NURSING DIAGNOSES
Nursing Diagnosis
A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. (Approved at the ninth NANDA Conference; amended in 2009 and 2013.)

Problem-focused Nursing Diagnosis
A clinical judgment concerning an undesirable human response to health conditions/life processes that exists in an individual, family, group, or community. In order to make a problem-focused diagnosis, the following must be present: defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences. Related factors (etiological factors) that are related to, contribute to, or antecedent to the diagnostic focus are also required.

Health-Promotion Nursing Diagnosis
A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state.  Health promotion responses may exist in an individual, family, group, or community. In order to make a health-promotion diagnosis, the following must be present: defining characteristics which begin with the phrase, “Expresses desire to enhance…”.

Risk Nursing Diagnosis
A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. In order to make a risk-focused diagnosis, the following must be present: supported by risk factors that contribute to increased vulnerability.

Syndrome
A clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.In order to make a syndrome diagnosis, the following must be present: two or more nursing diagnoses must be used as defining characteristics. Related factors may be used if they add clarity to the definition, but are not required.

DIAGNOSTIC AXES
Axis
An axis is operationally defined as a dimension of the human response that is considered in the diagnostic process. There are seven axes which parallel the International Standards Reference Model for a Nursing Diagnosis.

• Axis 1: the diagnostic focus
• Axis 2: subject of the diagnosis (individual, caregiver, family, group, community)
• Axis 3: judgment (impaired, ineffective, etc.)
• Axis 4: location (bladder, auditory, cerebral, etc.)
• Axis 5: age (infant, child, adult, etc.)
• Axis 6: time (chronic, acute, intermittent)
• Axis 7: status of the diagnosis (problem-focused, risk, health promotion).

The axes are represented in the labels of the nursing diagnoses through their values. In some cases, they are named explicitly, such as with the diagnoses, Ineffective Community Coping and Compromised Family Coping, in which the subject of the diagnosis (in the first instance “community” and in the second instance “family”) is named using the two values “community” and “family” taken from Axis 2 (subject of the diagnosis). “Ineffective” and “compromised” are two of the values contained in Axis 3 (judgment).

In some cases, the axis is implicit, as is the case with the diagnosis, Activity intolerance, in which the subject of the diagnosis (Axis 2) is always the patient. In some instances an axis may not be pertinent to a particular diagnosis and therefore is not part of the nursing diagnostic label. For example, the time axis may not be relevant to every diagnosis. In the case of diagnoses without explicit identification of the subject of the diagnosis, it may be helpful to remember that NANDA-I defines patient as: “an individual, family, group or community”.

Axis 1 (the diagnostic focus) and Axis 3 (judgment) are essential components of a nursing diagnosis. In some cases, however, the diagnostic focus contains the judgment (for example, Nausea); in these cases the judgment is not explicitly separated out in the diagnostic label. Axis 2 (subject of the diagnosis) is also essential, although, as described above, it may be implied and therefore not included in the label. The Diagnosis Development Committee requires these axes for submission; the other axes may be used where relevant for clarity.

Definitions of the Axes
Axis 1 The Diagnostic Focus
The diagnostic focus is the principal element or the fundamental and essential part, the root, of the diagnostic concept. It describes the “human response” that is the core of the diagnosis.

The diagnostic focus may consist of one or more nouns. When more than one noun is used (for example, Activity intolerance), each one contributes a unique meaning to the diagnostic focus, as if the two were a single noun; the meaning of the combined term, however, is different from when the nouns are stated separately. Frequently, an adjective (Spiritual) may be used with a noun (Distress) to denote the diagnostic focus Spiritual Distress. (see Chapter 4, Table 1, p. )

Axis 2 Subject of the Diagnosis
The person(s) for whom a nursing diagnosis is determined. The values in Axis 2 which represent the NANDA-I definition of “patient” are:

• Individual: a single human being distinct from others, a person.
• Caregiver: a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family: two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group: a number of people with shared characteristics.
• Community: a group of people living in the same locale under the same governance. Examples include neighborhoods and cities.

Axis 3 Judgment
A descriptor or modifier that limits or specifies the meaning of the diagnostic focus. The diagnostic focus together with the nurse’s judgment about it forms the diagnosis. The values in Axis 3 are found in Chapter 4, Table 2, p. .

Axis 4 Location
Describes the parts/regions of the body and/or their related functions – all tissues, organs, anatomical sites, or structures. For the locations in Axis 4, see Chapter 4, Table 3, p.

Axis 5 Age
Refers to the age of the person who is the subject of the diagnosis (Axis 2). The values in Axis 5 are noted below, with all definitions except that of older adult being drawn from the World Health Organization (2013):

• Fetus: an unborn human more than eight weeks after conception, until birth
• Neonate: a child < 28 days of age
• Infant: a child > 28 days and <1 year of age
• Child: person aged 1 to 9 years, inclusive
• Adolescent: person aged 10 to 19 years, inclusive
• Adult: a person older than 19 years of age unless national law defines a person as being an adult at an earlier age
• Older adult: a person > 65 years of age
  

Axis 6 Time
Describes the duration of the diagnostic concept (Axis 1). The values in Axis 6 are:

• Acute: lasting <3 months
• Chronic: lasting >3 months
• Intermittent: stopping or starting again at intervals, periodic, cyclic
• Continuous: uninterrupted, going on without stop.

Axis 7 Status of the Diagnosis
Refers to the actuality or potentiality of the problem/syndrome or to the categorization of the diagnosis as a health promotion diagnosis. The values in Axis 7 are: Problem-focused, Health Promotion, Risk, and Syndrome.

COMPONENTS OF A DIAGNOSIS
Diagnosis Label
Provides a name for a diagnosis that reflects, at a minimum, the diagnostic focus (from Axis 1) and the nursing judgment (from Axis 3). It is a concise term or phrase that represents a pattern of related cues. It may include modifiers.

Definition
Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.

Defining Characteristics
Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis or syndrome. This does not only imply those things that the nurse can see, but things that are seen, heard (e.g., the patient/family tells us), touched or smelled.

Risk Factors
Environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, group, or community to an unhealthy event. Only risk diagnoses have risk factors.

Related Factors
Factors that appear to show some type of patterned relationship with the nursing diagnosis. Such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. Only problem-focused nursing diagnoses and syndromes must have related factors; health-promotion diagnoses may have related factors, if they help to clarify the diagnosis.

DEFINITIONS FOR CLASSIFICATION OF NURSING DIAGNOSIS
Classification
Systematic arrangement of related phenomena in groups or classes based on characteristics that objects have in common.

Level of Abstraction
Describes the concreteness/abstractness of a concept:

• Very abstract concepts are theoretical, may not be directly measurable, are defined by concrete concepts, are inclusive of concrete concepts, are disassociated from any specific instance, are independent of time and space, have more general descriptors, and may not be clinically useful for planning treatment.
• Concrete concepts are observable and measurable, limited by time and space, constitute a specific category, are more exclusive, name a real thing or class of things, are restricted by nature, and may be clinically useful for planning treatment.
  

Nomenclature
A system or set of terms or symbols especially in a particular science, discipline, or art; the act or process or an instance of naming (Merriam-Webster, 2009).

Taxonomy
“Classification: especially orderly classification of plants and animals according to their presumed natural relationships”; the word is derived from the root word, taxon – “the name applied to a taxonomic group in a formal system of nomenclature” (Merriam-Webster, 2009).

References
Merriam-Webster, Inc. (2009). Merriam-Webster′s Collegiate Dictionary (11th ed.) Springfield, MA: Author.
Oxford Dictionary On-Line, British and World Version. (2013). Oxford University Press.  Available at: http://www.oxforddictionaries.com/
Pender, N.J., Murdaugh, C.L., & Parsons, M.A. (2006). Health promotion in nursing practice (5th Ed.). Upper Saddle River, NJ: Pearson Prentice-Hall.
World Health Organization (2013). Health topics: Infant, newborn. Available at: http://www.who.int/topics/infant_newborn/en/.
World Health Organization (2013). Definition of key terms. Available at: http://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/.

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