

190

体温过低(Hypothermia)

191

体温调节无效(Ineffective Thermoregulation)

192

领域12:舒适(Comfort)

有舒适增进的趋势(Readiness for Enhanced 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(Chronic Pain)

197

社交孤立(Social Isolation)

198

领域13:生长/发展(Growth/Development)

成人身心功能衰退(Adult Failure to Thrive)

199

生长发展迟缓(Delayed Growth and Development)

200

有发展迟缓的危险(Risk for Delayed Development)

201

有生长比例失调的危险(Risk for Disproportionate Growth)