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Guideline Summary
Guideline Title
Assessment of physical function. In: Evidence-based geriatric nursing protocols for best practice.
Bibliographic Source(s)
Kresevic DM. Assessment of physical function. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 89-103.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Kresevic DM. Assessment of function. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 23-40.

Scope

Disease/Condition(s)

Functional decline

Guideline Category
Evaluation
Management
Risk Assessment
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Nursing
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To provide a standard of practice protocol to maximize physical functioning, prevent or minimize decline in activities of daily living (ADL) function, and plan for transitions of care

Target Population

Hospitalized older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Comprehensive functional assessment
    • Basic activities of daily living (ADL)
    • Instrumental ADL (IADL)
    • Mobility
  2. Use of standard instruments to assess function

Management

  1. Maximization of function and prevention of decline
    • Maintenance of daily routine
    • Education of elders, family, and formal caregivers
    • Encouraging activity
    • Minimization of bed rest
    • Alternatives to physical restraints
    • Assessment and treatment of pain
    • Environmental design
    • Regaining baseline functional status
    • Physical and occupational therapies
  2. Helping older individuals cope with functional decline
    • Determining realistic functional capacity
    • Caregiver education and support
    • Use of community resources
    • Documentation of interventions
    • Management of protein and caloric intake
Major Outcomes Considered
  • Performance of activities of activities of daily living (ADL)
  • Functional decline
  • Competence in preventive and restorative strategies for function
  • Use of physical restraints
  • Readmission rate
  • Quality of life
  • Morbidity and mortality

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Assessment Parameters

  • Comprehensive functional assessment of older adults includes independent performance of basic activities of daily living (ADLs), social activities, or instrumental activities of daily living (IADLs), the assistance needed to accomplish these tasks, and the sensory ability, cognition, and capacity to ambulate (Campbell et al., 2004 [Level I]; Doran et al., 2006 [Level VI]; Freedman, Martin, & Schoeni, 2002 [Level I]; Kane & Kane, 2000 [Level VI]; Katz et al., 1963 [Level I]; Lawton & Brody, 1969 [Level IV]; Lightbody & Baldwin, 2002 [Level VI]; McCusker, Kakuma, & Abrahamowicz, 2002 [Level I]; Tinetti & Ginter, 1988 [Level I]).
    • Basic ADLs (bathing, dressing, grooming, eating, continence, transferring)
    • IADLs (meal preparation, shopping, medication administration, housework, transportation, accounting)
    • Mobility (ambulation, pivoting)
  • 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 [Level I]; Pearson, 2000 [Level VI]).
  • The clinician should document baseline functional status and recent or progressive declines in function (Graf, 2006 [Level V]).
  • Function should be assessed over time to validate capacity, decline, or progress (Applegate, Blass, & Franklin, 1990 [Level IV]; Callahan et al., 2002 [Level VI]; Kane & Kane, 2000 [Level VI]).
  • Standard instruments selected to assess function should be efficient to administer and easy to interpret. They should provide useful practical information for clinicians and should be incorporated into routine history taking and daily assessments (Kane & Kane, 2000 [Level VI]; Kresevic et al., 1998 [Level VI]) (see the "Availability of Companion Documents" field for tools).
  • 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 (Counsell et al., 2000 [Level II]; Covinsky et al., 1998 [Level II]; Kresevic et al., 1998 [Level VI]; Landefeld et al., 1995 [Level II]).

Care Strategies

Strategies to Maximize Functional Status and to Prevent Decline

  • 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 (Kresevic & Holder, 1998 [Level VI]; Landefeld et al., 1995 [Level II]).
  • Educate older adults, family, and formal caregivers on the value of independent functioning and the consequences of functional decline (Graf, 2006 [Level V]; Kresevic & Holder, 1998 [Level VI]; Vass et al., 2005 [Level II]).
    • Physiological and psychological value of independent functioning.
    • Reversible functional decline associated with acute illness (Hirsch, 1990 [Level IV]; Sager & Rudberg, 1998 [Level II]).
    • Strategies to prevent functional decline: exercise, nutrition, pain management, and socialization (Kresevic & Holder 1998 [Level VI]; Landefeld et al., 1995 [Level II]; Siegler, Glick, & Lee, 2002 [Level VI]; Tucker, Molsberger, & Clark, 2004 [Level VI]).
    • Sources of assistance to manage decline.
  • Encourage activity including routine exercise, range of motion, and ambulation to maintain activity, flexibility, and function (Counsell et al., 2000 [Level II]; Landefeld et al., 1995 [Level II]; Pedersen & Saltin, 2006 [Level I]).
  • Minimize bed rest (Bates-Jensen et al., 2004 [Level V]; Covinsky et al., 1998 [Level II]; Kresevic & Holder, 1998 [Level VI]; Landefeld et al., 1995 [Level II]).
  • Explore alternatives to physical restraints use (see the National Guideline Clearinghouse [NGC] summary of the Hartford Institute for Geriatric Nursing guideline Physical restraints and side rails in acute and critical care settings) (Kresevic & Holder, 1998 [Level VI]; Covinsky et al., 1998 [Level II]).
  • Judiciously use medications, especially psychoactive medications, in geriatric dosages (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Reducing adverse drug events in older adults) (Inouye et al., 1998 [Level III]).
  • Assess and treat for pain (Covinsky et al., 1998 [Level II]).
  • Design environments with handrails, wide doorways, raised toilet seats, shower seats, enhanced lighting, low beds, and chairs of various types and height (Cunningham & Michael, 2004 [Level I]; Kresevic & Holder, 1998 [Level VI]).
  • Help individuals regain baseline function after acute illnesses by using exercise, physical or occupational therapy consultation, nutrition, and coaching (Conn et al., 2003 [Level I]; Covinsky et al., 1998 [Level II]; Engberg et al., 2002 [Level II]; Forbes, 2005 [Level VI]; Hodgkinson, Evans, & Wood, 2003 [Level I]; Kresevic et al., 1998 [Level VI]).

Strategies to Help Older Individuals Cope with Functional Decline

  • Help older adults and family members determine realistic functional capacity with interdisciplinary consultation (Kresevic & Holder, 1998 [Level VI]).
  • Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts (Graf, 2006 [Level V]).
  • Carefully document all intervention strategies and patient responses (Graf, 2006 [Level V]).
  • Provide information to caregivers on causes of functional decline related to acute and chronic conditions (Covinsky et al., 1998 [Level II]).
  • 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 [Level II]).
  • Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences (Edington et al., 2004 [Level II]; Landefeld et al., 1995 [Level II]).
  • Provide caregiver support and community services, such as home care, nursing, and physical and occupational therapy services to manage functional decline (Covinsky et al., 1998 [Level II]; Graf, 2006 [Level V]).

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Patients

  • Maintenance of safe level of activities of daily living (ADLs) and ambulation
  • Provision of necessary adaptations to maintain safety and independence including assistive devices and environmental adaptations
  • Attainment of highest quality of life despite functional level

Providers

  • Increased assessment, identification, and management of patients susceptible to or experiencing functional decline. Routine assessment of functional capacity despite level of care
  • Ongoing documentation and communication of capacity, interventions, goals, and outcomes
  • Competence in preventive and restorative strategies for function
  • Competence in assessing safe environments of care that foster safe independent function

Institution

  • System-wide incorporation of functional assessment into routine assessments
  • Reduced incidence and prevalence of functional decline
  • Decreased morbidity and mortality rates associated with functional decline
  • Reduction in the use of physical restraints, prolonged bed rest, Foley catheters
  • Decreased incidence of delirium
  • Increased prevalence of patients who leave hospital with baseline or improved functional status
  • Decreased readmission rate
  • Increased early utilization of rehabilitative services (occupational and physical therapy)
  • Provision of geriatric-sensitive physical care environments that facilitate safe, independent function such as caregiver educational efforts and walking programs
  • Provision of continued interdisciplinary assessments, care planning, and evaluation of care related to function
Potential Harms

Not stated

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Mobile Device Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Kresevic DM. Assessment of physical function. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 89-103.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (revised 2012)
Guideline Developer(s)
Hartford Institute for Geriatric Nursing - Academic Institution
Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Denise Kresevic, RN, PhD, GNP-BC, GCNS-BC, Nurse Researcher, Louis Stokes Cleveland VAMC, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Kresevic DM. Assessment of function. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 23-40.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Try This® - issue 2: Katz Index of Independence in Activities of Daily Living (ADL). New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in Portable Document Format (PDF) at the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.
  • Try This® - issue 23: The Lawton Instrumental Activities of Daily Living (IADL) Scale. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2013. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.
  • Try This® - issue 31: Reducing functional decline in older adults during hospitalization: a best practices approach. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF at the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

The ConsultGeriRN app for mobile devices is available through the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on May 30, 2003. The information was verified by the guideline developer on August 25, 2003. This guideline was updated by ECRI Institute on June 18, 2008. The updated information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 24, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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