Fatigue

Fatigue is a feeling of excessive tiredness, lack of energy, or exhaustion accompanied by a strong desire to rest or sleep. This common symptom is distinct from weakness, which involves the muscles, but may occur with it.

Fatigue is a normal and important response to physical overexertion, prolonged emotional stress, and sleep deprivation. However, it can also be a nonspecific symptom of a psychological or physiologic disorder — especially viral or bacterial infection and endocrine, cardiovascular, or neurologic disease.

Fatigue reflects both hypermetabolic and hypometabolic states in which nutrients needed for cellular energy and growth are lacking because of overly rapid depletion, impaired replacement mechanisms, insufficient hormone production, or inadequate nutrient intake or metabolism.

History

Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern indicates a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.

Ask about related symptoms and any recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and any appetite or weight changes. Carefully review the patient’s medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.

Obtain a thorough drug history, noting use of any opioid or drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk of carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector.

Physical assessment

Begin your physical assessment by observing the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation. Then, take your patient’s vital signs and perform a complete physical examination.

Medical causes

Acquired immunodeficiency syndrome

In addition to fatigue, acquired immunodeficiency syndrome (AIDS) may cause fever, night sweats, weight loss, diarrhea, and a cough, followed by several concurrent opportunistic infections. The patient may also show signs of malnutrition.

Adrenocortical insufficiency

Mild fatigue, the hallmark of adrenocortical insufficiency, initially appears after exertion and stress but later becomes more severe and persistent. Weakness and weight loss typically accompany GI disturbances, such as nausea, vomiting, anorexia, abdominal pain, and chronic diarrhea; hyperpigmentation; orthostatic hypotension; and a weak, irregular pulse.

Anemia

Fatigue following mild activity is commonly the first symptom of anemia. Associated findings vary but generally include listlessness, irritability, inability to concentrate, pallor, tachycardia, and dyspnea.

CULTURAL CUE:To detect anemia-related pallor in the dark-skinned patient, assess his oral mucosa.

Anxiety

Chronic, unremitting anxiety invariably produces fatigue, commonly characterized as nervous exhaustion. Other persistent findings include apprehension, indecisiveness, restlessness, insomnia, trembling, and increased muscle tension.

Cancer

Unexplained fatigue is commonly the earliest sign of cancer. Related findings reflect the type, location, and stage of the tumor and typically include pain, nausea, vomiting, anorexia, weight loss, abnormal bleeding, and a palpable mass.

Chronic fatigue syndrome

Chronic fatigue syndrome, the cause of which is unknown, is characterized by incapacitating fatigue. Other findings are sore throat, myalgia, low-grade fever, painful lymph nodes, sleep disturbances, and cognitive dysfunction.

Chronic obstructive pulmonary disease

The earliest and most persistent symptoms of chronic obstructive pulmonary disease (COPD) are progressive fatigue and dyspnea. The patient may also experience a chronic and usually productive cough, weight loss, barrel chest, cyanosis, slight dependent edema, and poor exercise tolerance.

Cirrhosis

Severe fatigue typically occurs late in cirrhosis, accompanied by weight loss, bleeding tendencies, jaundice, hepatomegaly, ascites, dependent edema, severe pruritus, and decreased level of consciousness (LOC).

Depression

Persistent fatigue unrelated to exertion nearly always accompanies chronic depression. Associated somatic complaints include headache, anorexia (occasionally, increased appetite), constipation, and sexual dysfunction. The patient may also experience insomnia, slowed speech, agitation or bradykinesia, irritability, loss of concentration, feelings of worthlessness, and persistent thoughts of death.

Diabetes mellitus

Fatigue, the most common symptom in diabetes mellitus, may begin insidiously or abruptly. Related findings include weight loss, blurred vision, polyuria, polydipsia, and polyphagia.

Heart failure

Persistent fatigue and lethargy characterize heart failure. Left-sided heart failure produces exertional and paroxysmal nocturnal dyspnea, orthopnea, and tachycardia. Right-sided heart failure produces jugular vein distention and possibly a slight but persistent nonproductive cough. In both types, mental status changes accompany later signs and symptoms, including nausea, anorexia, weight gain and, possibly, oliguria. Cardiopulmonary findings include tachypnea, inspiratory crackles, palpitations and chest tightness, hypotension, narrowed pulse pressure, ventricular gallop, pallor, diaphoresis, clubbing, and dependent edema.

Hypercortisolism

Hypercortisolism typically causes fatigue, related in part to accompanying sleep disturbances. Unmistakable signs include truncal obesity with slender extremities, buffalo hump, moon face, purple striae, acne, and hirsutism; increased blood pressure and muscle weakness are other findings.

Hypopituitarism

With hypopituitarism, fatigue, lethargy, and weakness usually develop slowly. Other insidious effects may include irritability, anorexia, amenorrhea or impotence, decreased libido, hypotension, dizziness, headache, visual disturbances, and cold intolerance.

Hypothyroidism

Fatigue occurs early in hypothyroidism, along with forgetfulness, cold intolerance, weight gain, metrorrhagia, and constipation. Related findings include coarse hair and alopecia; anorexia; edema; dry, flaky skin; and thinning nails.

Infection

With chronic infection (such as acute bacterial endocarditis), fatigue is commonly the most prominent symptom — and sometimes the only one. Low-grade fever and weight loss may accompany signs and symptoms that reflect the type and location of infection, such as burning upon urination or swollen, painful gums.

With acute infection, brief fatigue typically accompanies headache, anorexia, arthralgia, chills, high fever, and such infection-specific signs as cough, vomiting, or diarrhea.

Lyme disease

Besides fatigue and malaise, signs and symptoms of Lyme disease include intermittent headache, fever, chills, expanding red rash, and muscle and joint aches. In later stages of this tick-borne disease, patients may suffer arthritis, fluctuating meningoencephalitis, and cardiac abnormalities, such as a brief, fluctuating atrioventricular heart block.

Malnutrition

Easy fatigability is common in patients with protein-calorie malnutrition, along with lethargy and apathy. Patients may also exhibit weight loss, muscle wasting, sensations of coldness, pallor, edema, and dry, flaky skin.

Myasthenia gravis

The cardinal symptoms of myasthenia gravis are easy fatigability and muscle weakness, which worsen as the day progresses. They also worsen with exertion and abate with rest. Related findings depend on the specific muscles affected.

Myocardial infarction

With myocardial infarction (MI), fatigue can be severe but is typically overshadowed by chest pain. Related findings include dyspnea, anxiety, pallor, cold sweats, increased or decreased blood pressure, and abnormal heart sounds.

Narcolepsy

One or more of the following characterizes narcolepsy: hypersomnia, hypnagogic hallucinations, cataplexy, sleep paralysis, and insomnia. Fatigue is a common symptom as well.

Renal failure

Acute renal failure commonly causes sudden fatigue, drowsiness, and lethargy. Oliguria, an early sign, is followed by severe systemic effects: ammonia breath odor, nausea, vomiting, diarrhea or constipation, and dry skin and mucous membranes. Neurologic findings include muscle twitching and changes in personality and LOC, possibly progressing to seizures and coma.

With chronic renal failure, insidious fatigue and lethargy occur with marked changes in all body systems, including GI disturbances, ammonia breath odor, Kussmaul’s respirations, bleeding tendencies, poor skin turgor, severe pruritus, paresthesia, visual disturbances, confusion, seizures, and coma.

Restrictive lung disease

Chronic fatigue may accompany the characteristic signs and symptoms of restrictive lung disease: dyspnea, cough, and rapid, shallow respirations. Cyanosis first appears with exertion; later, even at rest.

Rheumatoid arthritis

With rheumatoid arthritis, fatigue, weakness, and anorexia precede localized articular findings: joint pain, tenderness, warmth, and swelling along with morning stiffness. Assessment findings may include enlarged lymph nodes, fever, leukopenia, anemia, subcutaneous nodules, pericarditis, and Raynaud’s phenomenon.

Systemic lupus erythematosus

Fatigue usually occurs in patients with systemic lupus erythematosus (SLE), along with generalized aching, malaise, low-grade fever, headache, and irritability. Primary signs and symptoms include joint pain and stiffness, butterfly rash, and photosensitivity. Also common are Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers.

Thyrotoxicosis

With thyrotoxicosis, fatigue may occur with characteristic signs and symptoms, including an enlarged thyroid, tachycardia and palpitations, tremors, weight loss despite increased appetite, diarrhea, dyspnea, nervousness, diaphoresis, heat intolerance, amenorrhea and, possibly, exophthalmos.

Valvular heart disease

All types of valvular heart disease commonly produce progressive fatigue and a cardiac murmur. Additional signs and symptoms vary but generally include exertional dyspnea, cough, and hemoptysis.

Other causes

Carbon monoxide poisoning

With carbon monoxide poisoning, fatigue occurs along with headache, dyspnea, and confusion, and can eventually progress to unconsciousness and apnea.

Drugs

Fatigue may result from various drugs, notably antihypertensives and sedatives. In persons receiving cardiac glycoside therapy, fatigue may indicate toxicity.

Special considerations

If fatigue results from organic illness, help the patient determine which daily activities he may need help with and how he should pace himself to ensure sufficient rest. You can help him reduce chronic fatigue by alleviating pain, which may interfere with rest, or nausea, which may lead to malnutrition. He may benefit from referral to a community health nurse or housekeeping service. If fatigue results from a psychogenic cause, refer him for psychological counseling.

Pediatric pointers

When evaluating a child for fatigue, ask his parents if they’ve noticed any change in his activity level. Fatigue without an organic cause occurs normally during accelerated growth phases in preschool-age and prepubescent children. However, psychological causes of fatigue must be considered — for example, a depressed child may try to escape problems at home or school by taking refuge in sleep. In a pubescent child, consider the possibility of drug abuse, particularly of hypnotics and tranquilizers.

Geriatric pointers

Always ask elderly patients about fatigue because this symptom may be insidious and mask more serious underlying conditions in this age-group. Temporal arthritis, which is much more common in people older than age 60, is usually characterized by fatigue, weight loss, jaw claudication, proximal muscle weakness, headache, vision disturbances, and associated anemia.

Patient counseling

Regardless of the cause of fatigue, you may need to help the patient alter his lifestyle to achieve a balanced diet, a program of regular exercise, and adequate rest. Counsel him about setting priorities, keeping a reasonable schedule, and developing good sleep habits. Teach stress management techniques as appropriate.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Weakness: Introduction (review 3888 causes)
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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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