护理诊断项目表详解.doc_咨信网zixin.com.cn

资源描述

护理诊断项目表领域1：健康增进Health Promotion 类别1：健康察觉 Health Awareness 娱乐活动缺失（00097）Deficient Diversional Activity 静态生活方式（00168）Sedentary Lifestyle 类别2：健康管理Health Management 社区健康缺失（00215）Deficient Community Health 危险倾向旳健康行为（00188）Risk-Prone Health Behavior 无效性健康维护（00099） Ineffective Health Maintenance 准备妥增进免疫状态（00186）Readiness for Enhanced Immunization Status 无效性保护能力（00043） Ineffective Protection 无效性自我健康管理（00078）Ineffective Self-Health Management 准备妥增进自我健康管理（00162）Readiness for Enhanced Self-Health Management 家庭治疗计划处置失当（00080） Ineffective Family Therapeutic Regimen Management 领域2：营养 Nutrition 类别1：摄食Ingestion 母乳局限性（00216）Insufficient Breast Milk 无效性婴儿哺喂模式（00107）Ineffective Infant Feeding Pattern 营养失衡：少于身体需要（00002）Imbalanced Nutrition： Less Than Body Requirements 营养失衡：多于身体需要（00001）Imbalanced Nutrition： More Than Body Requirements 准备妥增进营养（00163）Readiness for Enhanced Nutrition 风险性营养失衡：多于身体需要（00003）Risk for Imbalanced Nutrition：More Than Body Requirements 吞咽障碍（00103）Impaired Swallowing 类别2：消化Digestion 目前没有类别3：吸取Absorption 目前没有类别4：代谢 Metabolism 风险性不稳定血糖浓度（00179）Risk for Unstable Blood Glucose Level 新生儿黄疸（00194）Neonatal Jaundice 风险性新生儿黄疸（00230）Risk for Neonatal Jaundice 风险性肝脏功能障碍（00178）Risk for Impaired Liver Function 类别5：水化 Hydration 风险性电解质失衡（00195）Risk for Electrolyte Imbalance 准备妥增进体液平衡（00160）Readiness for Enhanced Fluid Balance 体液容积缺失 (00027) Deficient Fluid Volume 体液容积过量 (00026) Excess Fluid Volume 风险性体液容积缺失 (00028) Risk for Deficient Fluid Volume 风险性体液容积失衡 (00025) Risk for imbalance Fluid Volume 领域3：排泄与互换 Elimination and Exchange 类别1：泌尿功能Urinary Function 功能性尿失禁（00020） Functional Urinary Incontinence 满溢性尿失禁（00176）Overflow Urinary Incontinence 反射性尿失禁（00018）Reflex Urinary Incontinence 压力性尿失禁（00017）Stress Urinary Incontinence 急切性尿失禁（00019）Urge Urinary Incontinence 风险性急切性尿失禁（00022）Risk for Urge Urinary Incontinence 排尿型态障碍（00016）Impaired Urinary Elimination 准备妥增进排尿型态（00166）Readiness for Enhanced Urinary Elimination 尿潴留（00023）Urinary Retention 类别2：胃肠功能 Gastrointestinal Function 便祕（00011） Constipation 感受性便祕（00012） Perceived Constipation 风险性便祕（00015） Risk for Constipation 腹泻（00013） Diarrhea 胃肠能动性失常（00196） Dysfunctional Gastrointestinal Motility 风险性胃肠能动性失常（00197）Risk for Dysfunctional Gastrointestinal Motility 排便失禁（00014）Bowel Incontinence 类别3：皮肤功能 Integumentary Function 目前没有类别4：呼吸功能Respiratory Function 气体互换障碍（00030）Impaired Gas Exchange 领域4：活动／休息Activity/Rest 类别1：睡眠／休息Sleep/Rest 失眠（00095）Insomnia 睡眠剥削（00096）Sleep Deprivation 准备妥增进睡眠型态（00165）Readiness for Enhanced Sleep 睡眠型态紊乱（00198）Disturbed Sleep Pattern 类别2：活动／运动Activity /Exercise 风险性废用症候群（00040） Risk for Disuse Syndrome 床上移动功能障碍（00091）Impaired Bed Mobility 身体活动功能障碍（00085）Impaired Physical Mobility 轮椅移动功能障碍（00089）Impaired Wheelchair Mobility 移位能力障碍（00090） Impaired Transfer Ability 步行障碍（00088）Impaired Walking 类别3：能量平衡Energy Balance 能量场紊乱（00050） Disturbed Energy Field 疲倦（00093） Fatigue 漫游（00154） Wandering 类别4：心血管／肺部反映Cardiovascular/Pulmonary Responses 活动无耐力（00092）Activity Intolerance 风险性活动无耐力（00094）Risk for Activity Intolerance 低效性呼吸型态（00032） Ineffective Breathing Pattern 心输出量减低（00029）Decreased Cardiac Output 风险性胃肠灌流失效（00202） Risk for Ineffective Gastrointestinal Perfusion 风险性肾脏灌流失效（00203）Risk for Ineffective Renal Perfusion 自主性换气障碍（00033）Impaired Spontaneous Ventilation 周边组织灌流失效（00204）Ineffective Peripheral Tissue Perfusion 风险性心脏组织灌流减少（00200） Risk for Decreased Cardiac Tissue Perfusion 风险性脑组织灌流失效（00201）Risk for Ineffective Cerebral Tissue Perfusion 风险性周边组织灌流失效（00228）Risk for Ineffective Peripheral Tissue Perfusion 呼吸机戒断反映功能失常（00034）Dysfunctional Ventilatory Weaning Response 类别5：自我照顾Self-care 持家能力障碍（00098）Impaired Home Maintenance 准备妥增进自理（00182）Readiness for Enhanced Self-Care 沐浴自理能力缺失（00108）Bathing Self-Care Deficit 穿着自理能力缺失（00109）Dressing Self-Care Deficit 进食自理能力缺失（00102）Feeding Self-Care Deficit 如厕自理能力缺失（00110）Toileting Self-Care Deficit 忽视自我健康管理（00193）Self Neglect 领域5：知觉／认知Perception/Cognition 类别1：注意力Attention 单侧身体忽视（00123）Unilateral Neglect 类别2：定向力Orientation 环境解析障碍症候群（00127）Impaired Environmental Interpretation Syndrome 类别3：感觉／知觉 Sensation/Perception 目前没有类别4：认知Cognition 急性意识混乱（00128）Acute Confusion 慢性意识混乱（00129）Chronic Confusion 风险性急性意识混乱（00173）Risk for Acute Confusion 冲动控制无效 ( 00222 ) Ineffective Impulse Control 知识缺少 ( 00126 ) Deficient Knowledge 准备妥增进知识 ( 00161) Readiness for Enhanced Knowledge 记忆减退 ( 00131 ) Impaired Memory 类别5：沟通Communication 准备妥增进沟通 ( 00157 ) Readiness for Enhanced Communication 言词沟通障碍 ( 00051 ) Impaired Verbal Communication 领域6：自我知觉Self-Perception 类别1：自我概念Self-concept 无望感（00124）Hopelessness 风险性个人尊严受损（00174）Risk for Compromised Human Dignity 风险性孤寂（00054）Risk for Loneliness 个人认同紊乱（00121）Disturbed Personal Identity 风险性个人认同紊乱（00225）Risk for Disturbed Personal Identity 准备妥增进自我概念（00167） Readiness for Enhanced Self-Concept 类别2：自尊Self-esteem 长期性低自尊（00119）Chronic Low Self-Esteem 情境性低自尊（00120）Situational Low Self-Esteem 风险性长期低自尊（00224）Risk for Chronic Low Self-Esteem 风险性情境低自尊（00153）Risk for Situational Low Self-Esteem 类别3：身体心像Image 身体心像紊乱（00118）Disturbed Body Image 领域7：角色关系Role Relationships 类别1：照顾者角色Caregiving Roles 无效性母乳哺喂（00104） Ineffective Breastfeeding 母乳哺喂中断（00105）Interrupted Breastfeeding 准备妥增进母乳哺喂（00106）Readiness for Enhanced Breastfeeding 照顾者角色紧张（00061）Caregiver Role Strain 风险性照顾者角色紧张（00062）Risk for Caregiver Role Strain 亲职障碍（00056）Impaired Parenting 准备妥增进养育功能（00164）Readiness for Enhanced Parenting 风险性养育障碍（00057） Risk for Impaired Parenting 类别2：家庭关系 Family Relationship 风险性依附关系障碍（00058）Risk for Impaired Attachment 家庭运作功能障碍（00063） Dysfunctional Family Processes 家庭运作功能紊乱（00060） Interrupted Family Processes 准备妥增进家庭运作功能（00159） Readiness for Enhanced Family Processes 类别3：角色扮演Role Performance 人际关系失常（00223） Ineffective Relationship 准备妥增进人际关系（00207） Readiness for Enhanced Relationship 风险性人际关系失常（00229）Risk for Ineffective Relationship 亲职角色冲突（00064） Parental Role Conflict 角色扮演无效（00055） Ineffective Role Performance 社交互动障碍（00052） Impaired Social Interaction 领域8：性学Sexuality 类别1：性认同Sexual Identity 目前没有类别2：性功能Sexual Function 性功能障碍（00059）Sexual Dysfunction 性生活型态失常（00065）Ineffective Sexuality Pattern 类别3：生殖Reproduction 分娩过程不当（00221）Ineffective Childbearing Process 准备妥增进分娩过程（00208） Readiness for Enhanced Childbearing Process 风险性分娩过程不当（00227） Risk for Ineffective Childbearing Process 风险性母婴共扰（00209）Risk for Disturbed Maternal/Fetal Dyad 领域9：调适／压力耐受Coping/Stress Tolerance 类别1：创伤后反映Post-truma Responses 创伤后症候群（00141）Post-Trauma Syndrome 风险性创伤后症候群（00145）Risk for Post-Trauma Syndrome 强暴创伤症候群（00142）Rape-Trauma Syndrome 迁移压力症候群（00114） Relocation Stress Syndrome 风险性迁移压力症候群（00149）Risk for Relocation Stress Syndrome 类别2：调适反映Coping Responses 无效性活动计划（00199）Ineffective Activity Planning 风险性无效性活动计划（00226）Risk for Ineffective ActivityPlanning 焦急（00146）Anxiety 防御性因应能力（00071）Defensive Coping 无效性因应能力（00069） Ineffective Coping 准备妥增进因应能力（00158）Readiness for Enhanced Coping 无效性社区因应能力（00077） Ineffective Community Coping 准备妥增进社区因应能力（00076） Readiness for Enhanced Community Coping 受损性家庭因应能力（00074）Compromised Family Coping 家庭因应失能（00073）Disabled Family Coping 准备妥增进家庭因应能力（00075）Readiness for Enhanced Family Coping 死亡焦急（00147） Death Anxiety 否认行为不当（00072） Ineffective Denial 成人生存功能衰竭（00101） Adult Failure to Thrive 恐惊（00148）Fear 哀伤（00136）Grieving 复杂性哀伤（00135）Complicated Grieving 风险性复杂性哀伤（00172）Risk for Complicated Grieving 准备妥增进权能（00187）Readiness for Enhanced Power 无力感（00125） Powerlessness 风险性无力感（00152）Risk for Powerlessness 个人复原力障碍（00210）Impaired Individual Resilience 准备妥增进复原力（00212）Readiness for Enhanced Resilience 风险性危及复原力（00211）Risk for Compromised Resilience 慢性悲哀（00137） Chronic Sorrow 压力负荷过重（00177）Stress Overload 类别3：神经行为压力Neurobehavioral Stress 自主性反射障碍（00009） Autonomic Dysreflexia 风险性自主反射障碍（00010） Risk for Autonomic Dysreflexia 紊乱性婴儿行为（00116） Disorganized Infant Behavior 风险性紊乱性婴儿行为（00115）Risk for Disorganized Infant Behavior 准备妥增进调节性婴儿行为（00117）Readiness for Enhanced Organized Infant Behavior 颅内调适能力减少（00049）Decreased Intracranial Adaptive Capacity 领域10：生命原则Life Principles 类别1：价值 Value 准备妥增进但愿（00185）Readiness for Enhanced Hope 类别2：信念 Beliefs 准备妥增进心灵安适（00068）Readiness for Enhanced Spiritual Well-Being 类别3：价值／信念／行动一致Value/Belief/Action Congruence 准备妥增进决定能力（00184） Readiness for Enhanced Decision-Making 抉择冲突（00083）Decisional Conflict 道德困扰（00175）Moral Distress 不遵从（00079） Noncompliance 宗教信奉障碍（00169）Impaired Religiosity 准备妥增进宗教信奉（00171）Readiness for Enhanced Religiosity 风险性宗教信奉障碍（00170）Risk for Impaired Religiosity 心灵困扰（00066） Spiritual Distress 风险性心灵困扰（00067）Risk for Spiritual Distress 领域11：安全／保护Safety/Protection 类别1：感染Infection 风险性感染（00004）Risk for Infection 类别2：身体伤害Physical Injury 呼吸道清除功能失效（00031）Ineffective Airway Clearance 风险性肺吸入（00039）Risk for Aspiration 风险性出血（00206）Risk for Bleeding 齿列生长障碍（00048）Impaired Dentition 风险性干眼症（00219）Risk for Dry Eye 风险性跌倒（00155）Risk for Falls 风险性损伤（00035） Risk for Injury 口腔粘膜受损（00045）Impaired Oral Mucous Membrane 风险性围术期体位损伤（00087）Risk for Perioperative Positioning Injury 风险性周边血管神经功能障碍（00086）Risk for Peripheral Neurovascular Dysfunction 风险性休克（00205） Risk for Shock 皮肤完整性受损（00046） Impaired Skin Integrity 风险性皮肤完整性受损（00047）Risk for Impaired Skin Integrity 风险性婴儿猝死症候群（00156）Risk for Sudden Infant Death Syndrome 风险性窒息（00036）Risk for Suffocation 术后复原延迟（00100）Delayed Surgical Recovery 风险性热损伤（00220）Risk for Thermal Injury 组织完整性受损（00044）Impaired Tissue Integrity 风险性创伤（00038）Risk for Trauma 风险性血管创伤（00213） Risk for Vascular Trauma 类别3：暴力 Violence 风险性对别人旳暴力行为（00138）Risk for Other-Directed Violence 风险性对自己旳暴力行为（00140）Risk for Self-Directed Violence 自我残害（00151）Self-Mutilation 风险性自我残害（00139）Risk for Self-Mutilation 风险性自杀（00150）Risk for Suicide 类别4：环境危害Environmental Hazards 污染（00181）Contamination 风险性污染（00180）Risk for Contamination 风险性中毒（00037）Risk for Poisoning 类别5：防卫过程Defensive Processes 风险性碘剂显影不良反映（00218）Risk for Adverse Reaction to Iodinated Contrast Media 乳胶过敏反映（00041）Latex Allergy Response 风险性过敏反映（00217）Risk for Allergy Response 风险性乳胶过敏反映（00042）Risk for Latex Allergy Response 类别6：体温调节Thermoregulation 风险性体温失衡（00005）Risk for Imbalanced Body Temperature 体温过高（00007） Hyperthermia 体温过低（00006）Hypothermia 体温调节失常（00008） Ineffective Thermoregulation 领域12：舒服Comfort 类别1：身体舒服Physical Comfort 舒服障碍（00214） Impaired Comfort 准备妥增进舒服（00183）Readiness for Enhanced Comfort 恶心（00134）Nausea 急性疼痛（00132）Acute Pain 慢性疼痛（00133）Chronic Pain 类别2：环境舒服Environmental Comfort 舒服障碍（00214）Impaired Comfort 类别3：社会舒服Social Comfort 社交隔离（00053）Social Isolation 领域13：生长／发育Growth/Development 类别1：生长Growth 风险性不成比例生长（00113）Risk for Disproportionate Growth 类别2：发育 Development 生长及发育延迟（00111）Delayed Growth and Development 风险性发育延迟（00112）Risk for Delayed Development

展开阅读全文