Want to know more

FUNCTION
Nursing Standard of Practice Protocol: Assessment of Function in Acute Care

Evidence-Based Content - Updated January 2008

 

Denise M. Kresevic, RN, PhD

 

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

The following nursing care protocol has been designed to help bedside nurses to monitor function in elders, to prevent decline, and to maintain the function of elders during acute hospitalization.

 
Back to top

Objective

The goal of nursing care is to maximize the physical functioning, prevent or minimize decline in ADL function, and plan for future care needs.

 
Back to top

Background

A. Functional status of individuals describes the capacity and performance of safe ADLs and IADLs.1, 2, 3, 4 and is a sensitive indicator of health or illness in elders and therefore a critical nursing assessment.5, 6, 7, 8

B. Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, toileting schedules, enhanced communication, adaptive equipment, and attention to medications and dosages). 9, 10, 11, 12

C. Some functional decline may occur progressively and is not reversible. This decline often accompanies chronic and terminal disease states such as degenerative joint disease, Parkinson’s disease, dementia, heart failure, and cancer.13

D. Functional status is influenced by physiological aging changes, acute and chronic illness, and adaptation to the physical environment. Functional decline is often the initial symptom of acute illness such as infections (e.g., pneumonia and urinary tract infection). These declines are usually reversible and require medical evaluation.1, 14 Functional status is contingent on motivation, cognition, and sensory capacity, including vision and hearing. 15

E. Risk factors for functional decline include injuries, acute illness, medication side effects, pain, depression, malnutrition, decreased mobility, prolonged bedrest (including the use of physical restraints), prolonged use of foley catheters,and changes in environment or routines. 10, 11, 16

F. Additional complications of functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, and increased risk for long-term institutionalization and depression. 11, 16, 17

G. Recovery of function can also be a measure of return to health, such as for those individuals recovering from exacerbations of cardiovascular or respiratory diseases and acute infections, recovering from joint replacement surgery, or new strokes.3

H. Functional status evaluation assists in planning future care needs post-hospitalization, such as short-term skilled care and home care. 11, 18.

I. Physical environments of care with attention to the special needs of older adults serve to maintain and enhance function (i.e., chairs with arms, elevated toilet seat, levers versus door knobs, enhanced lighting).7, 11

 
Back to top

Assessment Parameters

A. Comprehensive functional assessment of elders includes independent performance of basic ADLs, social activities, or IADLs, the assistance needed to accomplish these tasks, and sensory ability, cognition, and capacity to ambulate. 2, 3, 4, 6, 7, 20, 21, 22, 23, 37

1. Basic Activities of Daily Living (ADL)

a. Bathing

b. Dressing

c. Grooming

d. Eating

e. Continence

f. Transferring

2. Instrumental Activities of Daily Living (IADL)

a. Meal preparation

b. Shopping

c. Medication administration

d. Housework

e. Transportation

f. Accounting

3. Mobility

a. Ambulation

b. Pivoting

B. Elderly patients may view their health in terms of how well they can function rather than in terms of disease alone. Strengths should be emphasized as well as needs for assistance. 15,24

C. The clinician should document baseline functional status and recent or progressive decline in function.18

D. Function should be assessed over time to validate capacity, decline, or progress.1, 2, 25

E. Standard instruments selected to assess function should be efficient to administer and easy to interpret. They should provide useful practical information for clinicians and be incorporated into routine history taking and daily assessments. 2, 19

F. Interdisciplinary communication regarding functional status, changes, and expected trajectory should be part of all care settings. 10, 11, 19,

G. Multidisciplinary team conferences including patient and family whenever possible. 17, 19

 
Back to top

Care Strategies

A. Strategies to maximize functional status and to prevent decline:

1. Maintain individual's daily routine. Help to maintain physical, cognitive, and social function through physical activity and socialization. Encourage ambulation, allow flexible visitation, including pets, and encourage reading the newspaper. 11, 19

2. Educate elders, family, and formal caregivers on the value of independent functioning and the consequences of functional decline.19, 26

a. Physiological and psychological value of independent functioning.

b. Reversible functional decline associated with acute illness. 13, 14

c. Strategies to prevent functional decline: exercise, nutrition, pain management and socialization.11, 19, 27, 28

d. Sources of assistance to manage decline.

3. Encourage activity, including routine exercise, range of motion, and ambulation to maintain activity, flexibility, and function. 10, 11, 27

4. Minimize bed rest. 9, 11, 17, 19

5. Explore alternatives to physical restraints use. 17, 19

6. Judiciously use medications, especially psychoactive medications, in geriatric dosages. 30

7. Assess and treat for pain.17

8. Design environments with handrails, wide doorways, raised toilet seats, shower seats, enhanced lighting, low beds, and chairs of various types and height. 19, 31

9. Help individuals regain baseline function after acute illnesses by using exercise, physical therapy consultation, nutrition, and coaching. 19, 32, 33, 34, 35

10. Obtain assessment for physical and occupational therapies needed to help regain function. 17

B. Strategies to help older individuals cope with functional decline

1. Help older adults and family members determine realistic functional capacity with interdisciplinary consultation. 19

2. Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts. 18

3. Carefully document all intervention strategies and patient response. 18

4. Provide information to caregivers on causes of functional decline related to acute and chronic conditions. 17

5. Provide education to address safety care needs for falls, injuries, and common complications. Short-term skilled care for physical therapy may be needed; long-term care settings may be required to ensure safety. 17.

6. Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences. 11, 36

7. Provide caregiver support community services, such as home care, nursing, and physical and occupational therapy services to manage functional decline. 17, 18

 
Back to top

Expected Outcomes

A. Patients will:

1. Maintain safe level of ADL and ambulation.

2. Make necessary adaptations to maintain safety and independence, including assistive devices and environmental adaptations.

3. Strive to attain highest quality of life despite functional level.

B. Providers can demonstrate:

1. Increased assessment, identification, and management of patients susceptible to or experiencing functional decline. Routine assessment of functional capacity despite level of care.

2. Ongoing documentation and communication of capacity, interventions, goals, and outcomes.

3. Competence in preventive and restorative strategies for function.

4. Competence in assessing safe environments of care that foster safe independent function.

C. Institution will experience:

1. System-wide incorporation of functional assessment.

2. A reduction in incidence and prevalence of functional decline.

3. A decrease in morbidity and mortality rates associated with functional decline

4. Reduction in the use of physical restraints, prolonged bedrest, foley catheters

5. Decreased incidence of delirium.

6. An increase in prevalence of patients who leave hospital with baseline or improved functional status.

7. Decreased readmission rate.

8. Increased early utilization of rehabilitative services (occupational and physical therapy).

9. Support of institutional policies/programs that promote function.

10. Evidence of geriatric sensitive physical care environments that facilitate safe independent function such as caregiver educational efforts and walking programs.

11. Evidence of continued interdisciplinary assessments, care planning, and evaluation of care related to function.

 
Back to top

Relevent Practice Guidelines

Several resources are now available to guide adoption of evidenced based nursing interventions to enhance function in older adults.

A. AHRQ Clinical Practice Guidelines1996. Accessed 10/2006.
http://www.ahrq.gov/clinic/cpgonline.htm

B. Joanna Briggs Best Practice: McGill University website accessed 10/2006.
http://www.muhc-ebn.mcgill.ca/

C. Joanna Briggs Best Practice: McGill University website accessed 10/2006
http://www.muhc-ebn.mcgill.ca/EBN_tools.htm

D. National Quality Forum website, accessed, October, 2006
http://www.qualityforum.org/nursing/defult.htm

E. Registered Nurses Association of Ontario (RNAO)/NGC, 2005; McGill University website accessed 10/2006.
http://www.muhc-ebn.mcgill.ca/EBN_tools.htm

F. Geriatric protocols -University of Iowa.
www.nursing.uiowa.edu/centers/gnirc/protocols.htm

 
Back to top

For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Kresevic, D. M. (2008). Assessment of function. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-based geriatric nursing protocols for best practice. (3rd ed.) (pp. 23-40). New York: Springer Publishing Company, Inc.

 

References

1. Applegate, W. B., Blass, J., & Franklin, T. (1990). Instruments for the functional assessment of older patients. New England Journal of Medicine, 322, 1207–1214. Evidence Level IV: Nonexperimental Study.

2. Kane, R. A., & Kane, R. L. (2000). Assessing older persons: Measures, meaning, and practical applications. New York: Oxford. Evidence Level VI: Expert Opinion.

3. Katz, S., Ford, A. B., Moscokowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness and the aged: The index of ADL. A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914–919. Evidence Level I: Systematic Review.

4. Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179–186. Evidence Level IV: Nonexperimental Study.

5. Byles, J. E. (2000). A thorough going over: Evidence for health assessments for older persons. Austrialian & New Zealand Journal of Public Health, 24, 117–123. Evidence Level I: Systematic Review.

6. Campbell, S. E., Seymour, D. G., Primrose, W. R., & ACME-plus Project (2004). A systematic literature review of factors affecting outcomes in older medical patients admitted to hospital. Age and Ageing, 33, 110–115. Evidence Level I: Systematic Review.

7. Kresevic, D., & Holder, C. (1998). Interdisciplinary care. Clinics in Geriatric Medicine, 14, 787–798. Evidence Level VI: Expert Opinion.

8. Mezey, M. D., Rauckhorst, L. H., & Stokes, S. A. (1993). Health assessment of the older individual. New York: Springer Publishing Company. Evidence Level VI: Expert Opinion.

9. Bates-Jensen, B. M., Alessi, C. A., Cadogan, M., Levy-Storms, L., Jorge, J., Yoshil, J., et al. (2004). The minimum data set bedfast quality indicators: Differences in nursing homes. Nursing Research, 53, 260–272. Evidence Level V: Program Evaluation.

10. Counsell, S. R., Holder, C. M., Liebenauer, L. L., Palmer, R. M., Fortinsky, R. H., Kresevic, D. M., et al. (2000). Effects of a multicomponent intervention on functional outcomes and process of care of hospitalized older patients: A randomized controlled tiral of Acute Care for Elders (ACE) in a community hospital. Journal of the American Geriatric Society, 48(12), 1572–1581. Evidence Level II: Individual Experimental Study.

11. Landefeld, C. S., Palmer, R. M., Kresevic, D. M., Fortinsky, R. I., & Kowa, J. (1995). A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New England Journal of Medicine, 332, 1338–1344. Evidence Level II: Individual Experimental Study.

12. Palmer, R. M., et al. (1998). Clinical intervention trials: the ACE unit. Clin Geriatric Med, 14, 831-49.

13. Hirsch, C. H. (1990). The natural history of functional morbidity in hospitalized older patients. Journal of the American Geriatrics Society, 38, 1296–1303. Evidence Level IV: Nonexperimental Study.

14. Sager, M., & Rudberg, M. M. (1998). Functional decline associated with hospitalization for acute illnesses. Clinics in Geriatric Medicine, 14, 669–679. Evidence Level II: Individual Experimental Study.

15. Pearson, V. I. (2000). Assessment of function in older adults. In R. I. Kane & R. A. Kane (Eds.), Assessing older persons: Measures, meanings and practical applications (pp. 17–34). New York: Oxford University Press. Evidence Level VI: Expert Opinion.

16. Creditor, M. C. (1993). Hazards of hospitalization of elderly. Annals of Internal Medicine, 118, 219–223. Evidence Level VI: Expert Opinion.

17. Covinsky, K. E., Palmer, R. M., Kresevic, D. M., Kahana, E., Counsell, S. R., Fortinsky, R. H., et al. (1998). Improving functional outcome in older patients. Joint Commission Journal on Quality Improvement, 24(2), 63–76. Evidence Level II: Individual Experimental Study.

18. Graf, C. (2006). Functional decline in hospitalized older adults. American Journal of Nursing, 106(1), 58–67. Evidence Level V: Narrative Review.

19. Kresevic, D., Counsel, S., Covinsky, K., Palmer, R., Landefeld, C. S., Holder, C., et al. (1998). A patient-centered model of acute care for elders. Nursing Clinics of North America, 3, 515–527. Evidence Level VI: Expert Opinion.

20. Freedman, V. A., Martin, L. G., & Schoeni, R. F. (2002). Recent trends in disability and functioning among older adults in the United States: A systematic review. Journal of the American Medical Association, 288(24), 3137–3146. Evidence Level I: Systematic Review.

21. Lightbody, E., & Baldwin, R. (2002). Inpatient geriatric evaluation and management did not reduce mortality but reduced functional decline. Evidenced Based Mental Health, 5, 109. Evidence Level VI: Expert Opinion.

22. McCusker, J., Kakuma., R., & Abrahamowicz, M. (2002) Predictors of functional hospitalized elderly patients: A systematic review. Journals of Geronotology. Series A: Biologiical Sciences and Medical Sciences 57A, M569-77. Evidence Level I: Systematic Review.

23. Tinetti, M. E., & Ginter, S. F. (1988). Identify mobility dysfunctions in elderly patients: Standard neuromuscular examination or direct assessment? Journal of the American Medical Association, 259, 1190–1193. Evidence Level I: Meta-analysis.

24. Dopp, C. A., & Jeste, D. V. (2006). Definitions and predictors of successful aging: A comprehensive review of larger quantitative studies. American Journal of Geriatric Psychiatry, 14(1), 6–20. Evidence Level I: Systematic Review.

25. Callahan, E. H., Thomas, D. C., Goldhirsh, S. L., & Leipzig, R. M. (2002). Geriatric hospital medicine. Medical Clinics of North America, 86(4), 707–729. Evidence Level VI: Expert Opinion.

26. Vass, M., Avlund, K., Lauridsen, J., & Hendriksen, C. (2005). Feasible model for prevention of functional decline in older people: Municipality-randomized controlled trial. Journal of the American Geriatrics Society, 53(4), 563–568. Evidence Level II: Individual Experimental Study.

27. Tucker, D. M., et al. (2004). Walking and wellness: A collaborative program to maintain mobility in hospitalized older adults. Geritaric Nursing, 25, 242–245.

28. Siegler, E. L., Glick, D., & Lee, J. (2002). Optimal staffing for acute care of the elderly (ACE) units. Geriatric Nursing, 23(3), 152–155. Evidence Level VI: Expert Opinion.

29. Pedersen, B. K., & Saltin, B. (2006). Evidence for prescribing exercise as therapy in chronic disease. Scandinavian Journal of Medicine & Science in Sports, 16 (Supplement I), 3–63. Evidence Level I: Systematic Review.

30. Inouye, S. R. (1998). Does deliruim contribute to poor hospital outcomes? A three-site epidemiological study. J. Gen Intern Med, 13, 234-42. Evidence Level III: Quasi-experimental.

31. Cunningham, G. O., & Michael, Y. L. (2004). Concepts guiding the study of the impact of the built environment on physical activity for older adults: A review of the literature. American Journal of Health Promotion, 18(6), 435–443. Evidence Level I: Systematic Review.

32. Conn, V. S., Minor, M. A., Burks, K. J., Rantz, M. J., & Pomeroy, S. H. (2003). Integrative review of physical activity intervention research with aging adults. Journal of the American Geriatrics Society, 51(80), 1159–1168. Evidence Level I: Systematic Review.

33. Engberg, S., Serika, S. M., McDowell, B. J., Weber, E., & Brodak, I. (2002). Effectiveness of prompted voiding in treating urinary incontinence in cognitively impaired homebound older adults. Journal of Wound, Ostomy & Continence Nursing, 29(5), 252–265. Evidence Level II: Individual Experimental Study.

34. Hodgkinson, B., Evans, D., & Wood, J. (2003). Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice, 9(3), S19–S28. Evidence Level I: Systematic Review.

35. Forbes, D. A. (2005). An educational programme for primary healthcare providers improved functional abiltiy in older people living in the community. Evidenced Based Nursing, 8, 122. Evidence Level VI: Expert Opinion.

36. Edington, J., Barnes, R., Bryan, F., Dupree, E., Frost, G., Hickson, M., et al. (2004). A prospective randomized controlled trial of nutritional supplementation in malnourished elderly in the community: Clinical and health economic outcomes. Clinical Nutrition, 23(2), 195–204. Evidence Level II: Individual Experimental Study.

37. Doran, D. M., Harrison, M. B., Laschinger, H. S., Hiredes, J. P., Rukholm, F., Sudabum S., et al. (2006). Nursing-sensitive outcomes data collection in acute care and long-term-care settings. Nursing Research, 55(2 Supp.), S75–S81. Evidence Level VI: Expert Opinion.

Reprinted with permission from Springer Publishing Company. Kresevic, D. M. 2008. Assessment of Function. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice. (3rd ed.). New York: Springer Publishing Company, Inc.

Last updated - January 2008

 
Back to top