Physical Function

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

 

BACKGROUND

A.  Functional status of individuals describes the capacity and performance of safe ADL and IADL (Applegate et al., 1990; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969) and is a sensitive indicator of health or illness in older adults. It is, therefore, a critical nursing assessment (Buurman et al., 2011; Byles, 2000; Campbell et al., 2004; Kresevic et al., 1998; Mezey et al., 1993).

B.  Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, toileting schedules, enhanced communication, adaptive equipment, attention to medications and dosages, and management of pain [Barnes et al., 2012; Bates-Jensen et al., 2004; Boltz et al., 2010; Brown, Redden, Flood, & Allman, 2009; Counsell et al., 2000; Kalisch, Soohee, & Dabney, 2013; Landefeld et al., 1995; Palmer, Counsell, & Landefeld, 1998; Zisberger et al., 2011]).

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 (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990). Interprofessional team care meetings may be helpful in clarifying the trajectory of illness and referring for appropriate follow-up.

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 UTI). These declines are usually reversible and require medical evaluation (Applegate et al., 1990; Sager & Rudberg, 1998). Functional status is contingent on motivation, cognition, and sensory capacity, including vision and hearing (Pearson, 2000).

E.  Risk factors for functional decline include frailty injuries, acute illness, medication side effects, pain, depression, malnutrition, decreased mobility, prolonged bed rest (including the use of physical restraints), prolonged use of Foley catheters, and changes in environment or routines (Brown et al., 2009; Counsell et al., 2000; Landefeld et al., 1995; McCusker et al., 2002).

F.   Additional complications of functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, depression, and increased risk for long-term institutionalization and depression (Covinsky et al., 1998; Creditor, 1993; Landefield et al., 1995; see related chapters).

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, from joint replacement surgery, or from new strokes (Katz et al., 1963).

H.  Functional status evaluation assists patients and their families in planning future care needs post hospitalization, such as short-term skilled care, assisted living, home care, and need for community services (Boltz, Resnick, Chippendale, & Galvin, 2014; Graf, 2006; Landefeld et al., 1995), or long-term residential care.

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 vs. door knobs, enhanced lighting; Capezuti et al. 2008; Kresevic et al., 1998; Landefeld et al., 1995).

ASSESSMENT PARAMETERS

A.  Comprehensive functional assessment of older adults includes independent performance of basic ADL, social activities, or IADL, the assistance needed to accomplish these tasks, and sensory ability, pain level, cognition, and capacity to ambulate (Campbell et al., 2004; Doran et al., 2006; Freedman, Martin, & Schoeni, 2002; Kalish et al., 2013; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969; Lightbody & Baldwin, 2002; McCusker et al., 2002; Tinetti & Ginter, 1998).

  1. Basic ADL (bathing, dressing, grooming, eating, continence, transferring)
  2. IADL (meal preparation, shopping, medication administration, housework, transportation, accounting)
  3. Mobility (ambulation, pivoting)

B.  Older adults 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 (Depp & Jeste, 2006; Pearson, 2000).

C.  The clinician should validate, document, and communicate baseline functional status and recent or progressive decline in function (Boltz, Chippendale, Resnick, & Galvin, 2015; Gillis, MacDonald, & MacIssac, 2008; Graf, 2006).

D.  Function should be assessed over time to validate capacity, decline, or progress (Applegate et al., 1990; Callahan, Thomas, Goldhirsh, & Leipzig, 2002; Kane & Kane, 2000).

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, and documentation including electronic medical records (Hoogerduijn et al., 2006; Kane & Kane, 2000; Kresevic et al., 1998; see “Function” topic at www.consultgerirn.org for tools).

F.   Interprofessional communication regarding functional status, changes, and expected trajectory should be part of all care settings and should include the patient and family whenever possible (Counsell et al., 2000; Covinsky et al., 1998; Kresevic et al., 1998; Landefeld et al., 1995).

G.  Interprofessional rounds support promotion of function by addressing functional assessment (baseline and current), evaluating potential interventions, and helping develop a plan of care with measurable goals (Kresevic & Holder; 1998).

H.  Patient’s perceptions of function, quality of life, and goals of care should be assessed, documented, and communicated to the care team across all settings (Liebzeit et al., 2018).

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, encourage the individual to get out of bed for meals, allow flexible visitation, including pets, and encourage reading the newspaper. Encourage adjunctive interventions such as relaxation and music therapy (Boltz et al., 2015; Kresevic & Holder, 1998; Landefeld et al., 1995; Resnick et al., 2011).
  2. Educate older adults, family, and formal caregivers on the value of independent functioning and the consequences of functional decline (Graf, 2006; Kresevic & Holder, 1998; Vass, Avlund, Lauridsen, & Hendriksen, 2005); increased risk for complications such as malnutrition, falls, hospital readmissions, increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999); increased mortality (Boyd et al., 2005; Rozzini et al., 2005); and decreased functional recovery (Boltz et al., 2015; Boyd et al., 2005, Boyd, Ritchie, et al., 2008; Gill et al., 2004; Gillis et al., 2008; Volpato et al., 2007), ultimately decreasing quality of life.
    • Physiological and psychological value of independent functioning
    • Reversible functional decline associated with acute illness (Hirsch et al., 1990; Sager & Rudberg, 1998)
    • Strategies to prevent functional decline: exercise, nutrition, pain management, and socialization (Boltz, Resnick, Capezuti, Shuluk, & Secic, 2012; de Morton, Keating, & Jeffs, 2007; Kresevic & Holder, 1998; Landefeld et al., 1995; Siegler, Glick, & Lee, 2002; Tucker, Molsberger, & Clark, 2004)
    • Sources of assistance to manage decline
  3. Encourage activity, including routine exercise, range of motion, and ambulation to maintain activity, flexibility, and function (Counsell et al., 2000; Landefeld et al., 1995; Pedersen & Saltin, 2006).
  4. Minimize bed rest (Bates-Jensen et al., 2004; Covinsky et al., 1998; Kresevic & Holder, 1998; Landefeld et al., 1995).
  5. Explore alternatives to physical restraint use (e.g., cover tubings; use distraction; Covinsky et al., 1998; Kresevic & Holder, 1998; see Chapter 23, Assessing, Managing, and Preventing Falls in Acute Care).
  6. Judiciously use medications, especially psychoactive medications, in geriatric dosages (Inouye, Rushing, Foreman, Palmer, & Pompei, 1998; see Chapter 17, Advance Care Planning).
  7. Assess and treat for pain (Covinsky et al., 1998). Consider alternative and nonpharmacological interventions.
  8. Design environments with handrails; wide doorways; raised toilet seats; shower seats; enhanced lighting; low beds; and chairs of various types and height, including recliners and rocking chairs (Cunningham & Michael, 2004; Kresevic et al., 1998).
  9. Help individuals regain baseline function after acute illnesses by using exercise, physical or occupational therapy consultation, nutrition, and coaching (Conn, Minor, Burks, Rantz, & Pomeroy, 2003; Covinsky et al., 1998; Engberg, Sereika, McDowell, Weber, & Brodak, 2002; Forbes, 2005; Hodgkinson, Evans, & Wood, 2003; Kresevic et al., 1998).

B.  Strategies to help older individuals cope with functional decline

  1. Help older adults and family members determine realistic functional capacity based on health trajectory with interprofessional consultation (Kresevic & Holder, 1998).
  2. Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts (Graf, 2006). Palliative care consultation may offer the family and team important management strategies, particularly postacute care.
  3. Carefully document all intervention strategies and patient response (Graf, 2006).
  4. Provide information to caregivers on causes of functional decline related to acute and chronic conditions (Covinsky et al., 1998; Resnick et al., 2016).
  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 (Covinsky et al., 1998).
  6. Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences (Edington et al., 2004; Landefeld et al., 1995).
  7. Provide caregiver support and community services, such as senior centers, meals on wheels, home care, nursing, and physical and occupational therapy services to manage functional decline (Covinsky et al., 1998; Graf, 2006).

EXPECTED OUTCOMES

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 low functional level.
  4. Communicate preferences for care.

B.  Providers can demonstrate

  1. Increased assessment, identification, and management of patients susceptible to or experiencing functional decline. Provide routine assessment of functional capacity despite level of care.
  2. Ongoing documentation (electronic medical record) 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 bed rest, and Foley catheters use falls
  5. Decreased incidence of delirium
  6. An increase in prevalence of patients who leave the hospital with baseline or improved functional status
  7. Decreased readmission rate
  8. Increased early utilization of nutritional and rehabilitative services (occupational and physical therapy)
  9. Evidence of geriatric-sensitive physical care environments that facilitate safe, independent function such as low beds, comfortable chairs, and caregiver education on safe environmental design and exercise programs
  10. Evidence of continued interprofessional assessments, care planning, and evaluation of care related to function, including posthospital follow-up planning such as leadership support for interdisciplinary communication
  11. Leadership commitment to patient-centered care

RELEVANT PRACTICE GUIDELINES

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

A.  Agency for Healthcare Research and Quality and National Guideline Clearinghouse: www.guideline.gov

B.  McGill University Health Centre Research and Clinical Resources for Evidence Based Nursing: www.muhc-ebn.mcgill.ca

C.  National Quality Forum: www.qualityforum.org/Home.aspx

D.  Registered Nurses Association of Ontario. (2005). Clinical practice guidelines. Retrieved from www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID

E.  University of Iowa Hartford Center of Geriatric Nursing Excellence. (n.d.). Evidence-based practice guidelines. Retrieved from www.nursing.uiowa.edu

ABBREVIATIONS

ADL            Activities of daily living

IADL          Instrumental activities of daily living

UTI              Urinary tract infection

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 10:  Kresevic, D. (2021) Assessment of Physical Function in the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 133-148).  New York: Springer.

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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. doi:10.1111/j.1532-5415.2005.53201.x. Evidence Level II.

Volpato, S., Onder, G., Cavalieri, M., Guerra, G., Sioulis, F., Maraldi, C., … Fellin, R.; Italian Group of Pharmacoepidemiology in the Elderly Study (GIFI). (2007). Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization. Journal of General Internal Medicine, 22(5), 668–674. doi:10.1007/s11606-007-0152-1. Evidence Level IV.

Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society, 59(2), 266–273. doi:10.1111/j.1532-5415.2010.03276.x. Evidence Level IV.

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Symptoms

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