基础护理｜人卫出版NANDA【北美护理学会】护理诊断一览表(2015—2017)最新版

NANDA护理诊断一览表(2015—2017)

领域1:健康促进(Health promotion)

老年综合征(Frail elderly syndrome)

有老年综合征的危险(Risk for frail elderly syndrome)

健康管理无效(Ineffective health management)

有健康管理改善的趋势(Readiness for enhanced health management)

家庭健康管理无效(Ineffective family health management)

不依从行为(Noncompliance)

缺乏娱乐活动(Deficient diversional activity)

久坐的生活方式(Sedentary lifestyle)

缺乏社区保健(Deficient community health)

有健康行为改善的趋势(Risk-prone health behavior)

健康维持无效(Ineffective health maintenance)

防护无效(Ineffective protection)

领域2:营养(Nutrition)

肥胖(Obesity)

超重(Overweight)

有超重的危险(Risk for overweight)

母乳喂养无效(Ineffective breastfeeding)

母乳喂养中断(Interrupted breastfeeding)

有母乳喂养改善的趋势(Readiness for enhanced breastfeeding)

乳汁不足(Insufficient breast milk)

无效性婴儿喂养型态(Ineffective infant feeding pattern)

营养失调：低于机体需要量(Imbalanced nutrition:less than body

requirements)

有营养改善的趋势(Readiness for enhanced nutrition)

吞咽障碍(Impaired swallowing)

有血糖不稳定的危险(Risk for unstable blood glucose level)

新生儿黄疸(Neonatal jaundice)

有新生儿黄疸的危险(Risk for neonatal jaundice)有肝功能受损的危险(Risk for impaired liver function)

有电解质失衡的危险(Risk for electrolyte imbalance)

有体液平衡改善的趋势(Readiness for enhanced fluid balance)

体液不足(Deficient fluid volume)

有体液不足的危险(Risk for deficient fluid volume)

体液过多(Excess fluid volume)

有体液失衡的危险(Risk for imbalanced fluid volume)

领域3:排泄(Elimination and exchange)

慢性功能性便秘(Chronic functional constipation)

有慢性功能性便秘的危险(Risk for chronic functional constipation)

排尿障碍(Impaired urinary elimination)

有排尿功能改善的趋势(Readiness for enhanced urinary elimination)

功能性尿失禁(Functional urinary incontinence)

溢出性尿失禁(0verflow urinary incontinence)

反射性尿失禁(Reflex urinary incontinence)

压力性尿失禁(Stress urinary incontinence)

急迫性尿失禁(Urge urinary incontinence)

有急迫性尿失禁的危险(Risk for urge urinary incontinence)

尿潴留(Urinary retention)

便秘(Constipation)

有便秘的危险(Risk for constipation)

感知性便秘(Perceived constipation)

腹泻(Diarrhea)

胃肠动力失调(Dysfunctional gastrointestinal motility)

有胃肠动力失调的危险(Risk for dysfunctional gastrointestinal motility)

排便失禁(Bowel incontinence)

气体交换障碍(Impaired gas exchange)

领域4:活动/休息(Activity/rest)

坐起障碍(Impaired sitting)

站立障碍(Impaired standing)有心输出量减少的危险(Risk for decreased cardiac output)

有心血管功能受损的危险(Risk for impaired cardiovascular function)

失眠(Insomnia)

睡眠剥夺(Sleep deprivation)

有睡眠改善的趋势(Readiness for enhanced sleep)

睡眠型态紊乱Disturbed sleep pattern)

有废用综合征的危险(Risk for disuse syndrome)

床上活动障碍(Impaired bed mobility)

躯体活动障碍(Impaired physical mobility)

借助轮椅活动障碍(Impaired wheelchair mobility)

移动能力障碍(Impaired transfer ability)

行走障碍(Impaired walking)

疲乏(Fatigue)

漫游状态(Wandering)

活动无耐力(Activity intolerance)

有活动无耐力的危险(Risk for activity intolerance)

低效性呼吸型态(Ineffective breathing pattern)

心输出量减少(Decreased cardiac output)

有胃肠道灌注无效的危险(Risk for ineffective gastrointestinal perfusion)

有肾脏灌注无效的危险(Risk for ineffective renal perfusion)

自主呼吸障碍(Impaired spontaneous ventilation)

有心脏组织灌注不足的危险(Risk for decreased cardiac tissue perfusion)

有脑组织灌注无效的危险(Risk for ineffective cerebral tissue perfusion)

外周组织灌注无效(Ineffective peripheral tissue perfusion)

有外周组织灌注无效的危险(Risk for ineffective peripheral tissue

perfusion)

呼吸机依赖(Dysfunctional ventilatory weaning response)

持家能力障碍(Impaired home maintenance)

沐浴自理缺陷(Bathing self-care deficit)

穿着自理缺陷(Dressing self-care deficit)进食自理缺陷(Feeding self-care deficit)

如厕自理缺陷(Toileting self-care deficit)

有自理能力改善的趋势(Readiness for enhanced self-Care)

自我忽视(Self-neglect)

领域5:感知/认知(Perception/cognition)

情绪控制失调(Labile emotional control)

单侧身体忽视(Unilateral neglect)

急性意识障碍(Acute confusion)

有急性意识障碍的危险(Risk for acute confusion)

慢性意识障碍(Chronic confusion)

冲动控制无效(Ineffective impulse control)

知识缺乏(Deficient knowledge)

有知识增进的趋势(Readiness for enhanced knowledge)

记忆功能障碍(Impaired memory)

有沟通增进的趋势(Readiness for enhanced communication)

语言沟通障碍(Impaired verbal communication)

领域6:自我感知(Self-perception)

有希望增强的趋势(Readiness for enhanced hope)

无望感(Hopelessness)

有个人尊严受损的危险(Risk for compromised human dignity)

自我认同紊乱(Disturbed personal identity)

有自我认同紊乱的危险(Risk for disturbed personal identity)

有自控能力增强的趋势(Readiness for enhanced self-control)

长期低自尊(Chronic low self-esteem)

有长期低自尊的危险(Risk for chronic low self-esteem)

有情境性低自尊的危险(Risk for situational low self-esteem)

情境性低自尊(Situational low self-esteem)

体像紊乱(Disturbed body image)

领域7:角色关系(Role relationships)

照顾者角色紧张(Caregiver role strain)有照顾者角色紧张的危险(Risk for caregiver role strain)

养育功能障碍(Impaired parenting)

有养育功能改善的趋势(Readiness for enhanced parenting)

有养育功能障碍的危险(Risk for impaired parenting)

有依附关系受损的危险(Risk for impaired attachment)

家庭运作过程失常(Dysfunctional family processes)

家庭运作过程改变(Interrupted family processes)

有家庭运作过程改善的趋势(Readiness for enhanced family processes)

关系无效(Ineffective relationship)

有关系改善的趋势(Readiness for enhanced relationship)

有关系无效的危险(Risk for ineffective relationship)

父母角色冲突(Parental role conflict)

无效性角色行为(Ineffective role performance)

社会交往障碍(Impaired social interaction)

领域8:性(Sexuality)

性功能障碍(Sexual dysfunction)

性生活型态无效(Ineffective sexuality pattern)

生育进程无效(Ineffective childbearing process)

有生育进程改善的趋势(Readiness for enhanced childbearing process)

有生育进程无效的危险(Risk for ineffective childbearing process)

有母体与胎儿双方受干扰的危险(Risk for disturbed maternal-fetal dyad)

领域9:应对/应激耐受性(Coping/Stress Tolerance)

有社区应对增强的趋势(Readiness for enhanced community coping)

情绪调控受损(Impaired mood regulation)

有恢复能力障碍的危险(Risk for impaired resilience)

创伤后综合征(Post-trauma syndrome)

有创伤后综合征的危险(Risk for post-trauma syndrome)

强暴创伤综合征(Rape-trauma syndrome)

迁移应激综合征(Relocation stress syndrome)

有迁移应激综合征的危险(Risk for relocation stress syndrome)活动计划无效(Ineffective activity planning)

有活动计划无效的危险(Risk for ineffective activity planning)

焦虑(Anxiety)

妥协性家庭应对(Compromised family coping)

无能性家庭应对(Disabled family coping)

防卫性应对(Defensive coping)

应对无效(Ineffective coping)

有应对增强的趋势(Readiness for enhanced coping)

社区应对无效(Ineffective community coping)

有家庭应对增强的趋势(Readiness for enhanced family coping)

对死亡的焦虑(Death anxiety)

无效性否认(Ineffective denial)

恐惧(Fear)

悲伤(Grieving)

复杂性悲伤(Complicated grieving)

有复杂性悲伤的危险(Risk for complicated grieving)

有能力增强的趋势(Readiness for enhanced power)

无能为力感(Powerlessness)

有无能为力感的危险(Risk for powerlessness)

恢复能力障碍(Impaired resilience)

有恢复能力增强的趋势(Readiness for enhanced resilience)

持续性悲伤(Chronic sorrow)

压力负荷过重(Stress overload)

颅内调适能力降低(Decreased intracranial adaptive capacity)

自主反射失调(Autonomic dysreflexia)

有自主反射失调的危险(Risk for autonomic dysreflexia)

婴儿行为紊乱(Disorganized infant behavior)

有婴儿行为调节改善的趋势(Readiness for enhanced organized infant

behavior)

有婴儿行为紊乱的危险(Risk for disorganized infant behavior)

领域10:生活准则(Life Principles)

独立决策能力减弱(Impaired emancipated decision-making)

有独立决策能力增强的趋势(Readiness for enhanced emancipated

decision-making)

有独立决策能力减弱的危险(Risk for impaired emancipated decision-making)

有精神安适增进的趋势(Readiness for enhanced spiritual well-Being)

有决策能力增强的趋势(Readiness for enhanced decision making)

抉择冲突(Decisional conflict)

道德困扰(Moral distress)

宗教信仰减弱(Impaired religiosity)

有宗教信仰增强的趋势(Readiness for enhanced religiosity)

有宗教信仰减弱的危险(Risk for impaired religiosity)

精神困扰(Spiritual distress)

有精神困扰的危险(Risk for spiritual distress)

领域11:安全/防护(Safety/protection)

有角膜受损的危险(Risk for corneal injury)

有尿道损伤的危险(Risk for urinary tract injury)

有口腔黏膜受损的危险(Risk for impaired oral mucous membrane)

有压疮的危险(Risk for pressure ulcer)

有组织完整性受损(Risk for impaired tissue integrity)

有体温过低的危险(Risk for hypothermia)

有手术期体温过低的危险(Risk for perioperative hypothermia)

有感染的危险(Risk for infection)

清理呼吸道无效Ineffective airway clearance)

有误吸的危险(Risk for aspiration)

有出血的危险(Risk for bleeding)

有干眼症的危险(Risk for dry eye)

有跌倒的危险(Risk for falls)

有受伤的危险(Risk for injury)

有手术期体位性损伤的危险(Risk for perioperative positioning injury)有热损伤的危险(Risk for thermal injury)

牙齿受损(Impaired dentition)

口腔黏膜受损(Impaired oral mucous membrane)

有外周神经血管功能障碍的危险(Risk for peripheral neurovascular

dysfunction)

有休克的危险(Risk for shock)

皮肤完整性受损(Impaired skin integrity)

有皮肤完整性受损的危险(Risk for impaired skin integrity)

有婴儿猝死综合征的危险(Risk for sudden infant death syndrome)

有室息的危险(Risk for suffocation)

术后康复迟缓(Delayed surgical recovery)

组织完整性受损(Impaired tissue integrity)

有外伤的危险(Risk for trauma)

有血管损伤的危险(Risk for vascular trauma)

有对他人施行暴力的危险(Risk for other-directed violence)

有对自己施行暴力的危险(Risk for self-directed violence)

自残(Self-mutilation)

有自残的危险(Risk for self-mutilation)

有自杀的危险(Risk for suicide)

受污染(Contamination)

有受污染的危险(Risk for contamination)

有中毒的危险(Risk for poisoning)

有碘造影剂不良反应的危险(Risk for adverse reaction to iodinated contrast

media)

有过敏反应的危险(Risk for allergy response)

乳胶过敏反应(Latex allergy response)

有乳胶过敏反应的危险(Risk for latex allergy response)

有体温失调的危险(Risk for imbalanced body temperature)

体温过高(Hyperthermia)

体温过低(Hypothermia)体温调节无效(Ineffective thermoregulation)

领域12:舒适(Comfort)

分娩疼痛(Labor pain)

慢性疼痛综合征(Chronic pain syndrome)

有孤独的危险(Risk for loneliness)

舒适度减弱(Impaired comfort)

有舒适增进的趋势(Readiness for enhanced comfort)

恶心(Nausea)

急性疼痛(Acute pain)

慢性疼痛(Chronic pain)

社交孤立(Social isolation)

领域13:生长/发展(Growth/development)

有发育迟缓的危险(Risk for delayed development)

有生长比例失调的危险(Risk for disproportionate growth)