基础护理学辅导

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1、基础护理学辅导：128项护理诊断型态1：交换(EXCHANGING)营养失调：高于身体需要量(ALTEREDNUTRITION:MORETHANBODYREQUIREMENTS)营养失调：低于身体需要屋(ALTEREDNUTRITION：LESSTHANBODYREQUIREMENTS)营养失调：潜在的高于身体需要量(ALTEREDNUTRITION：POTENTIALFORMORETHANBODYREQUIREMENTS)冇感染的危险(RISKFORINFECTION)有休温改变的危险(RISKFORALTEREDBODYTEMPERATURE)体温过低(HYPOTHERMIA)休温过高(H

2、YPERTHERMIA)体温调节无效(INEFFECTIVETHERMOREGULATION)反射失调(DYSREFLEXIA)便秘(CONSTIPATION)感知性便秘(PERCEIVEDCONSTIPATION)结肠性便秘(COLONICCONSTIPATION)腹泻(DIARRHEA)大便失禁(BOWELINCONTINENCE)排丿來界常(ALTEREDURINARYELIMINATION)压迫性尿失禁(STRESSINCONTINENCE)反射性尿失禁(REFLEXINCOMTINENCE)急迫性尿失禁(URGEINCONTINENCE)功能性尿失禁(FUNCTIONALINCONT

3、INENCE)完全性尿火禁(TOTALINCONTINENCE)尿潴留（URINARYRETENTION）组织灌注量改变：（特定型）（肾、脑、心肺、胃肠、外周血管）［ALTEREDTISSUEPERFUSION(SPECIFYTYPE)(RENAL,CEREBRAL,CARDIOPULMONARY,GASTROINTESTINAL,PERIPHERAL)]体液过多(FLUIDVOLUMEEXCESS)体液不足(FLUIDVOLUMEDEFICIT)有体液不足的危险(RISKFORFLUIDVOLUMEDEFICIT)心输出量减少(DECREASEDCARDIACOUTPUT)气体交换受损(IM

4、PAIREDGASEXCHANGE)清理呼l及道无效(INEFFECTIVEAlRWAYCLEARANCE)低效性呼吸型态(INEFFECTIVEBREATHINGPATTERN)不能维持白主呼吸(INABILITYTOSUSTAINSPONTANEOUSVENTILATION)呼吸机依赖(DYSFUNCTIONALVENTILATORYWEANINGRESPONSE,DVWR)有受伤害的危险(RISKFORINJURY)有窒息的危险有中毒的危险有外伤的危险有误吸的危险(RISKFORSUFFOCATION)(RISKFORPOISONING)(RISKFORTRAUMA)(RISKFORAS

5、PIRATION)(COMMUNICATING)(IMPAIREDVERBALCOMMUNICATION)(RELATING)(IMPAIREDSOCIALINTERACTION)有废用综合征的危险(RISKFORDISUSESYNDROME)保护能力改变(ALTEREDPROTECTION)组织完整性受损(IMPAIREDTISSUEINTEGRITY)口腔粘膜改变(ALTEREDORALMUCOUSMEMBRANE)皮肤完整性受损(IMPAIREDSKININTEGRITY)有皮肤完整性受损的危险(RISKFORIMPAIREDSKININTEGRITY)适应能力下降：颅内的(DECRAS

6、EDADAPTIVECAPACITY：INTRACRANIAL)能量场困扰(ENERGYFlELDDISTURBANCE)型态2：沟通语言沟通障碍型态3:关系社交活动障碍社交孤立(SOCIALISOLATION)有孤独的危险(RISKFORLONELINESS)角色紊舌L(ALTEREDROLEPERFORMANCE)父母不称职(ALTEREDPARENTING)有父母不称职的危险(RISKFORALTEREDPARENTING)有亲子依恋改变的危险(RISKFORALTEREDPARENT/INFANT/CHILDATTACHMENT)性功能障碍(SEXUALDYSFUNCTION)家庭作用

7、改变(ALTEREDFAMILYPROCESS)照顾者角色困难(CAREGIVERROLESTRAIN)有照顾者角色困难的危险(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)型态4：赋予