7. Excessive fluid volume exceeds the definition: the individual is in a state of excessive intercellular fluid or interstitial fluid. Diagnostic basis: edema, tight and bright skin, fluid intake greater than excretion, dyspnea and weight gain. Related factors: it is related to the decompensation of regulatory mechanism, obstruction of venous return and excessive sodium/body fluid intake caused by acute and chronic renal failure. 8. There is a risk of fluid imbalance. The risk is defined as: the individual is in a state where the volume of blood vessels, tissues or intracellular fluid decreases or increases, or the fluid changes rapidly between them. 9. Nutritional disorders: nutrition, change: below the definition of physical needs: non-fasting individuals are or may be in a state of not necessarily losing weight, but their nutritional intake or metabolic needs are insufficient. Diagnostic basis: Non-fasting people complained of futility, muscle weakness and decreased serum albumin. Related factors: it is related to the increase of calorie demand, difficulty in fully absorbing calories, difficulty in swallowing, decreased nutrient absorption, decreased appetite, vomiting, anorexia and impaired digestive function. 10. Skin integrity is damaged. Definition of damage: the individual is in a state where the epidermis and/or dermis are changed or at risk of being in this state. Diagnostic basis: skin exfoliation, erythema, injury and itching. 1 1. Risk of impaired skin integrity Definition of risk of impaired skin integrity: The individual is in a state of epidermis and/or dermis change or the risk of being in this state. 12, Constipation Definition: The patient is in a state of feeling that the large intestine is blocked, resulting in less defecation and/or dry and hard stool. Diagnostic basis: dry stool, defecation less than three times a week, weakened bowel sounds, feeling unable to empty, extremely laborious defecation, feeling pain. Related factors: it is related to the decrease of metabolic rate, the decrease of response to defecation stimulation, the pain during defecation and the decrease of intestinal peristalsis caused by hypoxia. 13, constipation risk, the risk is defined as: the patient is in a state where the large intestine is likely to stagnate, resulting in little defecation or dry stool.
Risk factors: it is related to the decrease of defecation stimulus response, pain during defecation and the decrease of intestinal peristalsis caused by hypoxia. 14. definition of activity intolerance: an individual is in a state of reduced physiological ability and cannot tolerate daily expected or necessary activities. Diagnosis basis: weakness, dyspnea, dizziness, pale or silky complexion, unconsciousness and dizziness. Related factors: related to the damage of oxygen supply system, anemia, decreased blood volume, related to the lack of ability sources 15, decreased cardiac output, decreased definition: the individual is in a state of decreased cardiac pumping blood, leading to cardiac compensatory function. Diagnostic basis: low blood pressure, scanty urine, rapid pulse, restlessness, silky hair, dyspnea, fatigue and dizziness. 16, physical activity ability, impaired body definition: individuals are or may be in a state of limited physical activity, but they are not unable to move. Diagnostic basis: under certain circumstances, the purposeful activity ability is impaired, the activity scope is limited, the activity is limited, and the activity is unwilling. Related factors: decreased strength and endurance, nervous system diseases, muscular dystrophy and increased intracranial pressure. 17, definition of invalid breathing pattern: due to the change of breathing pattern, the individual is in an actual or potential state of full ventilation loss. Diagnostic basis: respiratory frequency and pattern change, pulse, sitting breathing, shortness of breath, hyperventilation 18, impaired gas exchange definition: the individual is in the existing or potential state of reduced gas (oxygen and carbon dioxide) throughput between alveoli and vascular system. Diagnostic basis: dyspnea during exertion, vague/nervous consciousness, tendency to assume three postures (19), inability to maintain white breath, inability to maintain spontaneous definition: the individual is in a state of not being able to maintain enough breath to support life needs. This is determined by the decrease of arterial blood gas, the increase of respiratory burden and the decrease of energy. Diagnostic basis: dyspnea, increased metabolic rate, increased fidgeting, increased heartbeat and decreased cooperation ability. 20. Lack of housekeeping ability: specific (eating, bathing/sanitation, dressing/grooming, such as using utensils in the toilet).
Self-care deficiency syndrome (please specify): (:eating, bathing/hygiene, dressing/grooming, going to the toilet, instrumental) Definition: The individual is in a state of impaired motor function or cognitive function, and the ability to perform five cognitive activities from the bow is reduced. 1. Diagnostic basis: self-care deficiency, bathing defect, dressing defect, going to the toilet defect, appliance defect. Related factors: related to secondary lack of cooperation, related to coma, related to cognitive defects, related to confusion. 2 1, definition of sleep pattern disorder: refers to that an individual is in or at risk of being in a state of quantitative and qualitative changes in his rest style, which leads to discomfort and affects his normal life. Diagnostic basis: difficulty in falling asleep or falling asleep, irritability and abnormal mood. Related factors: angina pectoris, respiratory diseases, dysuria and circulatory diseases. 22. Definition of acute pain: the individual feels or complains of severe discomfort or discomfort, and its duration is within 1 second to 6 months. Diagnostic basis: The patient complained of pain, anxiety, irritability, groaning, nausea and vomiting, unwillingness or inability to move, abnormal posture and expression. Related factors: related to this injury and reflex muscle spasm, abdominal pain, diarrhea, gastric ulcer and vomiting. 23, chronic pain chronic pain
6-month status
Definition: Individuals feel persistent or intermittent pain beyond the diagnostic basis: physical inactivity or immobility, skeletal muscle tension, rubbing the painful parts, fatigue and anxiety. Related factors: fever, tissue injury, reflex muscle spasm and abdominal pain. 24. Lack of knowledge deficit definition: individuals are in a state of insufficient knowledge or skills about diseases or treatment plans. Diagnostic basis: express the lack of knowledge or skills or ask for information in language, and express the incorrect understanding of the health status of Baiji dolphin. 25. Definition of inhalation risk: Individuals are at risk of easily inhaling secretions, solids or liquids into test tubes. Related factors: it is related to the decrease of consciousness level, the increase of gastrointestinal pressure and tracheoesophageal achalasia.
26. Perceptual change (concrete): (visual, auditory, olfactory, tactile and kinesthetic) Sensory change (normative): visual, auditory, sensory, taste, tactics, olfactory) Definition: It means that individuals or groups are abnormal or have abnormal risks in the amount, form or explanation of stimulation. Diagnostic basis: the individual's interpretation of environmental stimuli is inaccurate and/or the number and form of stimuli have changed negatively; There may be lost time or place, lost people, abnormal problem-solving ability, abnormal behavior or communication style. Related factors: cerebrovascular accident, neuropathy and personal isolation. 27. Definition of anxiety: Individuals or groups are in an anxious (uneasy) state with vague and unclear threats and stimuli to the white main nervous system. Diagnostic basis: increased heart rate, abnormal sensation, anxiety, shock reaction, forgetfulness, confusion and ignorance *AE o related factors: any factor related to actual or perceived heavy loss will interfere with people's basic needs for food, air, comfort and safety. 28. Definition of fatigue: It is a state that Bai Ji is aware of. In this state, he felt excessive and persistent fatigue, and his physical and mental activity decreased, which could not be alleviated after rest. Diagnosis basis: The chief complaint is that she is constantly tired, unable to maintain her daily activities, and her physical discomfort is aggravated. 29. Definition of fear: The state of physical or emotional distress experienced by individuals or groups when they perceive identifiable dangers. Diagnostic basis: fear, fright, withdrawal behavior, attention deficit and self-comfort. Related factors: it is related to the temporary or long-term influence of perception, out of control and unpredictable consequences. 30. Definition of despair: It is a persistent and subjective hunger. In this state, individuals feel that they have no choice or method for what they want or the problems that need to be solved, and they cannot use their abilities to achieve their personal goals. Diagnostic basis: slow response to time, indifferent response to situations, and decreased ability to solve problems and make decisions. Related factors: limited long-term activities, unable to participate in the activities that individuals want, unable to complete the goals that individuals think are valuable in life.
3 1, communication disorder communication, congenital definition: individuals are or may be in a state of reduced ability to send or receive information. Diagnostic basis: speech ability is impaired, and verbal and non-verbal information are inconsistent. Related factors: it is related to the disorder of unrealistic thinking and the secondary motor dysfunction of language muscles. 32. Definition of sadness: the state of an individual or family's psychological and physiological futile response to existing or expected losses (people, events, functions, status, relationships). Diagnostic basis: The individual states the existing or expected loss (person, thing, function, status, relationship), denial, guilt, futile thinking, depression and crying. Related factors: related to the loss of physical function or independence, related to long-term treatment, related to negative effects and loss. 33. Role obstacle Role performance, definition of change: the individual is or may be in a state where the role ability corresponding to standards and expectations is interrupted. Diagnostic basis: conflict with the role's concept and ability, the role's self-concept is disordered, and the role is denied. 34. Definition of rape trauma syndrome: The individual is in a state of compulsive and violent attack against his will and without his permission. Traumatic syndrome caused by this attack or attempted attack, the lifestyle disorder of the victim and the long-term process of lifestyle reorganization. Diagnostic basis: white complaint or sexual assault certificate and physical reaction. 35. Definition of migration stress (syndrome): As a result of migration from one environment to another, individuals are in a state of physical and psychological disorder. Diagnostic basis: loneliness, anxiety, depression, increased confusion, and related factors: it is related to the decline of adaptability to change and moderate or high environmental changes.
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Common nursing diagnosis in China
Common nursing diagnosis in China
1, injury risk, risk is
Definition: Individuals are at risk of injury due to perceptual or physiological defects, insufficient awareness of danger or developmental stage.
Risk factors: pathophysiological factors, treatment factors, situational factors and maturity factors.
Related factors: related to changes in brain function, changes in activity, and drugs affecting motor and sensory centers.
It has something to do with things, misjudgment and lack of safety awareness.
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2. Danger of suffocation.
Definition: The individual is in a dangerous state of dyspnea and suffocation.
Risk factors: pathophysiological factors, treatment factors, situational factors and maturity factors.
3, there is a risk of body temperature changes, there is a danger of being changed.
Definition: the individual is in a state where he may not be able to maintain his body temperature within the normal range (36~37C or 98~99.5 F).
4. Oral mucosa, change.
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Definition: The individual is in or at risk of oral cavity breakage.
Diagnostic basis: oral mucosal injury; There may be tongue coating, dry mouth, stomatitis, oral tumor, oral injury, mucosal leukoplakia, edema, hemorrhagic gingivitis and so on.
Related factors: pathophysiological factors, therapeutic factors and situational factors.
5, hyperthermia.
Definition: Affected by external factors, the individual's body temperature is rising continuously or possibly continuously, and the oral temperature is higher than 37.8c (100f) or the anal temperature is higher than 38.8c (101f).
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Diagnostic basis: the oral temperature is higher than 37.8c (100? ) or anal temperature is higher than 38, 8c (10 1 F), skin fever, tachycardia, deep breathing, sweating, local or systemic pain, loss of appetite, and skin redness.
Related factors: it is related to the decrease of sweating ability caused by specific drugs and the lack of water intake during strenuous activities.
It is related to the ineffective thermoregulation caused by age.
6. Lack of body fluids
Definition: fasting individuals are in a state of dehydration of blood vessels, interstitial cells or cells.
Diagnostic basis: insufficient oral liquid intake, weight loss, dry skin/mucosa, increased serum sodium, decreased skin fullness, thirst, nausea and loss of appetite.
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Related factors: related to the increase of urine volume, the decrease of drinking power, the excessive displacement of drainage tube and the increase of vulnerability.
7. Excessive body fluids and excessive body fluids
Definition: The individual is in a state of excessive intercellular fluid or interstitial fluid.
Diagnostic basis: edema, tight and bright skin, fluid intake greater than excretion, dyspnea and weight gain.
Related factors: it is related to the decompensation of regulatory mechanism and the obstruction of venous return caused by acute and chronic renal failure.
It is related to excessive sodium/body fluid intake.
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8. Body fluid imbalance is in danger of body fluid volume imbalance, and the danger is.
Definition: The individual is in a state where the volume of blood vessels, tissues or intracellular fluid decreases or increases, or the fluid changes rapidly between them.
9, malnutrition: less than the body needs nutrition.
ask
Definition: Non-fasting individuals, who are or may be, do not necessarily lose weight, but have nutritional intake.
The state of insufficient intake or metabolic demand.
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Diagnostic basis: Non-fasting people complained of futility, muscle weakness and decreased serum albumin.
Related factors: it is related to the increase of calorie demand, difficulty in fully absorbing calories, difficulty in swallowing, decreased nutrient absorption, decreased appetite, vomiting, anorexia and impaired digestive function.
10, skin integrity is damaged, damaged.
Definition: An individual is in a state in which epidermis and/or dermis are altered or at risk of being in such a state.
Diagnostic basis: skin exfoliation, erythema, injury and itching.
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1 1, skin integrity is damaged, and there is a risk of skin integrity damage.
Definition: An individual is in a state in which epidermis and/or dermis are altered or at risk of being in such a state.
12, constipation constipation
Definition: The patient is in a state of slow sensation in the large intestine, resulting in little defecation and/or very dry and hard defecation. Diagnostic basis: dry and hard stool, less than three times a week, weak bowel sounds, patients feel unable to empty, stool is extremely laborious and painful.
Related factors: it is related to the decrease of metabolic rate, the decrease of response to defecation stimulation, the pain during defecation and the decrease of intestinal peristalsis caused by hypoxia.
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13. The risk of constipation.
Definition: The patient is in a state where the large intestine is likely to stagnate, resulting in less defecation or dry stool.
Risk factors: it is related to the decrease of defecation stimulus response, pain during defecation and the decrease of intestinal peristalsis caused by hypoxia.
14, activity endurance, activity intolerance
Definition: The individual is in a state of reduced physiological ability, and can't stand the daily activities that he wants or needs.
Diagnosis basis: weakness, dyspnea, dizziness, pale or silky complexion, unconsciousness and dizziness.
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Related factors: it is related to the damage of oxygen supply system, anemia, decreased blood volume and insufficient source of ability.
15, cardiac output, decrease, decrease
Definition: The individual is in a state of reduced blood pumping, resulting in compensatory cardiac function.
Diagnostic basis: low blood pressure, scanty urine, rapid pulse, restlessness, silky hair, dyspnea, fatigue and dizziness.
16, physical activity, physical damage
Definition: A person is or may be in a state of limited physical activity, but he is not unable to move.
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Diagnostic basis: In a specific environment, the purposeful activity ability is impaired, the range of activities is limited, and it is alive.
Be bound and unwilling to move.
Related factors: decreased strength and endurance, nervous system diseases, muscular dystrophy, intracranial pressure.
Increase.
17, invalid breathing mode
Definition: Due to the change of breathing pattern, the individual is in a state of actual or potential loss of adequate ventilation.
State.
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Diagnostic basis: changes of breathing frequency and pattern, pulse, sitting breathing, shortness of breath and hyperventilation.
18, damaged gas exchange
Definition: The individual is in the existing or potential gas (oxygen and carbon dioxide) between alveoli and vascular system.
Carbon) decreases.
Diagnostic basis: dyspnea, mental confusion/nervousness during exertion, and tendency to assume three positions.
towards
19, unable to maintain the white main breathing adventure, unable to maintain spontaneity.
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Definition: The individual is in a state where he can't maintain enough breathing to support life needs. This is through arterial blood
Decreased qi activity, increased respiratory burden and decreased energy.
Diagnostic basis: dyspnea, increased metabolic rate, increased fidgeting, increased heartbeat and decreased cooperation ability.
20. Defects in housekeeping ability: specific (eating, bathing/sanitation, dressing/grooming, such as using utensils in the toilet).
Self-care deficiency syndrome (please specify): (:feeding, bathing/hygiene,
Dress/dress up, go to the toilet, tools)
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Definition: the motor function or cognitive function of an individual is impaired, and the ability to perform five physical activities has decreased since Gong I.
State.
Diagnostic basis: eating defects, bathing defects, dressing defects, toilet defects, production
This device has defects.
Related factors: related to secondary lack of cooperation, related to coma, related to cognitive defects, related to meaning.
About ambiguity.
Sleep pattern disorder
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Definition: refers to the quantitative change and qualitative change of individual's rest style, which leads to discomfort.
A state that affects normal life.
Diagnostic basis: difficulty in falling asleep or falling asleep, irritability and abnormal mood.
Related factors: angina pectoris, respiratory diseases, dysuria and circulatory diseases.
22. Severe pain
Definition: The individual feels or complains of severe discomfort or discomfort, and its duration is 1 second.
In six months.
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Diagnostic basis: The patient complained of pain, anxiety, irritability, groaning, nausea and vomiting, and reluctance to exercise.
Or unable to move, abnormal posture, pinched expression.
Related factors: related to this injury and reflex muscle spasm, abdominal pain, diarrhea, gastric ulcer and vomiting.
23, chronic pain chronic pain
6-month status
Definition: Individuals feel persistent or intermittent pain beyond the diagnostic basis: physical inactivity or immobility, skeletal muscle tension, rubbing the painful parts, fatigue and anxiety.
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Related factors: fever, tissue injury, reflex muscle spasm and abdominal pain.
24. Lack of knowledge deficit
Definition: The individual is in a state of insufficient knowledge or skills about the disease or treatment plan.
Diagnostic basis: express the lack of knowledge or skills or ask for information in language, and express the health status of Baiji dolphin.
Incorrect understanding.
25. Risk of aspiration.
Definition: The individual is in a dangerous state that secretions, solids or liquids are easily sucked into the tube.
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Related factors: it is related to the decrease of consciousness level, the increase of gastrointestinal pressure and tracheoesophageal achalasia.
26. Perceptual changes (specific): sensory perception (vision, hearing, smell, touch and movement)
Change (specify): vision, hearing, kinesthetic, taste, touch, vision.
Factory)
Definition: refers to the state that an individual or a group is in or has abnormal danger in the amount, form or explanation of stimulus.
Diagnostic basis: the individual's interpretation of environmental stimuli is inaccurate and/or the number and form of stimuli have changed negatively; There may be lost time or place, lost people, abnormal problem-solving ability, abnormal behavior or communication style.
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Related factors: cerebrovascular accident, neuropathy and personal isolation.