128个护理诊断及措施

一、交换(Exchanging)营养失调：高于机体需要量(AlteredNutrition：MoreThanBodyRequirements)营养失调：低于机体需要量(AlteredNutrition：lessThanBodyRequirements)营养失调：潜在高于机体需要量(AlteredNutrition：PotentialforMoreThanBodyRequirements)有感染的危险(RiskforInfection)有体温改变的危险(RiskforAlteredBodyTemperature)体温过低(Hypothermia)体温过高(Hyperthermia)体温调节无效(IneffectiveThermoregulatlon)反射失调(Dysreflexia)便秘(Constipation)感知性便秘(PerceivedConsttipation)结肠性便秘(ColonicConstipation)腹泻(Diarrhea)大便失禁(BowelInconttinence)排尿异常(AlteredUrinaryElimination)压迫性尿失禁(SiresIncontlnence)反射性尿失禁(ReflexIncontinence)急迫性尿失禁(UngeIncontinence)功能性尿失禁(FunctionalIncontinence)完全性尿失禁(TotalIncontlnencd尿储留(UrinaryRetentron)组织灌注量改变(肾、脑、心肺、胃肠、周围血管"AlteredTissuePerfuslorl(Renal，Cereral，CardlopulmonaryGastrolntestlnal,Peripheral))体液过多(FluidVolumeExcess)体液不足(FluidVolumeDeficit)体液不足的危险(RiskforFluidVolUmeDeficit)心输出量减少(Deer。A。EdCardlacouPu)气体交换受损(ImnairedGasExc5anse)清理呼吸道无效(IneffectheAirwayClearance)低效性呼吸型态(IneffectiveBreathingPattern)不能维持自主呼吸(InabilitytoSustainSpontaneousVentilation)呼吸机依赖(DysfunctionalVentilatoryWeaningResPonse，DVWR)有受伤的危险(RiskforInjury)有窒息的危险(RiskforSuffocation)有外伤的危险(RiskforTrauma)有误吸的危险(RiskforAspiration)自我防护能力改变(AlteredProtection)组织完整性受损(ImPairedTissueIntegrity)口腔粘膜改变(AlteredOralMucousMembrance)皮肤完整性受损(ImPairedSkinIntegrity)有皮肤完整性受损的危险(RiskforImPairedSkinIntegrity)调节颅内压能力下降(DecreasedAdaPtiveCaPacityIntracranial)精力困扰(EnergyFielddistubance)二、沟通(Communicating)语言沟通障碍(impairedVerbalCommunlcatlon)三、关系(Relating)社会障碍(ImpairedSoialInteratlon)社交孤立(SocialIsolition)有孤立的危险(Riskfor.Lonelines。)角色紊乱(AlteredRolePerformance)父母不称职(AlteredParenting)有父母不称职的危险(RiskforAlteredParenting)有父母亲子依恋改变的危险(RiskforAlteredParent/Infant/ChildAtt8Chffi6llt)性功能障碍(SexualDysfunction)家庭作用改变(AlteredFamilyProcess)照顾者角色障碍(CaresiverRoleStrain)有照顾者角色障碍的危险(RiskforCaregiverRoleStrain)家庭作用改变：酗酒(AlteredFamilyProcess：Alcoholism)父母角色冲突(ParentalRoleConflict)性生活型态改变(AlteredSexualityPatterns)四、赋予价值(Valuing)精神困扰(SpiritualDistress)增进精神健康：潜能性(PotentialforEnhanceSpiritualWell-Belug)五、选择(Choosing)个人应对无效(IneffctiveIndividualCoping)调节障碍(ImPairedAdjustment)防卫性应对(DefensiveCoping)防卫性否认(IneffectiveDenial)家庭应对无效：失去能力(IneffectiveFamilyCoping：Disabling)家庭应对无效：妥协性(IneffectivFamilyCoping：Compromised)家庭应对：潜能性(FamilyCoPing：PotentialforGrowth)社区应对：潜能性(PotentialforEnhancedCommunityCoPing)社区应对无效(IneffectiveCommunityCoping)遵守治疗 方案 气瓶 现场处置方案 .pdf气瓶 现场处置方案 .doc见习基地管理方案.doc关于群访事件的化解方案建筑工地扬尘治理专项方案下载 无效(个人的"IneffectiveManagementofTherapeuticRegimen)(lndividual)不合作(特定的)(Noncompliance)(Specitfy)遵守治疗方案无效(家庭的"IneffectiveManagementofTherapeuticRegimen：((Families)遵守治疗方案无效(社区的"IneffectiveManagementofThera—peuticRegimen：Community)遵守治疗方案有效(个人的"EffectiveManagementofThera—peuticRegimen：Individual)抉择冲突(特定的)(DecisionalConflict)(Specify)寻求健康行为(特定的)(HealthSeekingBehaviors)(Specity)六、活动(Moving)躯体移动障碍(ImPairedPhysicalMobility)有周围血管神经功能障碍的危险(RiskforPeriPheralNeurovas—cularDysfunction)有围手术期外伤的危险(RiskforPerloperatlvePositioningInjury)活动无耐力(ActivityIntolerance)疲乏(Fatigue)有活动无耐力的危险(RiskforActivityIntolerance)睡眠状态紊乱(SleepPatternDisturbance)娱乐活动缺乏(DiversionalActivityDeficit)持家能力障碍(ImpairedHomeMaintenanceManagement)保持健康的能力改变(AlteredHealthMaintenance)进食自理缺陷(FeedingSelfCareDeficit)吞咽障碍(ImpairedSwallowing)母乳喂养无效(IneffectiveBreastFeeding)母乳喂养中断(InterruntedBreast1ceding)母乳喂养有效(EffectiveBreastfeeding)婴儿吸吮方式无效(IneffectiveInfantFeedingPattern)沐浴/卫生自理缺陷(Bathing/HygieneSelfCareDeficit)穿戴/修饰自理障碍(Dressing/GroomingSelfCareDeficit)入厕自理缺陷(ToiletingSelfCareDeficit)生长发育改变(AlteredGrowthandDevelopment)环境改变应激综合征(RelocationStressSyndrome)有婴幼儿行为紊乱的危险(RiskforDisorganizedInfantBehavior)婴幼儿行为紊乱(DisorganizedInfantBehavior)增进婴幼儿行为(潜能性"potentialforDisorganizedInfantganlzedInfantkhavlor)七、感知(Perceiving)自我形象紊乱(BodyImagseDisturbance)自尊紊乱(SolfEsteemdisturbance)长期自我贬低(ChronicLowSelfEsteem)情境性自我贬低(SituationalLowSelfEsteem)自我认同紊舌［(PersonalIdentitydisturbance)感知改变(特定的)(视、听、运动、味、触、嗅)(Sensory/PerceptualAlterations)(specify)(Visual,Auditory,Kinesthetlc,Gustatory,Tao—tile,Olfactory)单侧感觉丧失(UnilateralNeglect)绝望(Honelessness)无能为力(Powerlessness)八、认知(Knowing)知识缺乏(特定的"KnowledgeDeficit)(Specify)定向力障碍(ImpairedEnvironmentalInterpretation)突发性意识模糊(AcuteConfusion)渐进性意识模糊(ChronicConfusion)思维过程改变(AlteredThoughtProcesses)记忆力障碍(ImPairedMemoryy)九、感觉(Feeling)疼痛(Pain)慢性疼痛(ChronicPain)功能障碍性悲哀(DysfunctionalCrievins)预感性悲哀(AnticiPatoryCrieving)有暴力行为的危险：对自己或对他人(RiskforViolence：Self-DirectedordrectedatOthers)有自伤的危险(RiskforSelfMutilation)仓伤后反应(Post—TraumaResponse)强奸创伤综合征(RaPe—TraumaSyndrome)强奸创伤综合征：复合性反应(Repe—TraumaSyndrome:CompoundReaction)强奸创伤综合征：沉默性反应(Rape—TraumaSyndrome：Silent)焦虑(Anxiety)恐惧(Fear)