5.2--护理诊断健康评估健康评估

附录项护理诊断一览表NANDA-I2352015〜2017领域健康促进1Health Promotion类别健康意识1:Health awareness缺乏娱乐活动Deficient diversionalactivity久坐的生活方式Sedentary lifestyle类别健康管理2health management老年综合征Frail elderlysyndrome有老年综合征的危险Risk forfrail elderlysyndrome缺乏社区保健Deficient communityhealth风险倾向的健康行为Risk-prone healthbehavior健康维持无效Ineffective healthmaintenance健康管理无效Ineffective health management有健康管理改善的趋势Readiness forenhanced healthmanagement家庭健康管理无效Ineffective familyhealthmanagement不依从行为Noncompliance防护无效Ineffective protection领域营养2Nutrition类别摄入1:Ingestion母乳不足Insufficient breastmilk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 forenhanced breastfeeding无效性婴儿喂养型态Ineffective infantfeeding pattern营养失调低于机体需要量Imbalanced nutrition:less thanbody requirements有营养改善的趋势Readiness forenhanced nutrition肥胖Obesity超重Overweight有超重的危险Risk foroverweight吞咽障碍Impaired swallowing类别代谢4Metabolism有血糖不稳定的危险Risk forunstable bloodglucose level新生儿黄疸Neonatal jaundice有新生儿黄疸的危险Risk forneonatal jaundice摘自Herdman TH,Kamitsuru SEds..NANDA InternationalNursing Diagnoses:DefinitionsClassification2015-

2017.10rh.[M].Oxford,UK:Wiley Blackwell,

2014.有肝功能受损的危险Risk forimpaired liverfunction类别水电解质5:Hydration有电解质失衡的危险Risk forelectrolyte imbalance有体液平衡改善的趋势Readiness forenhanced fluidbalance体液不足行De cientfluid volume有体液不足的危险Risk fordeficient fluidvolume体液过多Excess fluidvolume有体液失衡的危险Risk forimbalanced fluidvolume领域排泄3:Elimination andExchange类别泌尿功能1:Urinary function排尿障碍Impaired urinaryelimination有排尿功能改善的趋势Readiness forenhanced urinaryeliminationFunctional urinaryincontinence功能性尿失禁Overflow urinaryincontinence溢出性尿失禁Reflex urinaryincontinence反射性尿失禁Stress urinaryincontinence压力性尿失禁Urge urinaryincontinence急迫性尿失禁有急迫性尿失禁的危险尿潴留Risk forurge urinaryincontinenceUrinary retention类另胃肠功能U2Gastrointestinal function便秘Constipation有便秘的危险Risk forconstipation慢性功能性便秘Chronic functionalconstipation有慢性功能性便秘的危险Risk forchronic functionalconstipation感知性便秘Perceived constipation腹泻Diarrhea胃肠动力失调Dysfunctional gastrointestinalmotility有胃肠动力失调的危险Risk fordysfunctional gastrointestinalmotility排便失禁Bowel incontinence类另呼吸功能气体交换障碍U4Respiratory functionImpaired gasexchange领域活动/休息4Activity/Rest类别睡眠/休息1:Sleep/rest失眠Insomnia睡眠剥夺Sleep deprivation有睡眠改善的趋势Readiness forenhanced sleep睡眠型态紊乱Disturbed sleeppattern类别活动/锻炼2Activity/exercise有废用综合征的危险Risk fordisuse syndrome床上活动障碍Impaired bedmobility躯体活动障碍Impaired physicalmobility借助轮椅活动障碍Impaired wheelchairmobility坐起障碍Impaired sitting站立障碍Impaired standing移动能力障碍Impaired transferability行走障碍Impaired walking类别能量平衡3:Energy balance疲乏Fatigue游走状态Wandering类别心血管/呼吸反应4:Cardiovascular/pulmonary responses活动无耐力Activity intolerance有活动无耐力的危险Risk foractivity intolerance低效性呼吸型态Ineffective breathingpattern心输出量减少Decreased cardiacoutput有心输出量减少的危险Risk fordecreased cardiacoutput有心血管功能受损的危险有胃肠道灌注无Risk forimpaired cardiovascularfunction效的危险有肾脏灌注无效的危险Risk for Ineffective gastrointestinalperfusion Risk自主呼吸障碍forIneffectiverenal perfusionImpaired spontaneousventilation有心脏组织灌注不足的危险有脑组织灌Risk fordecreased cardiactissue perfusion注无效的危险外周组织灌注无效Risk forIneffective cerebraltissue perfusionIneffectiveperipheral tissueperfusion有外周组织灌注无效的危险呼吸机依赖Risk forineffective peripheraltissue perfusionDysfunctionalventilatory weaningresponse类别自我照护5:Self-care持家能力障碍Impaired homemaintenance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有自理能力增强的趋势自我忽视Readiness forenhanced self-care Self-neglect领域感知/认知5Perception/Cognition类别注意力1:Attention单侧身体忽视Unilateral neglect类别认知4:Cognition急性意识障碍Acute confusion有急性意识障碍的危险Risk foracute confusion慢性意识障碍Chronic confusion情绪控制失调Labile emotionalcontrol冲动控制无效Ineffective impulsecontrol知识缺乏Deficient knowledge有知识增进的趋势记忆功能障碍Readiness forenhanced knowledgeImpairedmemory类另沟通U5:Communication有沟通改善的趋势语言沟通障碍Readiness forenhanced communicationImpairedverbal communication领域自我感知6Self-Perception类别自我概念1:Self-concept有希望增强的趋势Readiness forenhanced hope无望感Hopelessness有个人尊严受损的危险自我认同紊乱Risk forcompromised humandignityDisturbed personalidentity有自我认同紊乱的危险有自我概念改善的趋势Risk fordisturbed personalidentity类别自尊Readiness forenhanced self-concept2Self-esteem长期低自尊Chronic lowself-esteem有长期低自尊的危险Risk forchronic lowself-esteem情境性低自尊Situational lowself-esteem有情境性低自尊的危险Risk forsituational lowself-esteem类别体像3:Body image体像紊乱Disturbed bodyimage领域角色关系7Role Relationships类别照顾者角色1:Caregiving roles照顾者角色紧张Caregiver rolestrain有照顾者角色紧张的危险Risk forcaregiver rolestrain养育功能障碍Impaired parenting有养育功能改善的趋势Readiness forenhanced parenting有养育功能障碍的危险Risk forimpaired parenting类另家庭关系U2Family relationships有依附关系受损的危险Risk forimpaired attachment家庭运作过程失常Dysfunctional familyprocesses家庭运作过程改变Interrupted familyprocesses有家庭运作过程改善的趋势Readiness forenhanced familyprocesses类别角色表现3:Role performance关系无效Ineffective relationship有关系改善的趋势Readiness forenhanced relationship有关系无效的危险Risk forineffective relationship父母角色冲突Parental roleconflict无效性角色行为Ineffective roleperformance社会交往障碍Impaired socialinteraction领域性8Sexuality类别性功能2:Sexual function性功能障碍Sexual dysfunction性生活型态无效Ineffective sexualitypattern类另生殖U3:Reproduction生育进程无效Ineffective childbearingprocess有生育进程改善的趋势Readiness forenhanced childbearingprocess有生育进程无效的危险Risk forIneffective childbearingprocess有母体与胎儿双方受干扰的危险Risk fordisturbed maternal-fetal dyad领域应对/应激耐受性9Coping/Stress Tolerance类别创伤后反应1:Post-trauma responses创伤后综合征Post-trauma syndrome有创伤后综合征的危险Risk forpost-trauma syndrome强暴创伤综合征Rape-trauma syndrome迁移应激综合征Relocation stresssyndrome有迁移应激综合征的危险Risk forrelocation stresssyndrome类另应对反应U2Coping responses活动计戈无效U Ineffectiveactivity planning有活动计划无效的危险Risk forineffective activityplanning焦虑Anxiety防卫性应对Defensive coping应对无效Ineffective coping有应对改善的趋势Readiness forenhanced coping社区应对无效Ineffective communitycoping有社区应对改善的趋势Readiness forenhanced communitycoping妥协性家庭应对Compromised familycoping无能性家庭应对Disabled familycoping有家庭应对改善的趋势Readiness forenhanced familycoping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 forcomplicated grieving情绪调控受损Impaired moodregulation有能力增强的趋势Readiness forenhanced power无能为力感Powerlessness有无能为力感的危险Risk forpowerlessness恢复能力障碍Impaired resilience有恢复能力增强的趋势Readiness forenhanced resilience有恢复能力障碍的危险Risk forimpaired resilience持续性悲伤Chronic sorrow压力负荷过重Stress overload类别神经行为应激3:Neurobehavioral stress颅内适应能力降低Decreased Intracranialadaptive capacity自主反射失调Autonomic dysreflexia有自主反射失调的危险Risk forautonomic dysreflexia婴儿行为紊乱Disorganized infant behavior有婴儿行为调节改善的趋势Readiness forenhanced organizedinfantbehavior有婴儿行为紊乱的危险Risk fordisorganized infantbehavior领域生活准则10Life Principles类别信念2Values有精神安适增进的趋势Readiness forenhanced spiritualwell-being类别价值/信念/行为一致性3:Value/belief/action congruence有决策能力增强的趋势Readiness forenhanced decision-making抉择冲突Decisional conflict独立决策能力减弱Impaired emancipateddecision-making有独立决策能力增强的趋势Readiness forenhanced emancipateddecisionmaking有独立决策能力减弱的危险Risk forimpaired emancipateddecision-making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 forenhanced religiosity有宗教信仰减弱的危险Risk forimpaired religiosity精神困扰Spiritual distress有精神困扰的危险Risk forspiritual distress领域安全/防护11:Safety/Protection类别感染1:Infection有感染的危险Risk forinfection类别身体损伤2:Physical injury清理呼吸道无效Ineffective airwayclearance有误吸的危险Risk foraspiration有出血的危险Risk forbleeding有干眼症的危险Risk fordry eye有跌倒的危险Risk forfalls有受伤的危险Risk forinjury有角膜受损的危险Risk forcorneal injury有手术期体位性损伤的危险Risk forperioperative positioninginjury有热损伤的危险Risk forthermal injury有尿道损伤的危险Risk forurinary tractinjury牙齿受损Impaired dentition口腔黏膜受损Impaired oralmucous membrane有口腔黏膜受损的危险Risk forimpaired oralmucous membrane有外周神经血管功能障碍的危险Risk forperipheral neurovasculardysfunction有压疮的危险Risk forpressure ulcer有休克的危险Risk forshock皮肤完整性受损Impaired skinintegrity有皮肤完整性受损的危险Risk forimpaired skinintegrity有婴儿猝死综合症的危险Risk forsudden infantdeath syndrome有窒息的危险Risk forsuffocation术后康复迟缓Delayed surgicalrecovery有术后康复迟缓的危险Risk fordelayed surgicalrecovery组织完整性受损Impaired tissueintegrity有组织完整性受损的危险Risk forimpaired tissueintegrity有创伤的危险Risk fortrauma有血管损伤的危险Risk forvascular trauma类别暴力3:Violence有对他人施行暴力的危险Risk forother-directed violence有对自己施行暴力的危险Risk forself-directed violence自残Self-mutilation有自残的危险Risk forself-mutilation有自杀的危险Risk forsuicide类另环境危害U4Environmental hazards受污染Contamination有受污染的危险Risk forcontamination有中毒的危险Risk forpoisoning类别防护过程5:Defensive processes有碘造影剂不良反应的危险Risk foradverse reactionto iodinatedcontrastmedia有过敏反应的危险Risk forallergy response乳胶过敏反应Latex allergyresponse有乳胶过敏反应的危险Risk forlatex allergyresponse类别体温调节6:Thermoregulation有体温失调的危险Risk forimbalanced bodytemperature体温过高Hyperthermia体温过低Hypothermia有体温过低的危险Risk forhypothermia有手术期体温过低的危险Risk forperioperative hypothermia体温调节无效Ineffective thermoregulation领域舒适12Comfort类别身体舒适1:Physical comfort舒适度减弱Impaired comfort有舒适增进的趋势Readiness forenhanced comfort恶心Nausea急性疼痛Acute pain慢性疼痛Chronic pain分娩疼痛Labor pain慢性疼痛综合征Chronic painsyndrome类别环境舒适2:Environmental comfort同类别中第、项112类另社会舒适U3:Social comfort含类别中第、项112有孤独的危险Risk forloneliness社交孤立Social isolation领域成长/发展13Growth/Development类别成长1:Growth有生长比例失调的危险Risk fordisproportionate growth类别发展2Development有发展迟缓的危险Risk fordelayed development（注各领域中暂无相应护理诊断的类别未列出）。