Mosby護理診斷手冊

第一單元護理診斷指引
依字母排序列出內外科及精神科診斷、診斷性檢查、臨床狀態、症狀及問題，和所建議的護理診斷。

第二單元照護計劃指引
依字母排序的每個護理診斷之定義、定義特徵、危險因子、相關因素、個案成果、措施、兒童及老人護理措施（若適用的話）、居家護理措施、具文化適切性的護理措施（若適用的話），以及個案 ／ 家屬衛教。

活動無耐力
Activity intolerance
潛在危險性活動無耐力
Risk for Activity intolerance
無效性活動計畫
Ineffective Activity planning
呼吸道清除功能失效
Ineffective Airway clearance
乳膠過敏反應
Latex Allergy response
潛在危險性乳膠過敏反應
Risk for latex Allergy response
焦慮
Anxiety
死亡焦慮
Death Anxiety
潛在危險性肺吸入
Risk for Aspiration
潛在危險性依附關係障礙
Risk for impaired Attachment
自主性反射障礙
Autonomic dysreflexia
潛在危險性自主反射障礙
Risk for Autonomic dysreflexia
危險傾向的健康行為
Risk-prone health Behavior
潛在危險性出血
Risk for Bleeding
身體心像紊亂
Disturbed Body Image
潛在危險性體溫不平衡
Risk for imbalanced Body temperature
排便失禁
Bowel incontinence
有效性母乳哺餵
Effective Breastfeeding
無效性母乳哺餵
Ineffective Breastfeeding
母乳哺餵中斷
Interrupted Breastfeeding
低效性呼吸型態
Ineffective Breathing pattern
心輸出量減少
Decreased Cardiac output
照顧者角色緊張
Caregiver role strain
潛在危險性照顧者角色緊張
Risk for Caregiver role strain
生育過程增進的準備度
Readiness for enhanced Childbearing process
舒適障礙
Impaired Comfort
舒適增進的準備度
Readiness for enhanced Comfort
溝通增進的準備度
Readiness for enhanced Communication
言詞溝通障礙
Impaired verbal Communication
決擇衝突
Decisional Conflict
親職角色衝突
Parental role Conflict
急性混亂
Acute Confusion
潛在危險性急性混亂
Risk for acute Confusion
慢性混亂
Chronic Confusion
便祕
Constipation
感受性便祕
Perceived Constipation
潛在危險性便祕
Risk for Constipation
汙染
Contamination
潛在危險性汙染
Risk for Contamination
無效性社區因應能力
Ineffective community Coping
社區因應能力增進的準備度
Readiness for enhanced community Coping
防禦性因應能力
Defensive Coping
危害性家庭因應能力
Compromised family Coping
家庭因應失能
Disabled family Coping
家庭因應能力增進的準備度
Readiness for enhanced family Coping
無效性因應能力
Ineffective Coping
因應能力增進的準備度
Readiness for enhanced Coping
潛在危險性嬰兒猝死症候群
Risk for Sudden Infant Death Syndrome （SIDS）
決策增進的準備度
Readiness for enhanced Decision-Making
否認行為不當
Ineffective Denial
齒列生長障礙
Impaired Dentition
潛在危險性發展遲緩
Risk for Delayed Development
腹瀉
Diarrhea
潛在危險性危及個人尊嚴
Risk for Compromised Human Dignity
道德困境
Moral Distress
潛在危險性廢用症候群
Risk for Disuse Syndrome
娛樂活動缺失
Deficient Diversional Activity
潛在危險性電解質不平衡
Risk for Electrolyte imbalance
能量場紊亂
Disturbed Energy Field
環境解析障礙症候群
Impaired Environmental interpretation syndrome
成人生存功能衰竭
Adult Failure to thrive
危險性跌倒
Risk for Falls
家庭運作過程失常
Dysfunctional Family processes
家庭運作過程紊亂
Interrupted Family processes
家庭運作過程增進的準備度
Readiness for enhanced Family processes
疲憊

Fatigue
恐懼
Fear
無效性嬰兒哺餵型態
Ineffective infant Feeding pattern
體液平衡增進的準備度
Readiness for enhanced Fluid balance
體液容積缺失
Deficient Fluid volume
潛在危險性體液容積缺失
Risk for deficient Fluid volume
體液容積過量
Excess Fluid volume
潛在危險性體液容積不平衡
Risk for imbalanced Fluid volume
氣體交換功能障礙
Impaired Gas exchange
潛在危險性血糖濃度不穩定
Risk for unstable blood Glucose level
哀傷
Grieving
複雜性哀傷
Complicated Grieving
潛在危險性複雜性哀傷
Risk for complicated Grieving
生長及發育延遲
Delayed Growth and development
潛在危險性不成比例生長
Risk for disproportionate Growth
無效性健康維護能力
Ineffective Health maintenance
無效性自我健康管理
Ineffective self Health management
持家能力障礙
Impaired Home maintenance
希望增進的準備度
Readiness for enhanced Hope
無望感
Hopelessness
體溫過高
Hyperthermia
體溫過低
Hypothermia
個人認同紊亂
Disturbed Personal Identity
免疫狀態增進的準備度
Readiness for enhanced Immunization status
功能性尿失禁
Functional Urinary Incontinence
溢流性尿失禁
Overflow urinary Incontinence
反射性尿失禁
Reflex urinary Incontinence
壓力性尿失禁
Stress urinary Incontinence
急迫性尿失禁
Urge urinary Incontinence
潛在危險性急迫性尿失禁
Risk for urge urinary Incontinence
混亂性嬰兒行為
Disorganized Infant Behavior
潛在危險性混亂性嬰兒行為
Risk for disorganized Infant behavior
系統性嬰兒行為增進的準備度
Readiness for Enhanced Organized Infant Behavior
潛在危險性感染
Risk for Infection
潛在危險性損傷
Risk for Injury
潛在危險性手術全期擺位傷害
Risk for perioperative positioning Injury
失眠
Insomnia
顱內調適能力降低
Decreased Intracranial adaptive capacity
新生兒黃疸
Neonatal Jaundice
知識缺失（特定的）
Deficient Knowledge （specify）
知識增進的準備度（特定的）
Readiness for enhanced Knowledge （specify）
靜態生活型態
Sedentary Lifestyle
潛在危險性肝功能障礙
Risk for impaired Liver function
潛在危險性孤寂
Risk for Loneliness
潛在危險性母體 ／ 胎兒雙方受擾
Risk for disturbed Maternal／Fetal dyad
記憶功能障礙
Impaired Memory
床上活動功能障礙
Impaired bed Mobility
身體活動功能障礙
Impaired physical Mobility
輪椅移動功能障礙
Impaired wheelchair Mobility
消化道活動功能失常
Dysfunctional gastrointestinal Motility
潛在危險性消化道活動功能障礙
Risk for dysfunctional gastrointestinal Motility
噁心
Nausea
忽略自我健康管理
Self Neglect
單側身體忽略
Unilateral Neglect
不遵從
Noncompliance
營養不均衡：少於身體需要
Imbalanced Nutrition: less than body requirements
營養不均衡：多於身體需要
Imbalanced Nutrition: more than body requirements
潛在危險性營養不均衡：多於身體需要
Risk for imbalanced Nutrition: more than body requirements
營養增進的準備度
Readiness for enhanced Nutrition
口腔黏膜受損
Impaired Oral mucous membrane
急性疼痛
Acute Pain
慢性疼痛
Chronic Pain
親職功能障礙
Impaired Parenting
潛在危險性親職功能障礙
Risk for impaired Parenting
親職功能增進的準備度
Readiness for enhanced Parenting
潛在危險性腎臟灌流失效
Risk for ineffective renal Perfusion
潛在危險性心臟組織灌流減少
Risk for decreased cardiac tissue Perfusion
潛在危險性腦組織灌流失效
Risk for ineffective cerebral tissue Perfusion
潛在危險性胃腸組織灌流失效
Risk for ineffective gastrointestinal tissue Perfusion
周邊組織灌流失效
Ineffective peripheral tissue Perfusion
潛在危險性周邊神經血管功能障礙
Risk for Peripheral neurovascular dysfunction
潛在危險性中毒
Risk for Poisoning
創傷後症候群
Post-Trauma syndrome
潛在危險性創傷後症候群
Risk for Post-Trauma syndrome
能力增進的準備度
Readiness for enhanced Power
無力感
Powerlessness
潛在危險性無力感
Risk for Powerlessness
無效性保護能力
Ineffective Protection
強暴創傷症候群
Rape-Trauma syndrome
關係增進的準備度
Readiness for enhanced Relationship
篤信宗教障礙
Impaired Religiosity
潛在危險性篤信宗教障礙
Risk for impaired Religiosity
宗教信仰增進的準備度
Readiness for enhanced Religiosity
遷移壓力症候群
Relocation stress syndrome
潛在危險性遷移壓力症候群
Risk for Relocation stress syndrome
潛在危險性危害性復原力
Risk for compromised Resilience
個人復原力障礙
Impaired individual Resilience
復原力增進的準備度
Readiness for enhanced Resilience
角色扮演不當
Ineffective Role performance
自我照顧能力增進的準備度
Readiness for enhanced Self-care
自我照顧能力缺失：沐浴
Self-Care deficit, Bathing
自我照顧能力缺失：穿著
Self-Care deficit, Dressing
自我照顧能力缺失：進食
Self-Care deficit, Feeding
自我照顧能力缺失：如廁
Self-Care deficit, Toileting
自我概念增進的準備度
Readiness for enhanced Self-Concept
長期性低自尊
Chronic low Self-Esteem
情境性低自尊
Situational low Self-Esteem
潛在危險性情境性低自尊
Risk for Situational low Self-Esteem
自我健康管理增進的準備度
Readiness for enhanced Self Health management
自我殘害
Self-Mutilation
潛在危險性自我殘害
Risk for Self-Mutilation
感覺知覺紊亂：視覺、聽覺、動覺、味覺、觸覺、嗅覺
Disturbed Sensory perception （Specify: Visal, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory）
性功能障礙
Sexual Dysfunction
性生活型態失常
Ineffective Sexuality Pattern
潛在危險性休克
Risk for Shock
皮膚完整性受損
Impaired Skin integrity
潛在危險性皮膚完整性受損
Risk for impaired Skin integrity
睡眠剝削
Sleep Deprivation
睡眠型態增進的準備度
Readiness for enhanced Sleep
睡眠型態紊亂
Disturbed Sleep Pattern
社交互動障礙
Impaired Social Interaction
社交隔離
Social isolation
慢性悲傷
Chronic Sorrow
心靈困擾
Spiritual distress
潛在危險性心靈困擾
Risk for Spiritual distress
心靈安適增進的準備度
Readiness for enhanced Spiritual well-being
壓力超負荷
Stress overload
潛在危險性窒息
Risk for Suffocation
潛在危險性自殺
Risk for Suicide
術後復原延遲
Delayed Surgical recovery
吞嚥障礙
Impaired Swallowing
家庭治療計畫處置不當
Ineffective family Therapeutic regimen management
體溫調節失常
Ineffective Thermoregulation
組織完整性受損
Impaired Tissue integrity
移位能力障礙
Impaired Transfer ability
潛在危險性創傷
Risk for Trauma
潛在危險性血管創傷
Risk for vascular Trauma
排尿型態障礙
Impaired Urinary Elimination
排尿型態增進的準備度
Readiness for enhanced Urinary elimination
尿瀦留
Urinary retention
自主性換氣障礙
Impaired spontaneous Ventilation
呼吸器戒斷反應功能失常
Dysfunctional Ventilatory weaning response
對他人的潛在危險性暴力行為
Risk for other-directed Violence
對自己的潛在危險性暴力行為
Risk for self-directed Violence
步行能力障礙
Impaired Walking

■作者簡介

Gail B. Ladwig
MSN, RN, CHTP, Professor Emeritus, Jackson Community College; Co-Owner and Nursing Consultant, Holistic Choices; Healing Touch Practitioner, Jackson, MI

■審閱簡介

簡淑慧 副教授
長庚技術學院護理系(所)
美國華盛頓大學護理學研究所博士

葉明莉 講師
亞東技術學院護理系
台北醫學大學醫學科學研究所博士候選人