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Clinical Nursing Skills

9.1 Assessing Functional Ability

Clinical Nursing Skills9.1 Assessing Functional Ability

Learning Objectives

By the end of this section, you will be able to:

  • Identify tools used to determine functional ability assessments
  • Develop nursing interventions related to performing ADLs
  • Differentiate isotonic, isometric, and isokinetic exercises

Hospitalization and decreased functional ability contribute to an increased risk of patient complications. Specifically, immobility or decreased mobility often contribute to health issues such as pressure injuries, pneumonia, blood clots, constipation, and physical deconditioning. These complications due to immobility and subsequent deconditioning can result in extended lengths of stay for patients (e.g. delay in discharge due to complications), increased costs related to hospitalization and treatment, and patient dissatisfaction with the quality of care. Therefore, assessment and management of functional ability are critical to prevent adverse effects and enhance patient recovery.

In the United States, approximately 35 percent of adults over the age of 65 report some difficulty in at least one activity of daily living (ADL), such as walking or climbing (Fuller-Thompson et al., 2023). Based on this statistic, it is critical that nurses assess functional and mobility status early to initiate ambulation routines and continue to reassess throughout the patient’s care to prevent complications in a patient’s recovery. Mobility assessments completed upon admission create a baseline for nurses to note improvements or setbacks in patients’ progress. Healthcare facilities should have policies and standardized evaluations for patient assessment and evaluation. Collaboration and communication between the nurse and the interdisciplinary team are essential to creating a safe plan of care for the patient.

Determining Functional Status

The functional status is a measurement of a patient’s ability to perform physical movements (e.g., walking, standing) and higher-level activities (e.g., activities of daily living, filling occupational and societal roles). An impairment or decline in functional status can impede daily routines, self-care, and autonomy. These impairments can be caused by disease (Figure 9.2), deconditioning, environmental changes, a shift in social supports, or advanced age.

X-ray showing rheumatoid arthritis in a hand
Figure 9.2 This patient has rheumatoid arthritis and has developed contractures in their hands, making eating, dressing, and toileting difficult to perform independently. (credit: modification of work "RheumatoideArthritisAP.jpg" by Bernd Brägelmann/Wikimedia Commons, CC BY 3.0)

A functional status assessment should be performed using a standardized, validated assessment tool. Two commonly utilized tools are the Katz Index of Independence in Activities of Daily Living (Katz ADL Index) and the Lawton-Brody Instrumental Activities of Daily Living Scale (Lawton Scale for IADL). The Katz ADL Index awards points for independent activities such as bathing, dressing, toileting, transferring, continence, and feeding. The higher scores indicate increased independence with ADLs. The Lawton Scale for IADL assesses independent living skills that are more complex and include shopping, laundry, handling finances, and other tasks. This scale identifies how a person is functioning at that present time. Scores range from 0 (low function, dependent) to 8 (high function, independent) for women; 0 to 5 for men.

Assisting with ADLs

An activity of daily living (ADL) is a routine activity to care for oneself independently. Assessment of ADLs is often used to determine a patient’s needs, whether it is dependent support, a change in living arrangements, paid caregivers, or implementation of durable medical equipment. A disruption in independent ADLs can result in patient safety issues or poor quality of life. Therefore, routine ADL screening is essential for nurses to determine if patients can independently meet their self-care needs.

ADLs are classified as basic ADLs or instrumental ADLs (IADLs) (Table 9.1). A basic ADL is a basic need such as toileting, dressing, bathing, eating, and ambulating. An instrumental ADL is more complex and relates to activities that would keep a patient independent in the community, such as managing medications, preparing food, and managing household chores.

Examples of Activities of Daily Living (ADLs) Examples of Instrumental Activities of Daily Living (IADLs)
Eating
Toileting
Bathing
Dressing
Transferring
Grooming
Cooking
Cleaning
Maintaining finances
Shopping
Preparing meals
Managing medications
Table 9.1 Examples of ADLs and IADLs

Preparing the Patient for Activities of Daily Living

In preparing patients for assistance with ADLs, nurses should focus on providing comfort, safety, and dignity, and promoting independence as much as possible. Nurses should always tell their patients when they are beginning a new task and inform them of all of the steps. All products and supplies should be set up prior to care, ideally with the patient’s preferred products.

Real RN Stories

Remember to Support Independence with ADLs

Nurse: Lashonda, RN
Clinical setting: Large hospital system
Years in practice: 7
Facility location: Hartford, Connecticut

I walked into my patient’s room to help assist them after bathing. The patient, an 87-year-old female named Wanda, already laid out her comb, deodorant, and lotion on the counter next to the sink. Wanda finished dressing and was buttoning her shirt. I saw that Wanda was struggling with the buttons because of arthritis, and I said “I can do that for you.” I walked over to button the last two buttons before Wanda had a chance to respond. Then I said that I would bring over Wanda’s supplies next to the sink. This time Wanda firmly said, “No dear. I will go over to the sink to comb my hair. I can do it . . . just like I could have finished buttoning my shirt.” Horrified, I realized that I wasn’t letting Wanda perform her ADLs and was interfering with her independence. I apologized and told Wanda that I’m here if she needs help but will wait for her to ask. Wanda was happy with that response. This story has stuck with me throughout my career, and I have since always asked my patients if they needed assistance with their ADLs.

If the patient can perform certain tasks, the nurse should allow them to and assist only when necessary. This supports patient autonomy and provides a way for the nurse to assess the patient’s abilities, and prepares the patient for discharge.

Safety is paramount when assisting patients with their ADLs. The nurse should ensure they have the space necessary to assist with care, the patient is in a safe position, and the appropriate level of assistance is available. For example, if a nurse is performing a bed bath on an immobile patient, assistance from another clinician is necessary to ensure proper turning and repositioning.

Finally, the nurse should ensure that the patient’s dignity is preserved during assistance with ADLs. Patients who can no longer care for themselves or perform simple tasks may be apprehensive about accepting help, feel like a burden, or be embarrassed. Nurses can provide reassurance and privacy to patients by covering certain body parts during bed baths, closing doors or curtains prior to procedures, actively listening to patients’ requests and needs, and acting professionally and respectfully. In addition, the nurse can ask the patient their preferences for activities while aiding. An example of this is a nurse asking the patient if they want bath soap/body wash applied in their bath water or applied to a small towel instead. This allows the patient to retain some control over the activity and lessen the feeling of helplessness.

Cultural Context

Generational Considerations When Assessing IADLs

Instrumental ADLs include activities that would keep a patient independent in the community. A 2017 study that examined IADL questionnaires used for older adults were more accurate for women over 65 than for men over 65 years of age (Sheehan & Tucker-Drob, 2019). Older men were more likely to state they could not perform certain IADL activities, such as cooking and housework, because they had not previously performed these tasks, not because of a physical restriction. Researchers suggested methods to address these biases, including measuring items that are gender neutral such as using the telephone and taking medication. If a patient scores low in a particular section, the nurse can ask additional patient history questions to obtain a more accurate assessment of IADLs in older generations. Additional questions to ask may include the following:

  • Were you ever in charge of grocery shopping?
  • Did you always prepare your own meals?
  • Who always did the house work?
  • Were you ever in charge of the household finances?

Preparing the Environment for Activities of Daily Living

Similar to preparing the patient, the environment of care should be safe and free of obstructions prior to ADL activities. The environment of care should be checked for any obstructions or potential fall risks (e.g., unsecured tubing, wires, equipment, wet floors, IV poles, linen carts) prior to patient ambulation. When a patient is getting dressed, toileting, or showering, the nurse should have all supplies available and within reach, and, depending on the patient’s functionality, avoid leaving them alone during ADL activity. Feeding/eating is another example where patients may need a tray set up or assistance with feeding. The nurse should be aware of the patient’s dietary requirements and physical capacity to eat meals so that they can adequately set up the environment for the patient.

Exercise

Performing ADL activities can be improved with exercises provided by an occupational or physical therapist. Exercise programs focus on functional exercise to promote mobility, ambulation, and functionality. These exercises do not require special equipment and are tailored to the patient’s needs. In a medical setting, therapeutic exercise uses intentional movement to develop strength and endurance and to increase range of motion and flexibility. These exercises use simple techniques to build on weakened areas of the body that prevent patients from performing ADLs (Figure 9.3).

A woman performs the cat-cow stretch on an exercise mat.
Figure 9.3 The cat-cow stretch is a therapeutic exercise that stretches the spine and hips with a series of movements that alternate between arching the back and hollowing it out. (credit: “Yoga at Your Park” by Mary O’Neill/Wikimedia Commons, Public Domain)

Types of Exercises

Building and maintaining muscles requires strength exercise, which focuses on increasing the maximum amount of force a muscle can exert. As older adults age, muscle mass decreases, especially in older adults who do not regularly exercise. Exercises are designed using body weight, resistance bands, and weights. The difficulty of the exercise can be modified as the patient begins to show progress. Examples of upper body strength exercises include shoulder presses, ball squeeze, front or lateral shoulder raises, and rowing with a band. Examples of lower body exercises include lunges, squats (Figure 9.4), bridges, and hip hinges.

Two people perform kettlebell squats in a gym while a trainer observes.
Figure 9.4 A kettlebell squat is an example of a strength exercise. (credit: modification of work "Fit to Fight" by Capt. Zach Anderson/United States Air Force, Public Domain)

Exercises addressing range of motion (ROM), which is how much a person can move or stretch parts of the body, aim to increase joint flexibility and mobility. A movement called stretching lengthens the muscles and is also complementary to ROM exercises to reduce muscle tension. However, patients must have proper form during these exercises and start gradually. Improper form can lead to injury and muscle strain. ROM exercises include flexion and extension of the hip, elbow, shoulder, and knee.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety: Fall Risk Prevention

Definition: Reduce risk for falls and patient harm.

Knowledge: The nurse will utilize the recommendations of the Agency for Healthcare Research and Quality (AHRQ) for best practices in fall prevention for all patients, regardless of fall status. The nurse will:

  1. Maintain universal fall precautions:
    1. Familiarize the patient with the environment.
    2. Have the patient demonstrate call bell use and ensure it is functioning correctly.
    3. Maintain the call bell within reach.
    4. Keep the patient’s personal possessions within safe reach.
    5. Have sturdy handrails in patient’s bathroom, room, and hallway.
    6. Place the hospital bed in a low position with the brakes locked.
    7. Keep the wheelchair wheel locked.
    8. Provide the patient with nonslip, comfortable, well-fitting footwear.
    9. Use night lights or supplemental lighting.
    10. Keep floor surfaces dry, clean, and uncluttered.
  2. Assess fall precautions every hour, including mentally reviewing fall prevention factors with the patient. This includes the “five Ps” which are:
    1. Pain—assess the patient’s pain level and provide interventions, if needed.
    2. Personal needs—offer help using the toilet, offer food or drink, and empty commodes/urinals.
    3. Position—help the patient get into a comfortable position or turn patients who are immobile to maintain skin integrity.
    4. Placement—make sure the patient’s essential needs (such as call bell, phone, reading material, toileting equipment) are within easy reach.
    5. Prevent falls—ask the patient/family to ring the call bell if the patient needs to get out of bed.
  3. Have a “closing script” at the end of each round that states, “If you need a nurse before I come back, use the call bell to request help.”

Attitude: The nurse will respect their individual role in fall prevention by adhering to safe, evidence-based practice standards.

Balance is another important aspect of functioning. A balance exercise is a movement to reduce the risk of falls among patients by focusing on body alignment and control, and include exercises such as single-leg balance (with or without an assistive device), high-knee marching, and heel raises.

Isometric Exercise

An isometric exercise is a movement related to the contractions of specific muscles or groups of muscles and then their release. These exercises do not require much movement but are beneficial in maintaining and building strength (Figure 9.5). A patient uses their body to tighten certain muscles for five to ten seconds, then releases. These exercises can also improve stabilization, which is beneficial for the joints and the core muscles of the body, such as the posterior chain and abdomen. Other benefits of isometric exercises have been noted, including enhancing mindfulness—because a patient is focused on that one area of the body for each exercise—and reducing arthritic pain with isolated movements.

A person holds the plank position.
Figure 9.5 This person is performing a plank exercise, which is an example of an isometric exercise, where this position is held for a period of time. (credit: modification of work "130110-F-XM103-005.JPG" by Don Lindsey/Joint Base San Antonio, Public Domain)

Isotonic Exercise

An isotonic exercise is a movement that requires muscles to resist weight over a range of motion. This causes a change in the lengthening or shortening of the muscle. Isotonic exercises require both concentric (a movement that increases the muscle tension then remains stable once the muscle shortens) and eccentric muscle contractions (a movement that lengthens the muscle as the resistance becomes greater than the force the muscle is producing). Examples of these types of exercises include pushups, squats, bicep curls, and lunges (Figure 9.6). For patients who are focusing on improving ADLs, these exercises can be incorporated with specific ADLs in mind. For example, if a patient is having difficulty getting up from a chair, they can perform slow bodyweight squats to strengthen their lower body.

A diagram shows the mechanics of a bicep curl. Part A shows a concentric contraction when lifting the weight up toward the chest. Part B shows an eccentric contraction when lowering the weight to the hips.
Figure 9.6 A bicep curl is an isotonic exercise where there are both concentric and eccentric contractions of the muscle. (a) Concentric contractions occur as the weight is lifted. (b) Eccentric contractions occur as the weight is returned to rest. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Isokinetic Exercise

As mentioned previously, exercises can be done with resistance bands (Figure 9.7). An isokinetic exercise is a resistance-based exercise that provides variable resistance to a movement. In these exercises, the speed of the movement is constant, but the resistance varies. Isokinetic exercises may require special equipment and are often used by physical and occupational therapists for rehabilitation and recovery. However, resistance bands can also be used to perform these exercises.

A person uses resistance bands to perform lateral raises.
Figure 9.7 This person is using a resistance band to vary the resistance during lateral raises. (credit: modification of work "Girl doing lateral raises with bands" by Tyler Read/Flickr, CC BY 2.0)

Aerobic Exercise

An aerobic exercise is any cardiovascular activity that increases a patient’s heart rate and respiration rate. Examples include walking, biking, rowing, jumping rope, climbing stairs, and hiking (Figure 9.8). Low-intensity aerobic exercises include marching in place, sit-to-stand chair transfers, and going up and down a step. Aerobic exercises benefit circulatory health by improving the capacities of the heart and lungs. The American Heart Association recommends a minimum of thirty minutes of cardiovascular exercise five to seven days per week (Piercy & Toriano, 2018). Patients who are gradually working on increasing ADLs may start with a reduced amount initially, but they should aim to increase their activity time to thirty minutes if they are able to do so. Every aerobic exercise should include a warm-up and cooldown. This decreases the risk of joint injury and increases blood flow to the muscles. The cooldown can include exercises to lower the heart rate and stretching.

Several people exercise on stationary bike in a gym.
Figure 9.8 Stationary bikes, elliptical machines, and treadmills are examples of machines that can be used for cardiovascular/aerobic exercise. (credit: U.S. Department of Defense, Public Domain)

Positive Effects of Exercise on the Body

Regular physical activity can positively impact a person’s physical, emotional, and mental well-being. Key benefits of exercise include preventing bone loss among older adults, relieving pain for certain conditions, helping prevent chronic disease, boosting immunity, and improving mood. In addition, a combination of strength training, aerobic activities, and balance and mobility exercises can reduce the risk of falls, improve functional activities (ADLs), manage weight, and promote sleep. Exercise can also promote social interactions and prevent isolation if done in a group, which significantly benefits physical and mental health.

Patient Education about Importance of Activity

Nurses are poised to provide tips and education to patients on the importance of regular activity. Exercises and exercising do not have to be complicated, and some simple, safe exercises can provide numerous benefits. These exercises can range from patients performing simple body-weight range-of-motion exercises, including isotonic and isometric exercises in a chair to walking in their neighborhood with a group of friends. Nurses should utilize their interprofessional team and work with occupational and physical therapy to create appropriate exercises for their patients. Improving and maintaining a healthy physical lifestyle can enhance a patient’s ability to continue with ADLs, thus promoting autonomy and independence.

Patient Conversations

What If Your Patient Appears Anxious about Returning to Previous Functional Status After Surgery?

Scenario: Cain Johnson is a registered nurse working in an orthopedic unit of a hospital in Kansas City, Kansas. He has been a nurse for four years, and at the hospital for two. Cain is caring for James, a 75-year-old retired landscaper who just had knee replacement surgery and is worried about returning to running. James has completed seven marathons and numerous half-marathons.

Patient: I just worry about my recovery. Getting this surgery was such as hard decision, but I was having a lot of knee pain in my right knee.

Nurse: I understand that you are worried. What specifically worries you?

Patient: I’m worried that I will not be able to run again. I have been doing it all my life and it gives me such a mental release. I wasn’t going to get the surgery because of the possibility of not running again. I know that sounds silly, but this is the best way for me to relax and de-stress. I feel that if I’m not active, then I’ll just spend my days watching TV, eating, and getting depressed. After my wife died last year, I really don’t have anyone to spend time with.

Nurse: That doesn’t sound silly at all. It seems that running was more than just a way to keep in good physical health, but also helped mentally. That is important. It may take you some time to recover from your surgery but with physical therapy and easing back into your daily tasks, you may be able to run again. Let’s say hypothetically, you were not able to run. What could you do instead?

Patient: Well, I would still want to be active. There is a group in my neighborhood that walks every morning at 7:00 a.m. I usually see them when I’m running. They’re all very friendly people but I haven’t gotten to know them. They seem to have a great time on their walks . . . they’re always laughing and talking.

Nurse: That sounds like a great plan after you recover a bit. Maybe you can join their walking group to see how that feels. Then, if you’re up for it, you can start running again. But if you aren’t, then you can stick with the group.

Patient: That’s not a bad idea. Walking could be just as good as running, and maybe I’ll make a friend or two in the neighborhood.

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