The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
The following nursing care protocol has been designed to help bedside nurses to monitor function in older adults, prevent decline, and maintain the function of older adults during acute hospitalization.
To maximize physical functioning, prevent or minimize decline in activity of daily living (ADL) function, and plan for transitions of care.
A. Functional status of individuals describes the capacity and performance of safe ADLs and instrumental activities of daily living (IADLs).1, 2, 3, 4 and is a sensitive indicator of health or illness in older adults 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. (Ref 11; 17; 18) 11, 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 posthospitalization, such as short-term skilled care, home care, and need for community services. (Ref 11; 19) 11,
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
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, 20, 21, 22, 23
1. Basic ADLs (bathing, dressing, grooming, eating, continence, transferring)
2. IADLs (meal preparation, shopping, medication administration, housework, transportation, accounting)
3. Mobility (ambulation, pivoting)
C. The clinician should document baseline functional status and recent or progressive decline in function. (Ref 19)
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. (Ref 2; 26) 2
F. Interdisciplinary communication regarding functional status, changes, and expected trajectory should be part of all care settings and should include the patient and family whenever possible (Ref 10; 11; 17; 26). 10, 11
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. (Ref 7; 11) 11
2. Educate older adults, family, and formal caregivers on the value of independent functioning and the consequences of functional decline. (Ref 7; 19; 27) 19
a. Physiological and psychological value of independent functioning.
d. Sources of assistance to manage decline.
5. Explore alternatives to physical restraints use (see Physical Restraints and Side Rails and Critical Care [link]) (Ref 7; 17) 17
6. Judiciously use medications, especially psychoactive medications, in geriatric dosages (see Reducing Adverse Drug Events) (Ref 31).
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. (Ref 7; 32)
B. Strategies to help older individuals cope with functional decline
1. Help older adults and family members determine realistic functional capacity with interdisciplinary consultation. (Ref 7)
2. Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts. (Ref 19)
3. Carefully document all intervention strategies and patient response. (Ref 19)
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. (Ref 11; 37) 11
7. Provide caregiver support and community services, such as home care, nursing, and physical and occupational therapy services to manage functional decline. (Ref 17; 19) 17
A. Patients can
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 into routine assessments.
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, and 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. Evidence of geriatric sensitive physical care environments that facilitate safe, independent function, such as caregiver educational efforts and walking programs.
10. Evidence of continued interdisciplinary assessments, care planning, and evaluation of care related to function.
Several resources are now available to guide adoption of evidenced based nursing interventions to enhance function in older adults.
A. Agency for Healthcare Research and Quality & National Guideline Clearing-
house; http://www.guideline.gov/ [link]
B. McGill University Health Centre Research & Clinical Resources for Evidence
Based Nursing; http://www.muhc-ebn.mcgill.ca/ [link]
C. National Quality Forum; http://www.qualityforum.org/Home.aspx [link]
D. Registered Nurses Association of Ontario. (2005). Clinical practice guidelines.
Retrieved from http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=27
E. University of Iowa Hartford Center of Geriatric Nursing Excellence. Evidence-
based practice guidelines. Retrieved from http://www.nursing.uiowa.edu/hartford/
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
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.
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.
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.
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.
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.
13. Hirsch, C. H., Sommers, L., Olsen, A., Mullen, L., & Winograd, C.H. (1990). The natural history of functional morbidity in hospitalized older patients. Journal of the American Geriatrics Society, 38(12), 1296–1303. Evidence Level IV.
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.
16. 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.
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.
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.
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.
22. 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.
23. Tinetti, M. E., & Ginter, S. F. (1998). Identifying mobility dysfunctions in elderly patients: Standard neuromuscular examination or direct assessment? Journal of the American Medical Association, 259(8), 1190–1193. Evidence Level I.
24. Depp, 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.
26. 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.
27. 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.
30. 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.
31. Inouye, S. R., Rushing, J.T., Foreman, M.D., Palmer, R.M., & Pompei, P. (1998). Does deliruim contribute to poor hospital outcomes? A three-site epidemiological study. Journal of General Internal Medicine, 13(4), 234-42. Evidence Level III.
32. 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.
33. 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.
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.
36. 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.
37. 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.
Last updated - August 2012