1、護理診斷術語護理診斷術語護理診斷術語nanda通過的以人類反應型態(human response patterns )的分類方法。現將人類反應型態分類方法的護理診斷分列如下：(1) 交換(exchanging )營養失調：高于機體需要量(altered nutrition:more thanbody requireme nts )營養失調：低于機體需要量(altered nutrition: less than body requireme nts )營養失調：潛在高于機體需要量(altered nutrition: potentialfor more tha n body requireme

2、 nts)有感染的危險(risk for infection)有體溫改變的危險(risk for altered body temperature )體溫過低(hypothermia )體溫過高(hyperthermia )體溫調節無效(in effective thermoregulati on)便秘(constipation )感知性便秘(perceived constipation)結腸性便秘(colonic constipation)腹瀉(diarrhea )大便失禁(encopresis )排尿異常(altered urinary elimination)壓迫性尿失禁(sires i

3、ncontinence )反射性尿失禁(reflex incontinence )急迫性尿失禁(urge incontinence)功能性尿失禁(functional incontinence )完全性尿失禁(total in co ntinence)尿儲留(urinary retention)組織灌注量改變 altered tissue perfusi on體液過多(fluid volume excess )體液不足(fluid volume deficit)體液不足的危險(risk for fluid volume deficit )清理呼吸道無效(in effective airway

4、cleara nee )低效性呼吸型態(in effective breathi ng pattern )不能 維持自 主呼吸 (in abilityto sustai n spontan eousven tilati on )呼吸機依賴(dysfunctional ventilatory weaning responsedvwr )有受傷的危險(risk for injury )有窒息的危險(risk for suffocation )有外傷的危險(risk for trauma )有誤吸的危險(risk for aspiration )自我防護能力改變(altered protection

5、 )組織完整性受損(impaired tissue integrity)皮膚完整性受損(impaired skin integrity)有皮膚完整性受損的危險(risk for impaired skin integrity)精力困擾(energy field disturbanee )(2) 溝通(com muni cati ng)語言溝通障礙(impaired verbal com muni cati on)(3) 關系(relating )社會障礙(impaired social interaction)社交孤立(social isolation )有孤立的危險(risk for Ion

6、eliness)角色紊亂(altered role performanee)父母不稱職(altered parenting)有父母不稱職的危險(risk for altered parenting)有父母親子依戀改變的危險(risk for altered pare nt/ infant/ child att8chffi6llt )性功能障礙(sexual dysfunction)家庭作用改變(altered family process )有照顧者角色障礙的危險(risk for caregiver role strain )家庭作用改變：酗酒(altered family process:

7、 alcoholism )父母角色沖突(parental role conflict)性生活型態改變(altered sexuality patter ns)(4) 賦予價值(valuing ) 精神困擾(spiritual distress )(5) 選擇(choosing )個人應對無效(in effective in dividual cop ing)調節障礙(impaired adjustment)防衛性應對(defensive coping)防衛性否認(in effective de nial)家庭應對無效：失去能力（in effectivefamily cop ing:disabl

8、ing )家庭應對無效：妥協性(in effective family cop ing:compromised )家庭應對：潛能性(family coping: potential for growth)社區應對：潛能性(potential for enhanced communitycoping )社區應對無效(in effective com mun ity cop ing )遵守治療方案無效(個人的)(in effective man ageme ntoftherapeutic regime n)(individual )不合作（特定的）(noncomplianee ) (specify

9、 )遵守治療方案無效（家庭的）(i neffective man ageme ntoftherapeutic regime n: families )遵守治療方案無效（社區的）(i neffective man ageme ntoftherapeutic regime n: commu nity遵守治療方案有效（個人的）(effective man ageme nt oftherapeutic regime n: in dividual)抉擇沖突(特定的)(decisional conflict) (specify )尋求健康行為(特定的)(health seeking behaviors )

10、(specify )(6) 活動(moving )軀體移動障礙(impaired physical mobility )有周圍血管神經功能障礙的危險(risk for peripheral n eurovascular dysfu ncti on)活動無耐力(activity intoleranee)疲乏(fatigue )有活動無耐力的危險(risk for activity intoleranee)睡眠狀態紊舌L( sleep pattern disturbanee )持家能 力障礙 (impaired home maintenance management )保持健康的能力改變(alte

11、red health maintenance )進食自理缺陷(feeding self care deficit )吞咽障礙(impaired swallowing)母孚 L喂養無效(in effective breast feedi ng)母孚L喂養有效(effective breast feeding)嬰兒吸吮方式無效(in effective infant feedi ng pattern )沐浴/衛生自理缺陷(bathing / hygiene self care deficit )穿戴/修飾自理障礙 (dressing /grooming self care deficit )入廁自

12、理缺陷(toileting self care deficit)生長發育改變(altered growth and development )環境改變應激綜合征(relocation stress syndrome )有嬰幼兒行為紊亂的危險( risk for disorganized infant behavior )嬰幼兒行為紊舌1( disorganized infant behavior )(7) 感知(perceiving )自我形象紊舌L( body image disturbanee)自尊紊舌1( self-esteem disturbanee)長期自我貶低(chronic lo

13、w self esteem )情境性自我貶低(situational low self esteem )自我認同紊舌L( personal identity disturbanee)感知改變(特定的)(視、聽、運動、味、觸、嗅)(sen sory/ perceptual alterations ) ( specify ) ( visual , auditory , kin esthetic , gustatory , tactile , olfactory )單側感覺喪失(unilateral neglect )絕望(hopelessness )無能為力(powerlessness )(8) 認知(knowing )知識缺乏(特定的)(knowledge deficit) (specify )定向力障礙(impaired environmental interpretation)突發性意識模糊(acute con fusion )漸進性意識模糊(chronic confusion)思維過程改變(altered thought processes ) 記憶力障礙(impaired memory )(9) 感覺(feeling )疼痛(pain )慢性疼痛(chronic pa in )有自傷的