Comprehensive Study Notes: Functional Assessment, ADLs, Care Delivery, Safety, and Pharmacology

Exam Logistics and Schedule

• Final exam is accumulative and could cover material from Day 1 through the last lecture next Wednesday.
• Final exam weight: 30\% of the overall grade. Aim for your highest possible score rather than fixating on a single target number.
• Schedule details mentioned:
  • Time window for a class/slot: 2:30\,\text{PM} \text{ to } 4:30\,\text{PM} on Monday.
  • Room mentioned: 185 (Room 185).
• EAQs (End-of-Assessment or Electronic Assessment Questions) status:
  • Some EAQs still being completed; remaining items will be added later.
  • Previous terms had EAQs; expectation is that students complete them by now.
• Upcoming topics:
  • This week: PowerPoint slides for today on Functional Ability and Safety; they’re combined into one lecture this term.
  • Next week: Disaster planning will be discussed.
  • A reminder that the room layout may be adjusted (Room 185 noted).

ADLs, Functional Ability, and the Roper–Logan–Tawcett Model

• The discussion centers on Activities of Daily Living (ADLs) using the Roper–Logan–Tawcett framework (12 ADLs).
• The speaker notes one ADL often surprising to students (likely a misreading of “dining” vs. another activity).
• Key purpose: Functional assessment to determine what tasks a patient can perform independently during a stay in any care setting.
• Functional assessment components:
  • Self-report tool: Patient reports their own perceived level of functioning across ADLs.
  • Performance-based tool: Clinician directly observes and records performance (e.g., walking, bending, dressing, toileting, feeding).
• When is a functional assessment required? Criteria include:
  • Loss of functional ability observable (one or more ADLs no longer independently performed).
  • Change in mental status affecting functioning.
  • Multiple comorbidities that impact function (comorbidities listed in the patient’s record).
  • Frail elderly individuals living in the community who may need support.
• Documentation and care planning:
  • RN typically completes the initial care plan; if no RN is available, other staff contribute to the care plan.
  • In Epic (electronic system), care plans exist for weekly charting of addressed ADLs; progress can be marked as completed or in progress.
  • At discharge, goals may be unmet or changed; ongoing care planning continues as needed.
• Risk recognition in interviews:
  • Discuss risk factors and risky behaviors.
  • Emphasize prevention in the health care system and understand reimbursement implications (e.g., hospital pays for an avoidable hospital-acquired condition such as a bed sore if not prevented; similar logic applies to HAIs and CAUTIs).
  • Emphasize the role of nurses in prevention and risk assessment.
• Community health and out-of-hospital care delivery:
  • Types of out-of-hospital care: Community-based health services and home health care (rehabilitation is related but distinct).
  • Community-based health nurses focus on population health, education, screenings (blood pressure, BMI, diabetes management), immunization days, and referrals to community resources.
  • Home health care nurses provide direct skilled care (e.g., IV antibiotics, tracheostomy care, ventilator support, G-tube feeding) and are concerned with the patient’s home environment and family support.
  • Initial assessments determine if home safety and environment can support the patient post-discharge; unsuitable homes may require alternative placements (e.g., long-term care facility) until conditions improve.
• Rehabilitation and the concepts of impairment vs disability:
  • Rehabilitation aims to restore function or maximize adaptation to a new normal after impairment or disability.
  • Impairment: A disturbance in functioning (e.g., broken hip, stroke with left-sided paralysis).
  • Disability: A measurable loss of function, categorized from Level 1 (slight) to Level 4 (total dependence). See details below.
  • New normal: After health events (burns, stroke, MI, amputation), the patient’s baseline may shift; rehabilitation should support coping with the new normal.
  • Goals of rehabilitation: Prevent complications and secondary disabilities; help patients cope and adapt to changes.
• Levels of disability (ROPER framework): Level 1 to Level 4, each with varying degrees of limitation in ADLs. Common themes include:
  • Level 1: Slight limitation; patient can still work/participate with minor adaptations.
  • Level 2: Moderate limitation; may require modifications to work or activity (e.g., standing desk, additional rest).
  • Level 3: Severe limitation; unable to work; significant assistance may be needed.
  • Level 4: Total disability; complete dependence on others for ADLs.
• Long-term care and living arrangements (per page 20 in the text):
  • Domiciliary care: Basic room and supervision; not a full medical facility.
  • Personal care homes: Independent living with access to medications and treatments under supervision; may provide several assistance services.
  • Intermediate care: 24-hour custodial care with staff support; not a hospital setting.
  • Skilled care: 24/7 skilled nursing with physician supervision; necessary for complex medical needs (RN, PT, speech therapy, etc.).
• Potential effects of relocation to long-term care facilities:
  • Institutionalization can lead to depersonalization, indignity, redefinition of normal, possible regression, and social withdrawal.
  • Prevention of these effects involves engagement in activities, social interaction, and ongoing support from staff.
• Parkinson’s disease: Functional loss due to neurological changes (dopamine-producing cell loss) causing motor disability.
  • Four primary symptoms: tremors, rigidity, bradykinesia, impaired balance/coordination with a tendency for a shuffling gait.

Safety, Errors, and Culture of Safety

• Types of errors to be aware of:
  • Diagnostic errors: Incorrect or missed diagnosis; failure to diagnose when indicated.
  • Treatment errors: Errors in medication administration or other treatment steps (e.g., incorrect medication or dose).
  • Preventative (near-miss) errors: Near misses where a problem was prevented; still a preventable error requiring remediation and education.
  • Communication failure: Inadequate handoff or failure to communicate critical patient information between staff.
• Active vs latent errors (pencil analogy):
  • Active errors occur at the point of care (sharp end of the pencil; the provider actively causes the error).
  • Latent errors are hidden system-level factors that can contribute to errors (blunt end of the pencil).
• Culture of safety principles:
  • Teamwork is essential to achieve high-quality care.
  • When errors occur, the focus should be on fixing the problem, not punishing individuals; accountability remains crucial.
  • Self-reporting and non-punitive reporting of errors support ongoing improvement.
• Medication safety and rights (practical reminders):
  • Five rights of medication administration: right patient, right drug, right dose, right route, right time.
  • Additional considerations include right documentation, right to refuse, and monitoring effectiveness/effects of the medication.
  • Near misses still constitute medication errors and should be reported for learning and prevention.
• Common medications discussed and nursing considerations:
  • Zolpidem (Ambien): Hypnotic/sedative for sleep; given at night; educate about taking on an appropriate schedule and with regard to meals (empty vs full stomach affects onset).
  • Carbidopa-levodopa (Sinemet): Dopaminergic therapy for Parkinson’s and restless leg syndrome; monitor for orthostatic changes and hypotension; avoid rapid position changes.
  • Amantadine (Similgine/Symmetral) or amantadine variants: Dopamine-related effects; antiviral origin; can cause CNS effects (confusion, hallucinations) and other adverse effects; monitor mental status and liver function.
  • Monitoring and assessment priorities for meds treating disease states include CNS status, hemodynamics (BP), liver function, and therapeutic response.
  • Sildenafil (Viagra): PDE-5 inhibitor; used for pulmonary arterial hypertension and erectile dysfunction; contraindicated with nitrates due to additive vasodilation and risk of severe hypotension; monitor for dizziness, low BP. If patient is on nitrates, avoid co-prescription.
  • Warfarin (Coumadin): Vitamin K antagonist; anticoagulant effect monitored by INR; target INR typically between 2.0 and 3.0 for many indications; antidote is Vitamin K; bleeding risk requires monitoring and dose adjustment.
  • Enoxaparin (Lovenox): Low molecular weight heparin; subcutaneous administration; prevents DVT; does not require routine blood level monitoring; antidote is Protamine sulfate; watch for hematomas and signs of bleeding.
  • INR monitoring and therapeutic goals: INR target range is commonly 2.0\text{-}3.0 depending on indication; factor in patient-specific risk.
• Practical patient safety reminders with these meds:
  • Always confirm timing and meals for sleep meds like zolpidem to ensure effectiveness.
  • Educate patients on orthostatic precautions with PD meds like Sinemet and amantadine.
  • Be vigilant for cognitive or behavioral changes with dopaminergic agents (risk of confusion or psychosis).
  • When prescribing sildenafil, ensure nitrates are not concurrently prescribed; review patient’s cardiac medications and BP.
  • For anticoagulants, ensure regular INR checks, document all dosing, and have a plan for antidotes if bleeding occurs.

Additional Pedagogical and Contextual Points

• The instructor stresses not to take lightly the content that seems lighter week-to-week, because final assessment could cover any material from all lectures.
• The discussion includes real-world implications: hospital payment structures tied to prevention (e.g., bedsores and HAIs), which underscores the importance of proactive nursing care.
• The importance of prior and ongoing education for providers and students, including documentation and communication, is emphasized to prevent errors and improve patient outcomes.
• A few terms and references mentioned for deeper study:
  • Giddings staging (refer to Giddings book; pages 429–430) for patient case references.
  • Outlining the concept of “new normal” in post-illness functioning and the redefinition of normal for patients.
  • The role of community health nurses in improving population health (aggregates) through education and screening in community settings.

References and Reminders

• Review pages 429–430 in the Giddings textbook for patient cases and staging details.
• Be prepared to discuss: (a) functional assessment criteria, (b) ADLs within the Roper–Logan–Tawcett model, (c) long-term care levels, (d) rehabilitation concepts (impairment vs disability), and (e) medication safety practices and antidotes.
• Clarify any ambiguous items (e.g., exact names of the 12 ADLs in your course materials) with your instructor or course resources to ensure alignment with your curriculum.