Nursing Care Fatigue and Nursing Care
What is Fatigue
Fatigue
is a universal symptom associated with most acute and chronic illnesses. It
also is a common complaint among otherwise healthy persons, and often is cited
as one of the most prevalent presenting symptoms in primary care practices.
Defining fatigue, however, has challenged scientists for years. No clear
biological marker of fatigue has been identified and fatigue remains a
perplexing symptom for all health care providers.
How Fatigue Considered as Health Issue
Not
only was fatigue named one of the top four symptoms for study by an expert panel
on symptom management convened by the National Institute of Nursing Research
(NINR) in the early 1990s, but recently fatigue has been singled out as among
the symptoms or health outcomes needing attention.
For standardized measurement
in the National Institutes of Health (NIH) Roadmap for Research initiatives
recently released. Be-cause nursing is centrally interested in symptoms and
symptom management; fatigue is of major concern for nurse researchers and
clinicians alike.
Fatigue as Nursing Diagnose
The
North American Nursing Diagnosis Association (NANDA) defines fatigue as:
“An overwhelming sustained sense of exhaustion and decreased capacity for
physical and mental work at usual level” (NANDA, 2003, p. 74).
Although a
number of nurse researchers have studied fatigue and offered various proposals
for categorizing fatigue, most accept the NANDA definition of fatigue. An
alternative view of fatigue as: The awareness of a decreased capacity for
physical and/or mental activity due to an imbalance in the availability,
utilization, and/or restoration of resources needed to perform an activity
(Aaronson, LS, et al., 1999) also has been proposed.
This definition is not in-
consistent with the NANDA definition; how ever, it adds a generic understanding
of potential causes of fatigue that may differ in different situations, in
order to facilitate. studying the mechanisms of fatigue in different clinical
conditions. This addition also allows for a clearer conception of fatigue as a
biobehavioral phenomenon.
Acute and Chronic Fatigue
With
increased recognition of the importance of studying symptoms within nursing,
more work on fatigue has emerged. Both investigators and study participants
have made distinctions between acute and chronic fatigue.
In one qualitative
study, participants distinguished acute fatigue from chronic fatigue in terms
of origin (specific single event vs. long-term ongoing condition), onset (quick
vs. slow), duration (brief vs. continuous), recovery (quick vs. slow) and
control (yes over acute, no over chronic) (Aaronson, Pallikkathayil , & Crighton
, 2003).
These distinctions are similar to those put forth by Piper (1989), who
identified acute fatigue as protective, linked to a single cause, of short
duration with a rapid onset, perceived as normal, generally occurring in
basically healthy persons with minimal impact on the person, and usually
relieved by rest.
Whereas chronic fatigue is identified as being perceived as
abnormal, having no known function or purpose, occurring in clinical
populations, having many causes, not particularly related to exertion,
persisting over time, having an insidious onset, not usually relieved by rest,
and having a major impact on the person (see also Potempa , 1993, for a review
of chronic fatigue).
Fatigue and Related to Health Conditions
In
the research and clinical literature, fatigue related to childbearing (see
Milligan & Pugh, 1994, for a review) and fatigue related to cancer (see
Irvine, Vincent, Bubela , Thompson, & Graydon, 1991; Smets , Garssen ,
Schuster Uitterhoeve , & de Haes , 1993; Winningham et al., 1994; and
Nail, 2002, for reviews) have received the most attention.
Even these areas,
however, remain largely understudied and poorly understood. While fatigue has
been studied in numerous chronic illnesses, such as AIDS, multiple sclerosis,
and rheumatoid arthritis, cancer-related fatigue is somewhat unique in that it
is often fatigue associated with the treatment for cancer (both radiation and
chemotherapy) that is most troublesome in terms of distress to the individual.
In fact, fatigue associated with cancer treatment has been cited as a major
reason for prematurely discontinuing treatment.
Fatigue as Related Symptom
Fatigue
also has been consistently associated with fever and infectious processes, and
one of the more puzzling manifestations of fatigue is what is currently called
chronic fatigue syndrome (CFS).
CFS is a diagnosis used for cases of severe and
persistent fatigue for which no specific cause has been identified (see Fukuda
et al., 1994, for the current full case definition of CFS and Reeves et al.,
2003, for recommended revisions to address the ambiguities in the current case
definition).
In the literature since the late 19th century. Preliminary
evidence from controlled studies and extensive clinical descriptions point to
both a hypothalamic pituitary-adrenal (HPA) disorder ( Demitrack et al., 1991)
and an immune system. dysregulation (Bearn & Wesseley , 1994) as likely
central mechanisms operating in CFS, Difficulty studying, understanding, and
consequently, treating fatigue is largely due to its ubiquitous nature and the
unknown, but likely multiple, causes of fatigue.
Unta ngling the relationship
between fatigue and depression, in particular, further confounds investigations
of fatigue. While fatigue is an identified symptom of depression, long-standing
chronic fatigue, unrelated to an existing affective disorder, actually may
precipitation depression.
Evidence that the HPA axis is implicated in both CFS
and depression, and that a different pattern of neuroendocrine disturbance in
CFS from that seen in depression has been identified in at least one study
(Ray, 1991), is encouraging for establishing an important distinction between
fatigue that is a symptomatic expression of depression and fatigue due to other
causes.
A lack of consistent, valid, and reliable measures of fatigue also
contributes to problems studying and understanding fatigue. Early work focused
on fatigue in the workplace and was conducted by industrial psychologists,
hygienists, and the military.
These measures focused on healthy individuals and
fatigue experienced at the time of measurement. More recent concern about the
debilitating and distressing health effects of fatigue in clinical populations
has led to the development of other measures targeting fatigue in ill persons.
There is now a plethora of generic measures of fatigue, as well as a growing
list of measures of fatigue in specific illnesses (e.g. cancer , AIDS).
However, because there is no known biochemical test or marker for fatigue, and
because fatigue is first and fore-most a subjective symptom, these measures of
fatigue generally rely on self-reports.
This also has led to several studies
that directly compare measures of fatigue within single samples (eg, Hwang,
Chang, & Kasimis , 2003; Meek et al., 2000).
A
major problem with so many different measures of fatigue is that each tap into
a somewhat different aspect of fatigue and, consequently, it is not clear
whether they are all measuring the same thing. some focus on the emotional and
cognitive expression of fatigue; others include the physical expression of
fatigue.
Some attempt to quantify the amount of fatigue; others include
attention to how fatigue interferes with activities of daily living. When
different measures of fatigue are used in different studies, it is difficult to
know if discrepant findings are due to real substantive differences in fatigue,
or simply to the differences in the measures.
This dilemma, in part, is why the
NIH Roadmap for Research initiative aimed at patient-reported outcomes is
concerned with identifying and standardizing self-report measures, including
fatigue.
Identifying a set of standardized measures of fatigue with strong
psychometric properties that clearly address the different aspects of fatigue
and its expression will go far in aiding future research on this occlusive
symptom.
Causes of Fatigue
There
may well be many causes of fatigue and each may ultimately be traced to a
specific disruption in the HPA axis, in the immune system, or in both. If so,
then continued investigations into CFS, in particular, may lead to a better
understanding of fatigue in other, more clearly diagnosed clinical problems.
Until such work is done that also suggests specific treatments for fatigue,
nursing intervention studies that target ameliorating fatigue in different
clinical populations must continue.
Although rest generally alleviates acute fatigue,
currently there are no known methods to eliminate the fatigue that plagues
persons with various chronic illnesses or those whose fatigue is secondary to
the treatments for their chronic illness. With the use of standardized measures
of fatigue, this is a fertile area for nursing research.