Gerentogoly Wk2 project

Running head: Functional Assessment

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Assessing the Functional Elements of the Older Adult

South University

Assessing the Functional Elements of the Older Adult

Completing a comprehensive assessment of an adult over 65 is a way for the nurse to identify any issues that need attention and help the patient have the best quality of life possible. The purpose of the screening is to provide care, preempt disease, retain good health, keep a record of health, minimize disabilities, and give a holistic approach to independent living (lecture online,wk.2). Various tools can be used to assess the patient for the functional ability during an assessment. I will use nursing tools that are applicable to the interviewed subject and analyze where potential problem areas are. After analyzing the information gathered, I will then connect the dots with formulating interventions for the problems identified. I will be discussing a 77-year-old female, AW, who lives independently at home alone.

The Patient interview

To ensure privacy of the person being discussed, I will refer to the interviewee as AW. AW lives alone in her single floor home close to her daughter and granddaughter. For the past seventy years she has had very few medical issues which include, arthritis, vision impairment, bursitis and plantar fasciitis (personal conversation, Appendix A) AW’s view on life is holistic and autonomous. AW has a good sense of control of her medical problems and indicates that she is “in good health”. AW agreed to a comprehensive assessment and each tool used was explained to her in detail. I believe her cognitive status was intact to understand and consent to this project. I will first discuss, as a nurse, the focus of assessment is on the day to day activities.

Assessment tools1

By nursing standards, the functional assessment is completed to measure a person’s ability to perform day to day task of living and self -care (Miller, 2015, p.100). The first tool I will discuss is the Tinetti Balance tool. The use of this tool was to assess AW’s steadiness, gait, and her overall ability to move sit and walk. Using verbal instructions, AW was asked to perform simple task such as sitting and standing, turning around and walking steps. There were an achievable 28 points to attain and AW scored a 27 on the Tinetti (see Appendix B). With an almost perfect score, I did not feel that this was a problem area for her plan of care.

The next tool described is the Katz Index of Independence in Activities of Daily Living, referred to as the Katz ADL. This tool is used to measure an elder person’s independent daily life duties. Such duties included, bathing, dressing, and toileting. The tool uses 6 activities of daily life to score the patient, and a possible total score of 6. For the Katz ADL assessment, AW scored a 6 (see Appendix C). The objective view of this tool indicates no need for interventions at this time. I would recommend that she is evaluated yearly for any decline now that a baseline has been established. The next assessment was of the home, using the Assessment of Home Safety Tool.

The importance of the home assessment is to identify any fall risk factors as well as identify any environmental factors that positively or negatively affect safety, functioning, and quality of life (Miller, 2015, p.106). Having a safe home environment include proper lighting, removal of rugs and furniture, as well as efficient heating and cooling of the home. Good lighting in the home is often overlooked, but it is essential to reading, and other activities enjoyed by the older adult. Proper lighting also helps to avoid tripping over objects, and seeing a wet area that the person may slip on. The proper climate of a home is also a vital part of quality of living, making sure that the person is comfortable where they spend most of their time. I used recommendations for the home safety assessment from the text by Miller (2015) and from the Medscape website to create a tailored version for AW (see appendix D). From this assessment there were identifiable needs for intervention to make the home safer. The problems identified were; furniture to close to walking areas, small pets walking around the feet of AW, unsecured rugs throughout the home, and no grab bars in the bathroom area. Interventions will be discussed in another section of this essay under the section inerventions. Lastly, I assessed AW using the Barthel Index of daily function’s as an addition to the Katz ADL.

When I found the Barthel Index and reviewed it, I felt that the information had already been established from the other tools used as in the Katz ADL. The main purpose for the Barthel index tool is determine the degree of independence, from any help, whether its physical or verbal to any degree. The Barthel Index is a record of what the patient does, not what they could do (strokecenter.org). When I did the Barthel test, AW had a perfect score of 20 which correlates with her Katz score (see Appendix E). I did not recognize any issues or problem areas during this assessment of AW. The mental assessment and cognitive tools were not used on this person, because the initial interview combined with the other tools provided enough information that I did not feel she had any memory loss or dementia tendencies. This 77-year-old proved to be as independent as I am at 41 and her overall health just as good. There were some noted changes related to aging to discuss that could be potential areas of intervention.

Age related changes.

AW was wearing glasses and spoke of her loss of good eye sight during our time of assessments. To complete her overall functional assessment, I asked AW questions about driving at night and reading to decide if she had age related changes. I also looked at her eyes with her glasses off and noticed the yellowing of her cornea and the drooping of her top eyelid. In the text by Miller (2015, p.336) yellowing of the cornea will cause interference of light passage to the retina making glares an issue. Eyelid droop, due to loss of elasticity in the skin and the muscles around the eye, can cause problems with vision if the skin is in the line of vision. AW’s visual acuity is corrected by her glasses but she stated that seeing at night while driving was difficult due the glare from the lights. Age related changes to the lens, pupil, retina and retinal-neural pathways cause the older adult to have a delay in adapting to dark and light (Miller, 2015, p.337). This causes an issue for the older adult to respond as quickly when driving and meeting cars with headlights on the road. Form this assessment I identified a problem area of safety that implies a need for intervention for AW with her vision and night driving.

Another age-related change to discuss is sleep. In AW’s health assessment she had complaints about trouble with sleeping patterns. Prolonged sleep latency, is the primary reason for aging adult’s loss of sleep efficiency. This is a latency is from increased time to fall asleep and increased frequency of awakenings during the night (Miller, 2015, p.512). Usually, the older adult take’s naps as way to compensate for the sleep loss. The interruption in the adult’s circadian rhythm is annoying but overall not bad for one’s health. Light sleep, known as non- REM, increases as the person ages. The non- REM phase is when hormones are released, muscles relax and restorative processes occur (Miller, 2015). This does however, cause drowsiness during the day and early rise times with late fall asleep times. AW has a need here as well for intervention to help improve her quality of life.

Lastly, in considering her health issues, her focus was on arthritis pain. In her interview she stated that she did not regularly exercise but she moves around, stretches and take’s walk’s some days (see Appendix A). As cited in text by Miller (2015, p.298), adults often avoid exercise due to arthritic pain. Age related changes here are, joints become less flexible with loss of fluid to cushion them, and muscles become more lax and less tone from changes in the muscle fibers and the central nervous system (medlineplus.gov). Due to the lack of desire to exercise regularly an intervention is needed to provide her with information about tailored programs of exercise. Controlling pain with arthritis can be a bit tricky when it comes to taking medications. The most often used medications are NSAID’s which can increase blood pressure. AW made it clear in her interview that she had personal beliefs about taking pain pills. In awareness of her beliefs, I feel that an intervention could be used to improve her knowledge of other pain relieving methods.

Interventions for problems.

My interventions for the problems identified during her assessment are my own tailored ideas using suggestions from other sources as cited in the references.

1. Problem-Seeing at night while driving. Intervention recommended-Encourage AW to group activities of driving to the daylight hours, refer her to an eye specialist, promote family help for night driving activities, and encourage eye care and checkups to keep glasses adjusted to eye changes.

2. Problem-Safety of the home environment. Interventions-teach risks of falling due to small pets around the feet when walking, encourage AW and family to make necessary changes of walking path to include moving furniture out of way, educate AW and family on assistive devices for bathroom such as shower bars and raised toilets, and raise awareness of in home call buttons for help.

3. Problem-Disturbed sleep patterns. Interventions-promote wellness by identifying risk factors for lack of sleep such as pain control for her arthritis, encourage daily physical activity such as exercise, educate to avoid alcohol, nicotine and caffeine close to bed time, and promote soothing music at bedtime.

4. Problem-Pain from arthritis. Interventions-educate sources of support from national and government organizations that are online that teach prevention and management, and encourage the use of non-pharmacological means to control pain such as heat or cold therapy.

After completing the functional assessment there was no need for a true mental assessment for AW. Her ability to answer, recall information and perform all tasks independently were sufficient for a mental assessment and no deficits were noted. Using all the tools discussed and her interview, I was able to formulate problem areas with interventions. After reviewing age related changes that pertained to AW I have recognized four problem areas of health and living well. From the problems noted, I applied nursing evidence based practice suggestions and ideas, from literature read and experience as a nurse to give at least three detailed interventions for each problem listed. The importance of assessing older adults is to identify conditions that affect not only health but level of functioning and quality of life (Miller, 2015, p.99).

References Internet Stroke Center. retreived from: http://www.strokecenter.org Miller, C. A. (2015). Nursing for wellness in older adults, (7th ed). [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469895277/ Medscape.com. Retreived from: http://medscape.com. Shelkey, M., Wallace, M., (2012). Katz index of independence in activities of daily living. New York University College of Nursing, I (2). South University Online (2018). NSG4067: Gerontological nursing: week 3: lecture 3. Retrieved from myeclassonline.com.

Appendix A

Patient Questionnaire by Chasidy Ward

Name: AM Age: 77

Personal communication, March …….

Brief background:

Has been self-employed for 40 years selling antiques, lives alone in a one-story house, enjoys internet surfing and selling antiques online and spending time with her daughter and friends. AW has a history of arthritis, plantar fasciitis, bursitis, trouble with sleeping at night and impaired vision. Visits to primary physician are infrequent but goes yearly for checkup. AW states she has not been hospitalized for any acute or chronic illness in the past.

1. Philosophy on living a long life:

Don’t take all the medicines the doctor tries to give you to take. Love the Lord and others as you do yourself.

2. Thoughts about when a person is considered “too old”

I think people tell me I’m too old to do things but really, I’m not too old until I can’t do something anymore such as lifting and moving furniture.

3. Opinion on the status and treatment of older adults

Very poorly, people treat you like you don’t know anything and like you aren’t capable of doing what they are.

4. Beliefs about health and illness

It is what you make it, a lot of is mental and how you take care of yourself over the years. You have to think young and never stop thinking your age depends on your mind set about it.

5. Health promotion activities he or she participates in

I try to stay moving and doing and stay off medication. When I sit to much and start getting stiff I get up and move around stretch or talk a walk most days. Educating myself over the years on vitamins and healing food choices.

6. Something special that helped the person live so long

Good genes and the other half is not taking all the prescribed drugs the doctors try to give you. If you are in pain its best to try natural things first like a heating pad or a cold pack. I don’t take a pain pill just because I’m hurting that’s usually the last result. I think certain foods heal you from a lot of aliments.

7. Life span of other family members

My mother and her siblings lived well beyond their 80’s, two of them up to 100 and 105. I don’t know my father’s history.

8. Special dietary traditions in patient’s culture attributed with aiding long life

Healing food and vitamins when you notice a deficiency. It’s not cultural but I eat food high protein without a lot of meats-I only eat chicken. I eat nuts and vegetables. And I don’t salt my food because of high BP so I won’t have to take the medicines.

9. Any remedies/medications that have been handed down in family/group. If yes, describe.

We used to put onions on our feet to take out fever but I don’t use that anymore. My grandmother always taught me to eat real food, not packaged stuff. Food right out the garden.

10. Patient’s description of current and past health status

Currently my health is good, I have had some bad times with arthritis and trouble falling asleep and staying asleep, but good otherwise. I don’t like to drive at night because its harder to see with the glare of the lights.

11. The values that guided life so far

I value the quality of life and good clean living. I don’t really know more than that

Additional Questions

12. What do you feel about how family’s treat their elder?

I think they don’t care of them in general until they are dying and most of them won’t take care of the elder if they are really sick. When I need it, I would hope to afford to pay someone to take care of me.

13. Have you fallen in the last three months?

No, not in over a year and I tripped on something behind me but I’m steady I watch carefully for stuff around me. I learned to wear good shoes and do balancing exercises I read about

14. Is there anything in your community to do for your age group?

Yes, there are centers and activities but I stay busy with my life and don’t entertain them. I would if I was bored and lonely. There is always yard work or a garden to tend to.

15. Who do you talk to and rely on for age related discussions and issues?

I have two friends my age with a lot in common and have known them both for 40 years. We all fear getting older and unable to do for ourselves and what will happen to us where we will go if we will be sent to a home and treated poorly.

Appendix B

TINETTI BALANCE ASSESSMENT TOOL

Facilitator: Chasidy Ward, RN Patient Name AW D.o.b. 1941_________

BALANCE SECTION

Patient is seated in hard, armless chair;

		Date
Sitting Balance	Leans or slides in chair Steady, safe	= 0 = 1	1
Rises from chair	Unable to without help Able, uses arms to help	= 0 = 1	2
	Able without use of arms	= 2
Attempts to rise	Unable to without help Able, requires > 1 attempt	= 0 = 1	2
	Able to rise, 1 attempt	= 2
Immediate standing Balance (first 5 seconds)	Unsteady (staggers, moves feet, trunk sway) Steady but uses walker or other support Steady without walker or other support	= 0 = 1 = 2	2
Standing balance	Unsteady Steady but wide stance and uses support	= 0 = 1	2
	Narrow stance without support	= 2
Nudged	Begins to fall Staggers, grabs, catches self	= 0 = 1	2
	Steady	= 2
Eyes closed	Unsteady Steady	= 0 = 1	1
Turning 360 degrees	Discontinuous steps Continuous	= 0 = 1	1
	Unsteady (grabs, staggers)	= 0	1
	Steady	= 1
Sitting down	Unsafe (misjudged distance, falls into chair) Uses arms or not a smooth motion	= 0 = 1	2
	Safe, smooth motion	= 2
	Balance score	16/16	16/16

TINETTI BALANCE ASSESSMENT TOOL

GAIT SECTION

Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace.

		Date
Indication of gait (Immediately after told to ‘go’.)	Any hesitancy or multiple attempts No hesitancy	= 0 = 1	1
Step length and height	Step to Step through R	= 0 = 1	2
	Step through L	= 1
Foot clearance	Foot drop L foot clears floor	= 0 = 1	2
	R foot clears floor	= 1
Step symmetry	Right and left step length not equal Right and left step length appear equal	= 0 = 1	2
Step continuity	Stopping or discontinuity between steps Steps appear continuous	= 0 = 1	1
Path	Marked deviation Mild/moderate deviation or uses w. aid	= 0 = 1	2
	Straight without w. aid	= 2
Trunk	Marked sway or uses w. aid No sway but flex. knees or back or uses arms for stability	= 0 = 1	2
	No sway, flex., use of arms or w. aid	= 2
Walking time	Heels apart Heels almost touching while walking	= 0 = 1	0
		Gait score	11/12	/12
	Balance score carried forward	16/16	/16
	Total Score = Balance + Gait score	27/28	/28

Tinetti Tool Score	Risk of Falls
≤18	High
19-23	Moderate
≥24	Low

Risk Indicators:

Appendix C

Katz Index of Independence in Activities of Daily Living

Name of Nurse: Chasidy Ward Patient name : AW age: 77

ACTIVITIES POINTS (1 OR 0)	INDEPENDENCE: (1 POINT) NO supervision, direction or personal assistance	DEPENDENCE: (0 POINTS) WITH supervision, direction, personal assistance or total care
BATHING POINTS:_____1______	(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity.	(0 POINTS) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing.
DRESSING POINTS:_______1____	(1 POINT) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.	(0 POINTS) Needs help with dressing self or needs to be completely dressed.
TOILETING POINTS:_____1______	(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.	(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.
TRANSFERRING POINTS:_____1______	(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable.	(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.
CONTINENCE POINTS:_____1______	(1 POINT) Exercises complete self control over urination and defecation.	(0 POINTS) Is partially or totally incontinent of bowel or bladder.
FEEDING POINTS:_____1______	(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.	(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

TOTAL POINTS = ___6___ 6 = High (patient independent) 0 = Low (patient not inedependent)

Appendix D

Home safety assessment

Assessment by Chasidy Ward

Patient: AW Age: 77

1. Is there adequate lighting at the entry way to the home and in the home? _yes

2. Is the floor clear of objects or furniture in the walking path around the home?__NO

3. Is the floor free of unsecured, untapped area rugs that may trip the patient?__NO

4. Is the home free of small pets walking around the feet of the patient?__NO

5. Does the shower have non- skid strips or slip-free bath mats?___NO

6. Bathroom has grab bars in shower or around toilet?___NO

7. Was the home temperature uncomfortable to the patient?___NO

NO= No is a need to be evaluated for intervention

YES=no issues identified

Appendix E

The Barthel Index

Assessment by Chasidy Ward

Person name: AW Age: 77

Instructions: Choose the scoring point for the statement that most closely corresponds to the patient's current level of ability for each of the following 10 items. Record actual, not potential, functioning. Information can be obtained from the patient's self-report, from a separate party who is familiar with the patient's abilities (such as a relative), or from observation. Refer to the Guidelines section on the following page for detailed information on scoring and interpretation.

Running head: Functional assessment

Functional assessment

Bowels

0 = incontinent (or needs to be given enemata)

1 = occasional accident (once/week) 2 = continent

Patient's Score: 2

Bladder

0 = incontinent, or catheterized and unable to manage

1 = occasional accident (max. once per 24 hours) 2 = continent (for over 7 days)

Patient's Score: 2

Grooming

0 = needs help with personal care 1 = independent face/hair/teeth/shaving (implements

provided)

Patient's Score: 1

Toilet use

0 = dependent

1 = needs some help, but can do something alone 2 = independent (on and off, dressing, wiping)

Patient's Score: 2

Feeding

0 = unable

1 = needs help cutting, spreading butter, etc. 2 = independent (food provided within reach)

Patient's Score: 2

(Collin et al., 1988)

Scoring:

Transfer

0 = unable – no sitting balance

1 = major help (one or two people, physical), can sit

2 = minor help (verbal or physical) 3 = independent

Patient's Score: 3

Mobility

0 = immobile

1 = wheelchair independent, including corners, etc.

2 = walks with help of one person (verbal or physical) 3 = independent (but may use any aid, e.g., stick)

Patient's Score: 3

Dressing

0 = dependent

1 = needs help, but can do about half unaided 2 = independent (including buttons, zips, laces, etc.)

Patient's Score: 2

Stairs

0 = unable

1 = needs help (verbal, physical, carrying aid) 2 = independent up and down

Patient's Score: 2

Bathing

0 = dependent

1 = independent (or in shower)

Patient Score: 1

Total Score: 20

Sum the patient's scores for each item. Total possible scores range from 0 – 20, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.

Sources:

· Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10(2):61-63.

· Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

· Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988;10(2):64-67.