🩺 基础护理，快速掌握 · 第4课，共5课 · 5 min
ADPIE：护理诊断不是医疗诊断
ADPIE: Nursing Diagnoses Are Not Medical Diagnoses
🔁 “Pneumonia”是一种医疗诊断。“与肺泡实变相关的气体交换受损”是一种护理诊断。考试非常重视这一区别，因为它决定了护士治疗什么。
🔁 'Pneumonia' is a medical diagnosis. 'Impaired gas exchange related to alveolar consolidation' is a nursing diagnosis. The exam cares deeply about that difference, because it defines what a nurse treats.
💡 核心要点
护理治疗的是患者对疾病的反应。目标是可衡量的、以患者为中心的、有时限的，评价决定计划是否改变。
Nursing treats the client's response to illness. Goals are measurable, client-centered and time-bound, and evaluation decides whether the plan changes.
🧠 为什么重要
ASSESSMENT收集主观资料（患者所说的内容）和客观资料（你观察和测量的内容）。DIAGNOSIS是NURSING诊断：患者对健康问题的反应，是护理可以独立治疗的问题，例如“跌倒风险”或“急性疼痛”。医疗诊断命名疾病，属于医疗服务提供者的职责。PLANNING设定以患者为中心、可衡量的目标，并附有时间框架（“患者将在出院前使用助行器行走50 feet”），并按优先级对它们排序。IMPLEMENTATION执行干预措施并记录它们。EVALUATION将结果与目标进行比较，并决定是继续、修改还是停止计划。这个过程是循环的；评价会引出新的评估。
ASSESSMENT collects subjective data (what the client says) and objective data (what you observe and measure). DIAGNOSIS is a NURSING diagnosis: the client's response to a health problem, something nursing can treat independently, such as 'risk for falls' or 'acute pain'. A medical diagnosis names the disease and belongs to the provider. PLANNING sets client-centered, measurable goals with a time frame ('client will ambulate 50 feet with a walker by discharge') and ranks them by priority. IMPLEMENTATION carries out the interventions and documents them. EVALUATION compares the outcome to the goal and decides whether to continue, modify or stop the plan. The process is cyclic; evaluation feeds a new assessment.
🏥 真实场景
🎯 写下的目标是：患者将理解糖尿病。这无法评价。改写为：患者将在周五出院前演示正确的insulin自我注射技术。现在到了周五评价时，答案是是或否，计划要么结束，要么继续。模糊的目标会产生模糊的护理。
🎯 Goal written: 'Client will understand diabetes.' Impossible to evaluate. Rewritten: 'Client will demonstrate correct insulin self-injection technique before discharge on Friday.' Now at Friday's evaluation the answer is yes or no, and the plan either closes or continues. Vague goals produce vague care.
📌 要点总结
- 主观资料是患者所说的内容；客观资料是你观察或测量的内容Subjective is what the client says; objective is what you observe or measure
- 护理诊断是患者的反应，而不是疾病A nursing diagnosis is the client's response, not the disease
- 目标必须可衡量、以患者为中心且有时限Goals must be measurable, client-centered and time-bound
📖 本课术语
护理程序（ADPIE） (Nursing process (ADPIE)): 评估、诊断、计划、实施和评价，是每个护理计划遵循的循环。
✅ 自我测试
哪一项是护理诊断而不是医疗诊断？Which statement is a nursing diagnosis rather than a medical diagnosis?
- 伴有周围神经病变的2型糖尿病Type 2 diabetes mellitus with peripheral neuropathy
- 在家跌倒导致的左股骨骨折Fractured left femur from a fall at home
- 气道清除无效Ineffective airway clearance
- 射血分数降低的心力衰竭Heart failure with reduced ejection fraction
答案: C · 气道清除无效
护理诊断描述的是护士可以治疗的患者反应；其他选项是由医疗服务提供者给出的疾病标签。射血分数降低的心力衰竭是由医疗服务提供者做出的医疗诊断，而不是护士通过护理诊断治疗的患者反应。
A nursing diagnosis describes a client response that nurses can treat; the others are disease labels made by providers. Heart failure with reduced ejection fraction is a medical diagnosis made by a provider, not a client response that nurses treat through a nursing diagnosis.
哪一项是客观资料的例子？Which is an example of objective data?
- “我睡得不好。”'I didn't sleep well.'
- 血压146/92Blood pressure 146/92
- “我感到恶心。”'I feel nauseated.'
- “我的疼痛是6分。”'My pain is a 6.'
答案: B · 血压146/92
客观资料是测量或观察到的。患者自己的陈述是主观的。将疼痛报告为6分是患者自己的主观陈述，而不是护士测量或观察到的数据。
Objective data is measured or observed. The client's own statements are subjective. Reporting pain as a 6 is the client's own subjective statement, not data measured or observed by the nurse.
哪个目标的写法正确？Which goal is correctly written?
- 护士将按医嘱每4小时给予止痛药Nurse will give pain medication every 4 hours as prescribed
- 患者在住院期间将感到舒适并休息良好Client will be comfortable and rest well during the hospital stay
- 患者将了解饮食Client will know about the diet
- 患者将把疼痛评为3/10或更低，时间在1小时内Client will rate pain 3/10 or less within 1 hour
答案: D · 患者将把疼痛评为3/10或更低，时间在1小时内
以患者为中心、可衡量且有时限。目标描述的是患者将实现什么，而不是护士将做什么。
Client-centered, measurable and time-bound. Goals describe what the client will achieve, not what the nurse will do.
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