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Jingdong book

护理诊断手册(第11版)

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护理诊断手册(第11版)

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Content Description

《护理诊断手册(第11版)》在新版时不仅增加了一些新的诊断名称和内容,而且还在护理目标中增加了NOC分类,在护理措施中增加了NIC分类,有助于和国际上最新的相应分类方法接轨。《护理诊断手册(第11版)》的出版,预期对整体护理的深入发展有所裨益,因而是临床护理人员的良师益友,也是护理专业师生不可缺少的参考书。但在学习过程中必须坚持洋为中用的原则,既要积极引进国外先进的研究成果,又要根据我国国情,结合实际灵活运用,以充分发挥其积极作用。
Catalogue

导言
一、如何作出准确的护理诊断
二、熟悉护理诊断
三、收集有效的相关资料
四、整理资料
五、区别护理诊断与合作性问题
六、正确地列出护理诊断
七、选择优先诊断
八、总结

第一部分 护理诊断
(按诊断概念的英文字母排序)
1.活动无耐力Activity Intolerance
2.适应力下降(颅内)
Adaptive Capacity.Decreased:Intracranial
3.调节障碍Adjustment,Impaired
4.焦虑 Anxiety
5.死亡焦虑Death,Anxiety,
6.有体温平衡失调的危险
Body Temperature,Risk for Imbalancetl
(1)体温过高HypertIlermia
(2)体温过低}typothermia
(3)体温调节无效Thermoregulation,Ineffective
7.排便失禁Bowel Incontinence
8.母乳喂养有效Breastfeeding,Effective
9.母乳喂养不当或无效Breastfeeding,Ineffective
10.母乳喂养中断Breastfeeding,Interrupted
11.心输出量减少Cardiac Output,Decreased
12.照顾者角色紧张Caregiver Role Strain
有照顾者角色紧张的危险Risk for Caregiver R0le Strain

13.不适Comfort,Impaired
(1)急性疼痛Acute Pain
(2)慢性疼痛Chronic Pain
14.恶心Nausea
15.沟通障碍Communication,Impaired
语言沟通障碍Communication,Impaired Verbal

16.意识障碍Confusion
(1)急性意识障碍Acute Confusion
(2)慢性意识障碍Chronic Confusion

17.便秘Constipation
(1)感知性便秘Perceived Constipation
(2)有便秘的危险Risk for Constipation

18.应对无效Coping,Ineffective
(1)防御性应对Defensive Coping
(2)无效性否认Ineffective Denial
19.社区应对无效Coping,Ineffective Community
20.社区有增强应对的愿望Coping,Readiness for Enhanced Community
21.家庭有增强应对的愿望Family Coping.Readiness for Enhanced
22.家庭妥协性应对Compromised Family Coping
23.家庭应对能力缺陷Disabled Family Coping
24.决策冲突Decisional Conflict
25.腹泻Diarrhea
26.废用综合征Disuse Syndrome
27.娱乐活动缺乏Deficient Diversional Activity
28.反射失调Dysreflexia有反射失调的危险Risk for Dysreflexia
29.能量场紊乱Disturbed Energy Field
30.环境解析障碍综合征Environmental Interpretation Syndrome,Impaired
31.家庭运作中断Family Processes,Interrupted
家庭运作改变:酗酒
Familv Processes,Dysfunctional:Alcoholism
32.疲乏Fatigue
33.恐惧Fear
34.体液不足Deficient Fluid Volume
35.体液过多Excess Fluid Volume
36.有体液失衡的危险Fluid Volume Imbalanced,Risk for

37.悲痛Grieving
(1)期待性悲痛Grieving,Anticipatory
(2)功能障碍性悲痛Grieving,Dysfunctional

38.生长发育迟缓Growth and Development,Delayed
(1)有发育迟缓的危险Risk for Delayed Development
(2)有生长不成比例的危险Growth,Risk for Disproportionate
(3)成人缺乏生命活力Adult Failure to Thrive
39.健康维持无效Health Maintenance,Ineffective
40.寻求健康行为(特定)Health Seeking Behaviors(Specify)
41.持家能力障碍Home Maintenance,Impaired
42.绝望Hopelessness
43.婴儿行为紊乱Infant Behavior,Disorganized
44.有婴儿行为紊乱的危险
Infant Behavior,Risk for Disorganized
45.婴儿有行为能力增强的潜力
Infant Behavior,Readiness for Enhanced Organized
46.有感染的危险Infection,Risk for
有感染传播的危险Infection Transmission,Risk for

47.有受伤的危险Injury,Risk for
(1)有误吸的危险Aspiration,Risk for
(2)有跌倒的危险Risk for Falls
(3)有中毒的危险Poisoning,Risk for
(4)有窒息的危险Suffocation,Risk for
(5)有外伤的危险Trauma,Risk for
48.有围手术期体位性损伤的危险
Injury,Risk for Perioperative Positioning
49.知识缺乏Deficient Knowledge
50.乳胶过敏反应Latex Allergv
有乳胶过敏反应的危险Latex Allergy,Risk for
51.有孤独的危险Loneliness,Risk for
52.个体处理治疗方案有效
Therapeutic Regimen Management,Effective Individual
53.处理治疗方案不当或无效
Therapeutic Regimen Management,Ineffective
第二部分 临床各科常见疾病的护理诊断与合作性问题
Book Abstract

4.促进个体安全的措施。
①确保个体带有识别卡。②适应环境,如果个体愿意,可以踱步或散步。③保持环境整洁。④把药品、清洁剂及其他有毒的化学物品放在个体不容易接近的地方。⑤如果个体不能使用呼叫按钮,使用其他方法(例如:铃、床头呼叫系统的分机)。
5.不鼓励使用限制性方法,探索其他方法(Quinn,1994)。
①如果个体的行为中断了治疗(例如:鼻胃管、导尿管,静脉输液),重新评价治疗是否恰当。②静脉输液治疗:输液管上蒙上纱布;如果个体出现脱水,制定一个进度计划为其提供饮水;使用对个体做最小限制的地点。③导尿管:评估尿失禁的原因,根据不同类型制定特殊的治疗计划,参见“排尿异常”;④集尿袋放置在床的一侧,尿管放置在两腿之间而不是从大腿上穿过,使用尼龙绷带固定。⑤胃管:定期检查对鼻孔的压迫;用松的医用腹带遮挡胃造瘘口;如果个体正在拔胃管,使用约束手套代替腕部约束带。⑥评价个体烦躁不安是否与疼痛有关,如果使用了镇痛剂,调整剂量以减少副作用。⑦把个体安置在有其他人可以帮助照看的房间里。⑧列出在个体意识障碍的时候能够为其提供帮助照看的家人和朋友。⑨给个体一些能抓握的东西(如:布制的、体内填充松软织物的动物玩具)。
6.确保身体舒适,维持基本健康需要(如:排泄、营养、洗浴、梳洗、卫生、清洁、安全)。
7.可参阅个别护理诊断来帮助有认知障碍且不能自理的个体。
8.使用各种疗法,促进对个体的刺激。
9.音乐疗法:
①在用餐时播放轻柔、熟悉的音乐。②给个体播放其年轻时喜欢的音乐。
Introduction

本书系HandbookofNURSINGDIAGNOSIS第11版的中译本。
为查阅方便,该书既未采用“人类反应型态”方式分类,也未以“功能性健康型态”分类,而是以开头字母次序排列编目。为了与有关诊断名称相比较,作者在论述某些诊断名称时,又将相关的诊断编撰成一组进行分析。例如:在讲述以字母“B”开头的“有体温改变的危险”时,将以字母“H”开头的“体温过高”和以字母“T”开头的“体温调节无效”编成一组。对此,译者予以尊重和保留。但在具体译文中,我们则将有关的编组目录删去,以便于阅读。
在翻译过程中,我们基本上采用直译的方法。但个别用直译难以表达其真实含义的内容,我们则采用意译的方法,特此说明。
关于护理诊断方面的专著,国内已有多个译本。同一名词,可能有几种不同的译法,以Characteristic为例,有的译为“依据”,有的译为“特征”。为不致在译名上引起混乱,只要译名没问题,我们均采用首译者的译法,如将Characteristic译为“依据”。
为了阅读方便,我们在部分条目上增加了序号。这是原作中没有的,特此说明。
在版面设计上,我们采用国内常用的方式进行了编排,以符合国人的阅读习惯。
参加本书翻译的,有从事临床护理工作多年的护理人员,也有从事多年教学的教师,均为硕士或在读博士、硕士。但由于水平有限,错误在所难免,敬请读者指正。

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