NUR 352: health assessment & functional ability

what are the 3 types of health assessments to gather patient information

1. emergency assessment
2. comprehensive (head to toe) assessment
3. focused (abbreviated) assessment

what is an emergency assessment

- urgent/life threatening situation (priority = support vital functions ABC)
- prioritize collection on medical history (medical history that brought them to you - the why)
- rapid exam (very fast)

what is a comprehensive (head to toe) assessment

- detailed history and physical exam (assess all systems but doesn’t dive deep)
- new hospital admission/primary care visit/initial home care visit

what is a focused (abbreviated) assessment

- evaluate status of previous problems
- monitor for new problems
- onset of an identified problem
(deep dive into a particular system to evaluate whether a client has a particular problem)

how should a nurse approach health assessment

- not a “once and done” situation
- frequent rounding to gather patient information
- everything that you learned previously about each patient is considered in the light of new information

how is a nursing assessment different from a provider assessment

- a provider uses data collected from a health assessment to diagnose any medical conditions and determine treatment
- nursing assessments focus is treating the human response to actual or potential heath problems

what is functional health

- helps ID how health impacts self-care ability, quality of life, areas in need of improvement
- factors: psychological, social, cultural, economical, and physical

what questions might you ask for functional health (part of health history)

- relationships/support and presence of violence
- values/beliefs/spirituality
- self esteem/coping/stress management
- impairments
- personal habits including substance use
- environmental/occupational hazards
- mental health

what are the two types of ADLs

- basic activities of daily living (BADLs): related to personal care and mobility like bathing, brushing teeth, eating, dressing
- instrumental activities of daily living (IADLs): related to more complex skills that are essential to living in a community like paying bills, cooking, grocery shopping, laundry, accessing transportation

what is scope of functional ability

- the scope is a continuum from full function to disability → varies from person to person and with same person at different points in life

what are interactions between health and disability influenced by (scope of functional ability)

- developmental and biological
- current state of health
- psychological
- social cultural
- environmental
- socioeconomic

what does functional status refer to in older adults

refers to safe, effective performance of activities of daily living essential of independent living

what is the theory: Roper-Logan-Tierney model of nursing

- focus on health rather than illness and promotes care directed towards health promotion and wellness
- 12 ADL’s essential to life
- assessed on admission and then throughout care for level of dependence and independence

what are the 12 ADL’s essential to life according to the Roper-Logan-Tierney model of nursing

1. maintaining a safe environment
2. communication
3. breathing
4. eating and drinking
5. elimination
6. washing and dressing
7. controlling temperature
8. mobilization
9. working and playing
10. expressing sexuality
11. sleeping
12. death

why is functional ability important to nursing

- indicator of existence or severity of disease: may be first indication of something wrong
- signal the need for services
- monitor success of treatment/disease progression (measure)
- facilitate cost-effectiveness in the provision of care
- alterations occur as primary and secondary problems

what do alterations occur as in functional ability

- occurs as primary and secondary problems
→ primary: those in which the ability to perform a particular function never developed
→ secondary: occurs after functional ability has been obtained (basically represent a loss of functional ability like someone develops a brain tumor and lost sight or balance)

what are the three dimensions of concern related to an individual’s functional ability

- risk recognition
- functional assessment: tools
- planning and delivering appropriate care to the level of ability

what is risk recognition

- recognition is essential for early identification of functional deficits, which is linked to health outcomes

what are situations that increase risk for functional impairment

- developmental abnormalities
- trauma (physical or psychological)
- disease (acute or chronic)
- social and cultural factors
- advance age
- cognitive function
- mental health issues (depression)
- comorbidities (presence of 2 chronic diseases or more) and socioeconomic factors

what is functional assessment and indications

- comprehensive functional assessment is time sensitive; it is an interprofessional effort
- indications: children with delayed developmental milestones; adults with loss of functional abilities, change in mental status, or multiple health conditions, or the frail elderly in a community setting (should be part of routine care)

what are approaches to functional assessment

- self-reporting tools: provides information from patient’s perception (advantage: simple form, low cost, no equipment needed; disadvantage: personal perception, answers will vary person to person, phasing of question, haven’t performed task due to cultural beliefs, pride)
- performance based tools: involve actual observation, measuring with repetition, timed tasks. These are preferred to avoid potential for inaccurate measurement inherent with self-report. Same tool should be used for reevaluation (advantage: observed with objective measurements; disadvantage: time consuming)

what is meaningful measurement delivery of care

- needs to address the areas of dependency and difficulty
- dependency: amount of assistance needed to function (no assistance, partial assistance, total assistance)
- difficulty: if can perform measure amount of difficulty (no difficulty, some difficulty, unable to perform)

what is the goal of care delivery

to maintain optimal independent function and prevent functional decline
- reduce risk
- early detection and screening
- management with multidisciplinary interventions; these interventions depend on the underlying cause of impairment

what are interventions to reduce risk

- teach patients and families about factors associated with maintaining high level functional ability, including
→ well balanced nutrition
→ regular physical activity
→ routine health checkup
→ stress management
→ regular participation in meaningful activity
→ fall prevention measures
→ avoidance of tobacco and other substances associated with abuse
→ self care assistance for activities of daily living both basic and instrumental
→ if needed, teaching safe use of assistive device

what does alterations in functional ability include

- autism spectrum disorder
- parkinson disease
- rheumatoid arthritis
- cerebral vascular accident (stroke)

what is the MoCA screening tool

- montreal cognitive assessment was designed as a rapid screening instrument for mild cognitive dysfunction, assessing attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, orientation
- takes approximately 10 mins and total possible score is 30, a score of 26 or above is considered normal.
- key tasks: alternating trail making (connecting numbers and letters), drawing a 3D cube, drawing a clock set to "10 past 11," naming animals (lion, rhino, camel), and serial 7s.

what is the MMSE screening tool

- mini mental status exam assessing cognition
- 30 points that is 5 to 10 mins used to detect cognitive impairment, often associated with alzheimer and dementia
- a score of <23 typically suggest cognitive impairment but can vary
- test: orientation (time and place), registration (repeating three objects), attention/calculation (counting backward by 7s or spell world backward), language (naming objects, following a 3-stage command, reading, and writing), visuospatial (copying a drawing)

what is the TUG screening tool

- timed up and go which assesses mobility
- patient wear their regular footwear and can use walking aid if needed. Begin by having the patient sit back in a standard arm chair and identify a line 3 meters or 10 feet away on the floor and when you say go, have the patient stand up from the chair and walk to the line on the floor at normal pace, turn, and then walk back to the chair at normal pace and sit down
- examiner notes postural stability, gait, stride length, and sway
- an older adult who takes 12 seconds or more to complete the TUG is considered at risk for falling.

what is the Katz screening tool

- Katz index of independence in ADL
- assesses functional status as a measurement of client’s ability to perform activities of daily living independently
- six functions assessed: bathing, dressing, toileting, transferring, continence, and feeding
- individuals receive 1 point for independence and 0 points for dependence in each category. A score of 6 indicates full function. A score of 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

what is the PHQ9 screening tool

- patient health questionnaire-9
- multipurpose instrument for screening, diagnosing, monitoring and measuring severity of depression

what is the morse fall risk screening tool

- morse fall scale is a rapid and simple method of assessing a patient’s likelihood of falling consisting of 6 variables: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait/transferring, and mental status