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Nursing Diagnosis: Fatigue Application of NANDA, NOC, NIC

Nursing Diagnosis: Fatigue
Betty J. Ackley

NANDA Definition: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Defining Characteristics: Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities

Related Factors:
Boring lifestyle; stress; anxiety; depression
Humidity; lights; noise; temperature
Negative life events; occupation
Sleep deprivation; pregnancy; poor physical condition; disease states (cancer, HIV, multiple sclerosis); increased physical exertion; malnutrition; anemia

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Endurance
·         Concentration
·         Energy Conservation
·         Nutritional Status: Energy

Client Outcomes
·         Verbalizes increased energy and improved well-being
·         Explains energy conservation plan to offset fatigue
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Energy Management
Nursing Interventions and Rationales
·         Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, mood, and usual pattern of activity. If client has cancer, consider use of an instrument such as the Profile of Mood State short form fatigue subscale, the Multidimensional Assessment of Fatigue, the Lee Fatigue Scale, or the Multidimensional Fatigue Inventory. These assessments have all shown to have good internal reliability. the Profile of Mood State Short Form Fatigue Scale was the strongest performer in one study (Meek et al, 2000).
·         Evaluate adequacy of nutrition and sleep. Encourage the client to get adequate rest. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep patternif appropriate. NOTE: Sometimes clients with chronic fatigue syndrome can sleep excessively and need support to limit sleeping. The most commonly suggested treatment for fatigue is rest (Nail, Winningham, 1995). Inadequate nutrition or poor sleep can contribute to fatigue.
·         Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated, such as anemia, electrolyte imbalance, hypothyroidism, depression, or medication effect. The presence of fatigue is associated with biological, psychological, social, and personal factors (Belza et al, 1993). Fatigue should not be tolerated if it can be readily reversed with treatment.
·         Work with the physician to determine if the client has chronic fatigue syndrome. The Centers for Disease Control and Prevention defines chronic fatigue syndrome as: Clinically evaluated, unexplained, persistent, or relapsing chronic fatigue (over six months duration) that is of new or definite onset (has not been lifelong); is not the result of ongoing exertion; is not alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. In addition, four or more the following symptoms must concurrently be present for over six months: impaired memory or concentration, sore throat, tender cervical or axial lymph nodes, muscle pain, multijoint pain, new headaches, unrefreshing sleep, and postexertion malaise lasting more than 24 hours (Walker, 1999).
·         Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope. Fatigue has been associated with depression, anxiety, anger, and mood disturbances (Potempa, 1993; Fisher, 1997).
·         Encourage client to keep a journal of activities, symptoms of fatigue, and feelings. The journal helps the client monitor progress toward resolving or coping with fatigue and express feelings, which helps with adjustment (Jones, 1992).
·         Assist client with ADLs as necessary; encourage independence without causing exhaustion.
·         Help client set small, easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily.
·         With physician's approval, refer to physical therapy for carefully monitored aerobic exercise program. Aerobic exercise and physical therapy can reduce fatigue in some oncology clients (MacVicar, 1989; Mock et al, 1994; Schwartz, 1998, 2000). An exercise program for patients receiving radiation treatments for cancer of the breast also helped improve emotional health and increased sleep (Mock et al, 1997) A customized exercise program can be helpful to the client with chronic fatigue syndrome (Jain, DeLisa, 1998).
·         Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association. Support groups can help clients deal with body changes and cope with the frequent depression that accompanies fatigue (Jones, 1992; Jain, DeLisa, 1998).
·         Help client identify essential and nonessential tasks and determine what can be delegated.
·         Give client permission to limit social and role demands if needed (e.g., switch to part-time employment, hire cleaning service). The nurse can help the client look at life realistically to balance available energy and energy demands.
·         For cardiac client, recognize that fatigue is common following a myocardial infarction (Lee et al, 2000). Refer to cardiac rehabilitation for carefully prescribed and monitored exercise program. Carefully monitored exercise is thought to decrease symptoms of fatigue in heart patients (Friedman, King, 1995).
·         For fatigue with multiple sclerosis, encourage energy conservation, "recharging efforts," excellent self-care, and keeping the temperature cool (Stuifbergen, Rogers, 1997).
·         For attentional fatigue, suggest restorative activities such as sitting outside, bird-watching, and gardening (Erickson, 1996). Being outside and enjoying nature can help people recover their strength and think more clearly.
·         If not coping well, refer for cognitive therapy to help deal with symptoms of fatigue and help change negative thought patterns. Cognitive therapy can be effective for clients with chronic fatigue syndrome (Fisher, 1997; Walker, 1999), also for clients with HIV (Rose et al, 1998).
·         If fatigue is associated with chemotherapy, be sure to treat nausea, vomiting, and pain effectively and prevent mouth sores if possible. Increased fatigue was seen in breast cancer clients receiving chemotherapy if they were also experiencing unrelieved pain, had nausea with vomiting, or developed mouth sores (Jacobsen et al, 1999).
·         Refer client to occupational therapy to learn new energy-conserving ways to perform tasks. Occupational therapy can help clients learn energy conserving techniques so that clients can perform ADLs without exhaustion.
·         If client is very weak, refer to physical therapy for prescription and use of a mobility aid such as a walker.
·         Identify recent losses; monitor for depression as a possible contributing factor to fatigue. Depression and fatigue are closely correlated; the elderly are more prone to depression because they frequently experience significant losses as they age.
·         Review medications for side effects. Certain medications (e.g., beta-blockers, antihistamines, pain medications) may cause fatigue in the elderly.

Home Care Interventions
·         Assess client's history and current patterns of fatigue as they relate to the home environment. Fatigue may be more pronounced in specific settings for physical or psychological reasons (e.g., rooms associated with loss of loved ones).
·         Assess home for environmental and behavioral triggers of increased fatigue (e.g., stairs required to reach bathroom, patterns of movement around home, cleaning activities that require high energy).
·         When assisting client with adapting to home and daily patterns, avoid activities of high energy output. Refer to occupational therapy to accomplish this if necessary.
·         Assist client with identifying or creating a safe, restful place within the home that can be used routinely (e.g., a room with familiar, nonthreatening, or nonfrightening belongings).
·         Refer cancer clients to a community-based pain and fatigue management program, such as the I Feel Better program, if available. A program such as I Feel Better was received with enthusiasm and rapid enrollment by cancer clients (Grant et al, 2000).
Client/Family Teaching
·         Share information about fatigue and how to live with it, including need for positive self-talk. Client education legitimizes fatigue and enhances client's control through self-care and positive self talk (Fisher, 1997).
·         Teach strategies for energy conservation (e.g., sitting instead of standing during showering, storing items at waist level).
·         Teach client to carry a pocket calendar, make lists of required activities, and post reminders around the house. Chronic fatigue is often associated with memory loss and sometimes difficulty thinking (Jain, DeLisa, 1998).
·         Teach the importance of following a healthy lifestyle with adequate nutrition and rest, pain relief, and appropriate exercise to decrease fatigue.
·         Teach stress-reduction techniques such as controlled breathing, imagery, and use of music. See Anxietycare plan if appropriate; anxiety is correlated with increased fatigue.

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