中国医生：您是否需要护理诊断？
2014/10/18 护士学习笔记
护士笔记微信/网站：HuShiBiJi.CoM昨天吐槽了一下优质护理服务，的确是，国外的护理无限接近于医疗，而我们的护理无限接近于生活护理。看看这些诊断，我们在临床上还在努力么？也是一篇写给医生的文章，我们来看看。
NANDA-I护理诊断 2012-2014
袁劍云 李慶功 翻譯整理 用於2012年中國會議
中国医生：您是否需要护理诊断？
各位大夫，我相信，你们绝大多数没见过下列的护理诊断清单；我知道，你们会问，护士还要什么“诊断”？甚至，可能还会有人从鼻子里轻蔑地“哼”一声。但是，我想说，这215个护理诊断，都是美国护士每天面对患者做出的临床判断，也是他们能够独立解决的健康问题，以及能够独立满足的患者需要。他们会根据这些护理诊断，付诸12000多项护理行动并给医院带来真金白银的收入。中国护士还不会做。
为了中国医生美好未来，我需要您告诉我：
看过清单，您的感想是什么？
2. 从医疗角度，中国医生帮助患者解决大概%多少的“护理诊断”？
3. 您认为，中国护士是否应当解决这些健康问题？
4. 您认为，中国护士做这些，能否降低并发症风险？
5. 您认为，中国护士做这些，能够改善医患关系？
6. 您认为，中国护士做这些，是否有助于解放医生的时间和精力？
您需要花一些时间。谢谢!
领域1:健康促进HealthPromotion
类别1：健康察觉 Health Awareness
娱乐活动缺失(00097)Deficient Diversional Activity
静态生活方式(00168)Sedentary Lifestyle
类别2：健康管理Health Management
社区健康缺失(00215)Deficient Community Health
危险倾向的健康行为(00188)Risk-Prone Health Behavior
无效性健康维护(00099) Ineffective Health Maintenance
准备妥增进免疫状态(00186)Readiness for Enhanced Immunization Status
无效性保护能力(00043) Ineffective Protection
无效性自我健康管理(00078)Ineffective Self-Health Management
准备妥增进自我健康管理(00162)Readiness for Enhanced Self-Health Management
家庭治疗计划处置失当(00080) Ineffective Family Therapeutic Regimen Management
领域2:营养Nutrition
类别1：摄食Ingestion
母乳不足(00216)Insufficient Breast Milk
无效性婴儿哺喂模式(00107)Ineffective Infant Feeding Pattern
营养失衡：少于身体需要(00002)Imbalanced Nutrition: Less Than Body Requirements
营养失衡：多于身体需要(00001)Imbalanced Nutrition: More Than Body Requirements
准备妥增进营养(00163)Readiness for Enhanced Nutrition
风险性营养失衡：多于身体需要(00003)Risk for Imbalanced Nutrition:More Than Body Requirements
吞咽障碍(00103)Impaired Swallowing
类别2：消化Digestion
目前没有
类别3：吸收Absorption
目前没有
类别4：代谢 Metabolism
风险性不稳定血糖浓度(00179)Risk for Unstable Blood Glucose Level
新生儿黄疸 (00194)Neonatal Jaundice
风险性新生儿黄疸 (00230)Risk for Neonatal Jaundice
风险性肝脏功能障碍(00178)Risk for Impaired Liver Function
类别5：水化 Hydration
风险性电解质失衡(00195)Risk for Electrolyte Imbalance
准备妥增进体液平衡(00160)Readiness for Enhanced Fluid Balance
体液容积缺失 (00027) Deficient Fluid Volume
体液容积过量 (00026) Excess Fluid Volume
风险性体液容积缺失 (00028) Risk for Deficient Fluid Volume
风险性体液容积失衡 (00025) Risk for imbalance Fluid Volume
领域3：排泄与交换EliminationandExchange
类别1：泌尿功能Urinary Function
功能性尿失禁(00020) Functional Urinary Incontinence
满溢性尿失禁(00176)Overflow Urinary Incontinence
反射性尿失禁(00018)Reflex Urinary Incontinence
压力性尿失禁(00017)Stress Urinary Incontinence
急迫性尿失禁(00019)Urge Urinary Incontinence
风险性急迫性尿失禁(00022)Risk for Urge Urinary Incontinence
排尿型态障碍(00016)Impaired Urinary Elimination
准备妥增进排尿型态(00166)Readiness for Enhanced Urinary Elimination
尿潴留(00023)Urinary Retention
类别2：胃肠功能 Gastrointestinal Function
便祕(00011) Constipation
感受性便祕(00012) Perceived Constipation
风险性便祕(00015) Risk for Constipation
腹泻(00013) Diarrhea
胃肠能动性失常(00196) Dysfunctional Gastrointestinal Motility
风险性胃肠能动性失常(00197)Risk for Dysfunctional Gastrointestinal Motility
排便失禁(00014)Bowel Incontinence
类别3：皮肤功能 Integumentary Function
目前没有
类别4：呼吸功能Respiratory Function
气体交换障碍(00030)Impaired Gas Exchange
领域4：活动/休息Activity/Rest
类别1：睡眠/休息Sleep/Rest
失眠(00095)Insomnia
睡眠剥削(00096)Sleep Deprivation
准备妥增进睡眠型态(00165)Readiness for Enhanced Sleep
睡眠型态紊乱(00198)Disturbed Sleep Pattern
类别2：活动/运动Activity /Exercise
风险性废用症候群(00040) Risk for Disuse Syndrome
床上移动功能障碍(00091)Impaired Bed Mobility
身体活动功能障碍(00085)Impaired Physical Mobility
轮椅移动功能障碍(00089)Impaired Wheelchair Mobility
移位能力障碍(00090) Impaired Transfer Ability
步行障碍(00088)Impaired Walking
类别3：能量平衡Energy Balance
能量场紊乱(00050) Disturbed Energy Field
疲惫(00093) Fatigue
漫游(00154) Wandering
类别4：心血管/肺部反应Cardiovascular/Pulmonary Responses
活动无耐力(00092)Activity Intolerance
风险性活动无耐力(00094)Risk for Activity Intolerance
低效性呼吸型态(00032) Ineffective Breathing Pattern
心输出量减低(00029)Decreased Cardiac Output
风险性胃肠灌流失效(00202) Risk for Ineffective Gastrointestinal Perfusion
风险性肾脏灌流失效(00203)Risk for Ineffective Renal Perfusion
自主性换气障碍(00033)Impaired Spontaneous Ventilation
周边组织灌流失效(00204)Ineffective Peripheral Tissue Perfusion
风险性心脏组织灌流减少(00200) Risk for Decreased Cardiac Tissue Perfusion
风险性脑组织灌流失效(00201)Risk for Ineffective Cerebral Tissue Perfusion
风险性周边组织灌流失效(00228)Risk for Ineffective Peripheral Tissue Perfusion
呼吸机戒断反应功能失常(00034)Dysfunctional Ventilatory Weaning Response
类别5：自我照顾Self-care
持家能力障碍(00098)Impaired Home Maintenance
准备妥增进自理(00182)Readiness for Enhanced Self-Care
沐浴自理能力缺失(00108)Bathing Self-Care Deficit
穿着自理能力缺失(00109)Dressing Self-Care Deficit
进食自理能力缺失(00102)Feeding Self-Care Deficit
如厕自理能力缺失(00110)Toileting Self-Care Deficit
忽略自我健康管理(00193)Self Neglect
领域5：知觉/认知Perception/Cognition
类别1：注意力Attention
单侧身体忽略(00123)Unilateral Neglect
类别2：定向力Orientation
环境解析障碍症候群(00127)Impaired Environmental Interpretation Syndrome
类别3：感觉/知觉 Sensation/Perception
目前没有
类别4：认知Cognition
急性意识混乱(00128)Acute Confusion
慢性意识混乱(00129)Chronic Confusion
风险性急性意识混乱(00173)Risk for Acute Confusion
冲动控制无效 ( 00222 ) Ineffective Impulse Control
知识缺乏 ( 00126 ) Deficient Knowledge
准备妥增进知识 ( 00161) Readiness for Enhanced Knowledge
记忆减退 ( 00131 ) Impaired Memory
类别5：沟通Communication
准备妥增进沟通 ( 00157 ) Readiness for Enhanced Communication
言词沟通障碍 ( 00051 ) Impaired Verbal Communication
领域6：自我知觉Self-Perception
类别1：自我概念Self-concept
无望感(00124)Hopelessness
风险性个人尊严受损(00174)Risk for Compromised Human Dignity
风险性孤寂(00054)Risk for Loneliness
个人认同紊乱(00121)Disturbed Personal Identity
风险性个人认同紊乱(00225)Risk for Disturbed Personal Identity
准备妥增进自我概念(00167) Readiness for Enhanced Self-Concept
类别2：自尊Self-esteem
长期性低自尊(00119)Chronic Low Self-Esteem
情境性低自尊(00120)Situational Low Self-Esteem
风险性长期低自尊(00224)Risk for Chronic Low Self-Esteem
风险性情境低自尊(00153)Risk for Situational Low Self-Esteem
类别3：身体心像Image
身体心像紊乱(00118)Disturbed Body Image
领域7：角色关系RoleRelationships
类别1：照顾者角色Caregiving Roles
无效性母乳哺喂(00104) Ineffective Breastfeeding
母乳哺喂中断(00105)Interrupted Breastfeeding
准备妥增进母乳哺喂(00106)Readiness for Enhanced Breastfeeding
照顾者角色紧张(00061)Caregiver Role Strain
风险性照顾者角色紧张(00062)Risk for Caregiver Role Strain
亲职障碍(00056)Impaired Parenting
准备妥增进养育功能(00164)Readiness for Enhanced Parenting
风险性养育障碍(00057) Risk for Impaired Parenting
类别2：家庭关系 Family Relationship
风险性依附关系障碍(00058)Risk for Impaired Attachment
家庭运作功能障碍(00063) Dysfunctional Family Processes
家庭运作功能紊乱(00060) Interrupted Family Processes
准备妥增进家庭运作功能(00159) Readiness for Enhanced Family Processes
类别3：角色扮演Role Performance
人际关系失常(00223) Ineffective Relationship
准备妥增进人际关系(00207) Readiness for Enhanced Relationship
风险性人际关系失常(00229)Risk for Ineffective Relationship
亲职角色冲突(00064) Parental Role Conflict
角色扮演无效(00055) Ineffective Role Performance
社交互动障碍(00052) Impaired Social Interaction
领域8：性学Sexuality
类别1：性认同Sexual Identity
目前没有
类别2：性功能Sexual Function
性功能障碍(00059)Sexual Dysfunction
性生活型态失常(00065)Ineffective Sexuality Pattern
类别3：生殖Reproduction
分娩过程不当(00221)Ineffective Childbearing Process
准备妥增进分娩过程(00208) Readiness for Enhanced Childbearing Process
风险性分娩过程不当(00227) Risk for Ineffective Childbearing Process
风险性母婴共扰(00209)Risk for Disturbed Maternal/Fetal Dyad
领域9：调适/压力耐受Coping/StressTolerance
类别1：创伤后反应Post-truma Responses
创伤后症候群(00141)Post-Trauma Syndrome
风险性创伤后症候群(00145)Risk for Post-Trauma Syndrome
强暴创伤症候群(00142)Rape-Trauma Syndrome
迁移压力症候群(00114) Relocation Stress Syndrome
风险性迁移压力症候群(00149)Risk for Relocation Stress Syndrome
类别2：调适反应Coping Responses
无效性活动计划(00199)Ineffective Activity Planning
风险性无效性活动计划(00226)Risk for Ineffective ActivityPlanning
焦虑(00146)Anxiety
防御性因应能力(00071)Defensive Coping
无效性因应能力(00069) Ineffective Coping
准备妥增进因应能力(00158)Readiness for Enhanced Coping
无效性社区因应能力(00077) Ineffective Community Coping
准备妥增进社区因应能力(00076) Readiness for Enhanced Community Coping
受损性家庭因应能力(00074)Compromised Family Coping
家庭因应失能(00073)Disabled Family Coping
准备妥增进家庭因应能力(00075)Readiness for Enhanced Family Coping
死亡焦虑(00147) Death Anxiety
否认行为不当(00072) Ineffective Denial
成人生存功能衰竭(00101) Adult Failure to Thrive
恐惧(00148)Fear
哀伤(00136)Grieving
复杂性哀伤(00135)Complicated Grieving
风险性复杂性哀伤(00172)Risk for Complicated Grieving
准备妥增进权能(00187)Readiness for Enhanced Power
无力感(00125) Powerlessness
风险性无力感(00152)Risk for Powerlessness
个人复原力障碍(00210)Impaired Individual Resilience
准备妥增进复原力(00212)Readiness for Enhanced Resilience
风险性危及复原力(00211)Risk for Compromised Resilience
慢性悲伤(00137) Chronic Sorrow
压力负荷过重(00177)Stress Overload
类别3：神经行为压力Neurobehavioral Stress
自主性反射障碍(00009) Autonomic Dysreflexia
风险性自主反射障碍(00010) Risk for Autonomic Dysreflexia
紊乱性婴儿行为(00116) Disorganized Infant Behavior
风险性紊乱性婴儿行为(00115)Risk for Disorganized Infant Behavior
准备妥增进调整性婴儿行为(00117)Readiness for Enhanced Organized Infant Behavior
颅内调适能力降低(00049)Decreased Intracranial Adaptive Capacity
领域10：生命原则LifePrinciples
类别1：价值 Value
准备妥增进希望(00185)Readiness for Enhanced Hope
类别2：信念 Beliefs
准备妥增进心灵安适(00068)Readiness for Enhanced Spiritual Well-Being
类别3：价值/信念/行动一致Value/Belief/Action Congruence
准备妥增进决定能力(00184) Readiness for Enhanced Decision-Making
抉择冲突(00083)Decisional Conflict
道德困扰(00175)Moral Distress
不遵从(00079) Noncompliance
宗教信仰障碍(00169)Impaired Religiosity
准备妥增进宗教信仰(00171)Readiness for Enhanced Religiosity
风险性宗教信仰障碍(00170)Risk for Impaired Religiosity
心灵困扰(00066) Spiritual Distress
风险性心灵困扰(00067)Risk for Spiritual Distress
领域11：安全/保护Safety/Protection
类别1：感染Infection
风险性感染(00004)Risk for Infection
类别2：身体伤害Physical Injury
呼吸道清除功能失效(00031)Ineffective Airway Clearance
风险性肺吸入(00039)Risk for Aspiration
风险性出血(00206)Risk for Bleeding
齿列生长障碍(00048)Impaired Dentition
风险性干眼症(00219)Risk for Dry Eye
风险性跌倒(00155)Risk for Falls
风险性损伤(00035) Risk for Injury
口腔粘膜受损(00045)Impaired Oral Mucous Membrane
风险性围术期体位损伤(00087)Risk for Perioperative Positioning Injury
风险性周围血管神经功能障碍(00086)Risk for Peripheral Neurovascular Dysfunction
风险性休克(00205) Risk for Shock
皮肤完整性受损(00046) Impaired Skin Integrity
风险性皮肤完整性受损(00047)Risk for Impaired Skin Integrity
风险性婴儿猝死症候群(00156)Risk for Sudden Infant Death Syndrome
风险性窒息(00036)Risk for Suffocation
术后复原延迟(00100)Delayed Surgical Recovery
风险性热损伤(00220)Risk for Thermal Injury
组织完整性受损(00044)Impaired Tissue Integrity
风险性创伤(00038)Risk for Trauma
风险性血管创伤(00213) Risk for Vascular Trauma
类别3：暴力 Violence
风险性对他人的暴力行为(00138)Risk for Other-Directed Violence
风险性对自己的暴力行为(00140)Risk for Self-Directed Violence
自我残害(00151)Self-Mutilation
风险性自我残害(00139)Risk for Self-Mutilation
风险性自杀(00150)Risk for Suicide
类别4：环境危害Environmental Hazards
污染(00181)Contamination
风险性污染(00180)Risk for Contamination
风险性中毒(00037)Risk for Poisoning
类别5：防卫过程Defensive Processes
风险性碘剂显影不良反应(00218)Risk for Adverse Reaction to Iodinated Contrast Media
乳胶过敏反应(00041)Latex Allergy Response
风险性过敏反应(00217)Risk for Allergy Response
风险性乳胶过敏反应(00042)Risk for Latex Allergy Response
类别6：体温调节Thermoregulation
风险性体温失衡(00005)Risk for Imbalanced Body Temperature
体温过高(00007) Hyperthermia
体温过低(00006)Hypothermia
体温调节失常(00008) Ineffective Thermoregulation
领域12：舒适Comfort
类别1：身体舒适Physical Comfort
舒适障碍(00214) Impaired Comfort
准备妥增进舒适(00183)Readiness for Enhanced Comfort
恶心(00134)Nausea
急性疼痛(00132)Acute Pain
慢性疼痛(00133)Chronic Pain
类别2：环境舒适Environmental Comfort
舒适障碍(00214)Impaired Comfort
类别3：社会舒适Social Comfort
社交隔离(00053)Social Isolation
领域13：生长/发育Growth/Development
类别1：生长Growth
风险性不成比例生长(00113)Risk for Disproportionate Growth
类别2：发育 Development
生长及发育延迟(00111)Delayed Growth and Development
风险性发育延迟(00112)Risk for Delayed Development
Reference:
NANDA International Nursing Diagnoses: Definitions & Classification 2012-2014, First Edition.
.Edited by T. Heather Herdman.
2012 NANDA International. Published 2012 by Blackwell Publishing Ltd.
Dr. Chien-yun Wu, RN, PhD. Translated above Nursing Diagnoses for her lecture in China 2012.
来源：“护士学习笔记”公众平台
作者：李庆功授权“护士学习笔记”微信公众平台转载
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