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.
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