I

NAN DA- 1 Definition

Consistent lack of orientation to person, place, time, or circumstances over more than 3 to 6 months neces­
sitating a protective environment

Defining Characteristics*

Major (Must Be Present, One or More)

Consistent disorientation
Chronic confusional states

Minor (May Be Present)

Loss of occupation Inability to reason
Inability to concentrate Slow in responding to questions
Loss of social functioning Inability to follow simple directions

Related Factors

Dementia* (Alzheimer's disease, multi-infarct dementia, Pick's disease, AID S dementia)

Parkinson's disease
Huntington's disease*
Depression*
Alcoholism

Author's Note

Environmentol lnterpretotion Syndrome describes an individual who needs a protective environment because of consis­
tent lack of orientation to person , place , time, or circumstances. This diagnosis is described under Chronic Confusion,
Wondering, and Risk for Injury. I nterventions focus on maintaining maximum level of independence and preventing injury.
Until clinical research differentiates this diagnosis from the aforementioned diagnoses , use Chronic Confusion , Wonder­
ing, or Risk for Injury depending on the data presented.

I
NAN DA- 1 Definition

An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the
usual level

Defining Characteristics*

Reports an unremitting and overwhelming lack of energy

Perceived need for additional energy to accomplish routine tasks
Reports inability to maintain usual routines
Reports feeling tired
Compromised concentration
Compromised libido
Increased physical complaints
Decreased performance

3 06
 Fatigue 3 07

Disinterest in surroundings
Lethargic; drowsy
Reports inability to maintain usual level of physical activity
Increase in physical complaints
Increase in rest requirements
Reports guilt for not keeping up with responsibilities
Reports inability to restore energy even after sleep
Introspection
Listlessness

Related Factors

Many factors can cause fatigue; combining related factors may be useful (e.g., related to muscle weakness,
accumulated waste products, inflammation, and infections secondary to hepatitis).

Bio-Pathophysiologic
Related to hypermetabolic state secondary to:
Viruses (e.g., Epstein-Barr) Fever Pregnancy*

Related to inadequate tissue oxygenation secondary to:

Chronic obstructive lung disease Congestive heart failure Anemia*
Peripheral vascular disease

Related to biochemical changes secondary to:

Endocri ne/Metabolic Disorders
Diabetes mellitus Pituitary disorders Acquired immunodeficiency
syndrome (AID S)
Hypothyroidism Addison's disease

Chronic Diseases
Renal failure Cirrhosis Lyme disease
Related to muscular weakness/wasting secondary to:
Myasthenia gravis Parkinson's disease Multiple sclerosis
AIDS Amyotrophic lateral sclerosis

Related to hypermetabolic state, competition between body and tumorfor nutrients, anemia, and stressors
associated with cancer
Related to malnutrition *
Related to nutritional deficits* or changes in nutrient metabolism secondary to:
Nausea Side effects of medications Vomiting
Gastric surgery Diarrhea Diabetes mellitus

Related to chronic inflammatory process secondary to:

AIDS Cirrhosis Arthritis
Inflammatory bowel disease Lupus erythematosus Renal failure
Hepatitis Lyme disease

Treatment Related
Biochemical changes secondary to:
Chemotherapy Radiation therapy Side effects of (specify)

Related to surgical damage to tissue and anesthesia

Related to increased energy expenditure secondary to:
Amputation Gait disorder Use of walker, crutches
3 08 SECTION 2 ° PART 1 ° Individual Nursing Diagnoses

Situational (Personal, Environmental)

Related to prolonged decreased activity and deconditioning secondary to:
Anxiety* Social isolation Fever
Nausea/vomiting Diarrhea Depression
Pain Obesity

Related to excessive role demands

Related to overwhelming emotional demands
Related to extreme stress*
Related to sleep disturbance

Maturational
Child/Adolescent
Related to hypermetabolic state secondary to:
Mononucleosis Fever

Related to chronic insufficient nutrients secondary to:

Obesity Excessive dieting Eating disorders

Related to effects of newborn care on sleep patterns and needfor continuous attention
Related to hypermetabolic state duringfirst trimester

Author's Note

Fatigue as a n u rsing diagnosis d iffers from acute tiredness. Tiredness is a transient, temporary state (*Rhoten, 1 982)
caused by lack of sleep, improper nutrition , increased stress , sedentary lifestyle, or temporarily increased work or social
responsibilities. Fatigue is a pervasive , subjective , drained feeling that cannot be eliminated; however, the nurse can as­
sist the person to adapt to it. Activity intolerance d iffers from fatigue in that the nurse wil l assist the person with activity
intolerance to increase endurance and activity.
The focus for the person with fatigue is not on increasing endurance . If the cause resolves or abates (e .g. , acute
infection, chemotherapy, rad iation), Fatigue as a diagnosis is discontinued and Activity Intolerance can be initiated to
focus on improving the deconditioned state.
I nd ividuals with peripheral vascular disease can serve as an example of the difference between Fatigue and Activity
Intolerance . Early in the disease process , the individual is taught to walk as exercise and to walk into the pain (inter­
mittent claudication), rest and to continue walking, this is Activity Intolerance. If the person does not exercise and/or
continues to use tobacco , the condition wil l worsen and any walking is severely compromised. The person must plan
activities and rest before and after, this is Fatigue .

Errors i n Diagnostic Statements

Fatigue related to feelings of lack of energy for routine tasks

When a person reports insufficient energy for routine tasks , the nurse performs a focus assessment and collects ad­
d itional data to determ ine whether Fatigue is appropriate or actually a symptom of another d iagnosis, such as Activity
Intolerance , Ineffective Coping, Interrupted Family Processes , Anxiety, or Ineffective Health Maintenance . When acute
or chronic condit ions cause fatigu e , the n u rse must determine whether the person can increase endurance (which
would cal l for Activity Intolerance) or needs energy conservation techniques to help accomplish des i red activities.
When fatigue resu lts from ineffective stress management or poor health habits , Fatigue or Activity Intolerance is not
indicated . During data collection to determine contributing factors , the nurse can record the diagnosis as Possible
Fatigue related to reports of lock of energy. Using a " possible" d iagnosis indicates the need for more data col lection to
rule out or confirm .
 Fatigue 3 09

Key Concepts

General Considerations
• Fatigue is a subjective experience with physiologic, treatment-related, and psychological components.
Fatigue in chronic diseases correlated strongly with abnormalities in mood, most typically depression and
anxiety Gong, Oudhoffc, & Epskamp, 2 0 1 0) .
• Acute tiredness i s a n expected response t o increased physical exertion, change i n daily activities, addi­
tional stress, or inadequate sleep. Acute physical fatigue occurs more rapidly in deconditioned muscles
(Grossman & Porth, 2 0 1 4) .
• US society values energy, productivity, and vitality. It views those without energy a s sluggish o r lazy. Fa­
tigue and tiredness are viewed negatively.
• Fatigue can be physical, mental, and motivational. Causes of fatigue are multifactorial. Careful assess­
ment of the causes can indicate specific interventions to reduce them.
• "Fatigue in individuals with a chronic disease is divided into central and peripheral fatigue. Central fa­
tigue results from alterations or abnormalities in neurotransmitter pathways within the central nervous
system (CNS)" Gong et a!., 2 0 1 0) .
• Peripheral fatigue results from neuromuscular dysfunction outside the CNS and relates t o impaired
neurotransmission in peripheral nerves and/or defects in muscular contraction, due to energy depletion,
inflammation, joint abnormalities, or muscle wasting. The contribution of peripheral and central fatigue
to overall fatigue in individuals may vary significantly between different diseases Gong et a!., 2 0 1 0).
• Individuals with chronic fatigue have increased sensitivity to serotonin-mediated hypothalamic activa­
tion, implying the existence of defective central serotonergic neurotransmission. This contributes to
depression Gong et a!., 2 0 1 0) .
• The principal CNS components o f the stress response include central corticotrophin-releasing hormone
(CRH) and the sympathetic nervous system. Individuals with chronic fatigue have altered diurnal cortisol
rhythm and blunted cortisol stress response, producing high stress levels causing fatigue Gong et a!., 2 0 1 0) .
• Self-reported fatigue has been associated with a worsening o r altering o f all o f the following (Gambert,
2 0 1 3):
• Physical function: reduced activities, prolonged periods of rest, uncoordinated movements, increased

risk of falling, and increased need for assistance to meet basic activities of daily living and instrumen­
tal activities of daily living
• Cognition: reduced alertness, decreased concentration, reduced clarity of thoughts, and increased

forgetfulness
• Emotional state: increased anger, emotional lability, and depression

• Social isolation: complete or near-complete lack of contact with other persons

• In addition, fatigue is an independent predictor of mortality and has been associated with a significant
reduction in overall functional status (Gambert, 2 0 1 3).
• Cancer-related fatigue has been reported in 3 5% to 1 00 % of cases and is reported to be the most dis­
tressing side effect. Stressors contributing to fatigue in individuals with cancer are illustrated in Box IL l .
• The fatigue related to radiation is unexplained but may b e related to increased metabolic effort by the
body to repair damage caused by the radiotherapy to healthy cells.
• Women receiving localized radiation to the breast reported that fatigue decreased in the second week but
increased and reached a plateau after week 4 until 3 weeks after treatment ceased. Fatigue levels did not
change significantly on weekends between treatments (*Greenberg, Sawicka, Eisenthal, & Ross, 1 992 ;
Haas, 2 0 1 1 ) .
• When fatigue i s a side effect of treatment, it does not resolve when the treatment ends, but gradually
lessens over months (*Nail & Winningham, 1 99 7 ; Bardwell & Ancoli-Israel, 2 008).

��=��! Pediatric Considerations

• Infants and small children cannot express fatigue. The nurse can elicit this information by interviewing
the parents and carefully assessing key functional health patterns (e.g., sleep-rest, activity-exercise [which
may reveal respiratory difficulties or activity intolerance] , and nutrition-metabolic [which may reveal
feeding difficulties]).
• Children at risk for fatigue include those with acute or chronic illness, congenital heart disease, exposure
to toxins, prolonged stress, or anemia.
• Children depend on parents/caregivers to modify the environment to mitigate effects of fatigue.
3 10 SECTION 2 ° PART 1 ° Individual Nursing Diagnoses

Box I I . I C O N T RI B U T I N G FACTORS TO FAT I G U E I N C L I E NTS WITH CAN C E R

Pathophysiologic
Hypermetabolic state associated with active tumor growth
Competition between the body and the tumor for nutrients
Chronic pain
Organ dysfunction (e .g. , hepatic, respiratory, gastrointestinal)

Treatment Related
Accumulation of toxic waste products secondary to radiation, chemotherapy
I nadequate nutritional intake secondary to nausea, vomiting
Anemia
Analgesics, antiemetics
Diagnostic tests
Surgery

Situational (Personal. Environmental)

Uncertainty about future
Fear of death , disfigu rement
Social isolation
Losses (role responsibi l ities, occu pational , body parts , function, appearance, economic)
Separation for treatments

•
Maternal Considerations
• Fatigue is common in early pregnancy due to increased metabolic requirements (Pillitteri, 2 0 1 4).
• Gardner reported that levels of fatigue in postpartum women increased at 2 weeks but decreased by
6 weeks. Factors associated with high postpartum fatigue were sleep alterations, additional children,
child care problems, less household help, less education, low family income, and young age of mother
(*Gardner, 1 99 1 ; Pillitteri, 2 0 1 4).
• "Postpartum fatigue is particularly challenging, because the new mother has demanding life tasks to
accomplish during this period of time . Postpartum fatigue may impact postpartum maternal role attain­
ment and may place a woman at increased risk for postpartum depression" (Corwin & Arbour, 2 007).

Geriatric Considerations
• "Although fatigue is common among older people, it is frequently underreported and often not even
evaluated because, much like pain, it is often identified by both the older individual and his or her family
or caregiver(s) as a natural part of the aging process" (Gambert, 2 0 1 3 ) .
• The normal effects o f aging d o n o t i n themselves increase the risk o f o r cause fatigue. Fatigue i n older
adults has basically the same etiologies as in younger adults. The difference is that older adults tend to
experience more chronic diseases than younger adults. Thus, fatigue in older adults is not the result of
age-related factors, but related to such risk factors as chronic diseases and medications (Miller, 2 0 1 5).
• The causes of fatigue in the older adults can be described under the following categories (Gambert,
2 0 1 3):
• Organic (infectious, immunologic/rheumatologic), chronic fatigue syndrome, physiologic, neoplastic­

related, toxin-related, cardiovascular- and pulmonary disease-related fatigue

• Medication-related fatigue, for example, nonsteroidal anti-inflammatory drugs, tetracycline, antipsy­

chotics, antidepressants, sleep medications, and pain medications

• Illicit drug- and alcohol-related fatigue

• Physiological fatigue, for example, inadequate sleep, insufficient rest, overactivity, poor physical con­

ditioning, stress, and changes in diet

• Frailty related to weight loss and sarcopenia (degenerative loss of skeletal muscle mass [0. 5 % to 1 %

loss per year after the age of 5 0] , quality, and strength associated with aging)
• Psychogenic fatigue: Psychiatric problems commonly cause fatigue. Depression is the most com­

monly associated disease entity. Features suggesting that fatigue is psychogenic include fatigue being
 Fatigue 311

present throughout the day, fatigue being present upon awakening, fatigue that improves later in the
day, and fluctuations in mood.
• Nutrition lacking sufficient quantities of calories, protein, and/or the essential vitamins and minerals

may lead to symptoms of fatigue.

o Vitamin D-deficient state can cause nonspecific symptoms, such as fatigue, loss of muscle strength,

bone and muscle pain, arthralgia, fibromyalgia-like syndromes, poor balance, and low mood.
o Subclinical vitamin B deficiency is common in the elderly and can result from absorption prob­
12
lems, proton-pump inhibitor overuse, excessive alcohol intake, or "tea and toast" diets. It can result
in fatigue, weight loss, neuropathy, memory impairment, and depression.
• Organic fatigue, the most common causes of which are infectious and immunologic/rheumatologic

• Chronic fatigue syndrome

• Disease-related fatigue, for example, cancer, cardiac, respiratory endocrine

• Toxin-related fatigue, for example, exposure to toxins, such as carbon monoxide and heavy metals.

Wood-burning stoves, kerosene heaters, automobile exhaust, and coal-burning plants produce carbon
monoxide. Acute exposure to high carbon monoxide levels can cause headaches, dizziness, and flu-like
symptoms . When chronic, low-level exposure occurs; however, more subtle symptoms may develop,
such as depression, fatigue, confusion, and memory loss (Gambert, 2 0 1 3 ) .
• According t o Miller (2 0 1 5), "the activity theory proposed that older adults would remain psychologically
and socially fit if they remained active." Participation in activities affirms a person's self-concept.
• Chronic fatigue, reported by approximately 70% of older adults, can result in diminished motor activity
and muscle tone. Note that anemia, very common in this population, is another possible contributor to
complaints of chronic fatigue (Miller, 2 0 1 5).

Focus Assessment Criteria

Subjective Data

Assess for Defining Characteristics

Descri ption of Fatigue

Onset
Pattern: morning, evening, transient, unfading/all day
Precipitated by what?
Relieved by rest?
Effects of Fatigue on
Activities of daily living Libido Concentration
Mood Leisure activities Motivation

Assess for Related Factors

Medical Condition (Acute, Chronic; Refer to Key Concepts)
N utritional I m balances
Treatments
Chemotherapy Radiation therapy
Medication side effects Stressors (e.g., excessive role demands, career, financial, family)

Goals

lmiil The person will participate in activities that stimulate and balance physical, cognitive, affective, and social
Fatigu e : Disruptive domains as evidenced by the following indicators :
Effects, Fatigue Level ,
• Discusses the causes of fatigue
Self- Management:
• Shares feelings regarding the effects of fatigue on life
C h ronic D i sease ,
• Establishes priorities for daily and weekly activities
Energy Conservation ,

N utritional Status,

Depression Level
3 12 SECTION 2 ° PART 1
Interventions
Energy Management,
Environmental Man­
agement, M utual G oal
Setting, Social ization
Enhancement, Cop­
ing En hancement,
Exercise Therapy
° Individual Nursing Diagnoses
Nursing interventions for this diagnosis are for people with fatigue regardless of etiology that cannot be
eliminated. The focus is to assist the individual and family to adapt to the fatigue state.
Assess Causative or Contributing Factors
• If fatigue has related factors that can be treated, refer to the specific nursing diagnosis as
• Lack of sleep; refer to Disturbed Sleep Pattern
• Poor nutrition; refer to Imbalanced Nutrition
• Sedentary lifestyle; refer to Sedentary Lifestyle
• Inadequate stress management; refer to Stress Overload
• Chronic excessive role or social demands; refer to Ineffective Coping
Explain the Causes of Fatigue (See Key Concepts)
R: In many chronic diseases, fatigue is the most common, disruptive, and distressing symptom, because it inter­
feres with self-care activities (Gambert, 201 3).
Allow Expression of Feelings Regarding the Effects of Fatigue on Life
• Identify difficult activities.
• Help the individual verbalize how fatigue interferes with role responsibilities.
• Encourage the individual to convey how fatigue causes frustration.
Assist to Identify Strengths, Abilities, and Interests
• Identify values and interests.
• Identify areas of success and usefulness; emphasize past accomplishments.
• Use information to develop goals with the individual.
• Assist in identifying sources of hope (e.g., relationships, faith, things to accomplish).
• Assist in developing realistic short- and long-term goals (progress from simple to more complex; use a
"goals poster" to indicate type and time for achieving specific goals).
R: Focusing on strengths and abilities may provide insight into positive events and lessen the tendency to overgen­
eralize the severity of disease, which can lead to depression.
Assist the Individual to Identify Energy Patterns
I nstruct the Individual to Record Fatigue Levels Every Hour Over 24 Hours; Select a Usual Day
• Ask the individual to rate fatigue using the Rhoten fatigue scale (0 = not tired, peppy; 1 0 = total exhaustion) .
• Record the activities during each rating.
Analyze Together the 24- Hour Fatigue Levels
• Times of peak energy
• Times of exhaustion
• Activities associated with increasing fatigue
Explain Benefits of Exercise and Discuss What Is Realistic
R: IdentifYing times ofpeak energy and exhaustion can aid in planning activities to maximize energy conserva­
tion and productivity.
Explain the Purpose of Pacing and Prioritization
• Explore what activities the individual views as important to maintain self-esteem.
• Attempt to divide vital activities or tasks into components (e.g., preparing menu, shopping, storing, cook-
ing, serving, cleaning up); the individual can delegate some parts and retain others.
• Plan important tasks during periods of high energy (e.g., prepare all meals in the morning).
• Assist the individual in identifying priorities and to eliminate nonessential activities.
• Plan each day to avoid energy- and time-consuming, nonessential decision making.
• Distribute difficult tasks throughout the week.
• Rest before difficult tasks, and stop before fatigue ensues.
R: The individual requires rest periods before or after some activities. Planning can provide for adequate rest and
reduce unnecessary energy expenditure. Such strategies can enable continuation of most desired activities, contrib­
uting to positive self-esteem.
 Fatigue 313

Teach Energy Conservation Techniques

• Modify the environment.
• Replace steps with ramps.

• Install grab rails.

• Elevate chairs from 3 to 4 inches.

• Organize kitchen or work areas.

• Reduce trips up and down stairs (e.g., put a commode on the first floor).

• Use a taxi instead of driving self.

• D elegate housework (e.g., employ a high school student for a few hours after school).

R: Strategies can be utilized to decrease energy used in activities ofdaily living.

• Discuss with individual some type of appropriate exercise component that could be integrated into their
life, for example, strengthening, stretching, chair exercises.

R: Predictors of healthy longevity are high intake ofplant-based foods (fruits, vegetables, nuts), high levels of
physical activity, and strong social networks (Hutnik, Smith, & Koch, 201 2; Miller, 201 5).
Promote Socialization With Family and Friends (Miller, 2 0 1 5)
• Encourage to participate in one social activity, weekly.
• Explain that feelings of connectedness decrease fatigue and stress.

R: Quality or type ofactivity reportedly is more important than quantity. Informal activities promoted well­
being the most, followed by formal structured activities, and last by solitary activities, which were found to have
little or no effect on life satisfaction (*Longino & Kart, 19 82).
Explain the Effects of Conflict and Stress on Energy Levels
• Teach the importance of mutuality in sharing concerns.
• Explain the benefits of distraction from negative events.
• Teach and assist with relaxation techniques before anticipated stressful events. Encourage mental imag-
ery to promote positive thought processes.
• Allow the individual time to reminisce to gain insight into past experiences.
• Teach to maximize aesthetic experiences (e.g., smell of coffee, feeling warmth of the sun).
• Teach to anticipate experiences he or she takes delight in each day (e.g., walking, reading favorite book,
writing a letter).
R: Focusing on strengths and abilities may provide insight into positive events and lessen the tendency to overgen­
eralize the severity of the disease, which can lead to depression.
• Help to identify how he or she can help others. Listening to others ' problems, using the computer to
access information and making phone calls

R: Reciprocity or returning support to one 's support system is vital for balanced and healthy relationships (*Tilden
& Weinert, 1987). Individuals with fatigue have difficulty with reciprocity.
Provide Significant Others Opportunities to Discuss Feelings in Private Regarding
• Changes in person with fatigue
• Caretaking responsibilities
• Financial issues
• Changes in lifestyle, role responsibilities, and relationships
• See Caregiver Role Strain for additional strategies for caregivers .

Initiate Health Teaching and Referrals, as Indicated

• Counseling
• Community services (Meals On �eels, housekeeper)
• Financial assistance

•
Maternal Interventions
• Explain the reasons for fatigue in first and third trimesters:
• Increased basal metabolic rate
• Changes in hormonal levels
 3 14 SECTION 2 ° PART 1 ° Individual Nursing Diagnoses

oAnemia
•Increased cardiac output (third trimester)
• Emphasize the need for naps and 8 hours of sleep each night.

R: Fatigue in the first and third trimesters is normal.

• Discuss the importance of exercise (e.g., walking).

R: Exercise provides emotional and physical benefits.

• For postpartum women, discuss factors that increase fatigue :
• Labor more than 3 0 hours
• Preexisting chronic disease

• Hemoglobin less than 10 g/dL or postpartum hemorrhage

• Episiotomy, tear, or cesarean section

• Sleeping difficulties

• Ill newborn or a congenital anomaly

• Dependent children at home

• Child care problems

• Unrealistic expectations

• No daytime rest periods

R: Explaining the reasons for fatigue can allay fears. Strategies can be discussed to reduce fatigue at home.

I
NAN DA- 1 Definition

Response to perceived threat that is consciously recognized as a danger

Defining Characteristics

Verbal Reports of Panic*

Alarm* Decreased self-assurance* Narrowed focus on source of
the fear*
Aggression Dread* Panic
Apprehension* Excitement* Terror*
Avoidance behaviors* Impulsiveness*
Being scared* Increased alertness*/tension

Visceral-Somatic Activity
Musculoskeletal
Shortness of breath
Fatigue*/limb weakness
Muscle tightness*

Respiratory
Increased rate*
Trembling

Cardiovascular
Palpitations
Rapid pulse*
Increased systolic blood pressure*

Skin
Flush/pallor*
Increased perspiration*
Paresthesia