美国护理诊断标准详解

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：1. 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Health Promotion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 V olume风险性体液容积缺失(00028) Risk for Deficient Fluid V olume风险性体液容积失衡(00025) Risk for imbalance Fluid V olume领域3：排泄与交换Elimination and Exchange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Role Relationships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/Stress Tolerance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Life Principles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 DevelopmentReference: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.。