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Personalizing self-care
Personalizing Self-Care Knowing where the patient fits on this scale can help you avoid unrealistic expectations.
SHIRLEY S. TRAVIS Patient's ability to bathe, dress, toilet and feed himself, transfer from one place to another, and stay continent can make the crucial difference between remaining at home and being admitted to a nursing home for long-term care. Is it any wonder that basic self-care is the focal point of long-term care placement decisions?
A
T h e ADL Index Comes Full Circle
The first attempt to classify patients by functional status rather than medical diagnoses dates back to the mid 1950s. A research group led by Sidney Katz constructed the "Index of Independence in Activities of Daily living," dubbed the "Index of ADL"(I). (See "Rating Functional Ability'at right.) The index provided the first way to quantitatively measure the progressive loss of ADL abilities as well as the return to independence in response to rehabilitation. The Index of ADL assigns a patient to one of six functional levels.. I have adapted the Index by assigning numbers ranging from 0 for independent Shirley S. Travis, RN, PhD, is ~/n associate professor of family and child development at the Virginia Polytechnic Institute and State University, Blacksburg, VA.
72 Geriatric Nursing March/April 1990
to 6 for totally dependent, based on the patient's abilities in bathing, dressing, toileting, transferring, continence, and feeding himself. In the index, feeding, continence, and transferring are considered to reflect simple biological functioning(2). By contrast, bathing, dressing, and toileting involve not only locomoter and neurological functioning but are also influenced by learning and culture(2). Over the years, Katz's research
RATING FUNCTIONAL ABILITY(2) Level O: Independent Level 1: Dependent bathing Level 2: Oependent bathing and dressing Level 3: Dependent bathing, dressing, and totleting Level 4: Dependent bathing, dressing, toileting, and transferring Level 5: Dependent bathing, dressing, toileting, transferring, and maintaining continence Level 6: Dependent bathing, dressing, toileting, transferring, maintaining continence, and feeding
teams have matched rehabilitation of elders to their scores on the index's hierarchy of ADLs. Some patients do not fit the hierarchy, however. In addition, the problem with a two-category (dependent-independent) rating scale is that the independent range of behaviors is very narrowly defined. With continence, for example, the patient must be in control of urination and bowel movements. All other behaviors, including occasional "accidents," are classified as dependent. It.is the task of the professional nurse to determine if the cause of the divergent pattern, for example, incontinence, is correctable. • • Although not a perfect predictor of patterns of functional decline and recovery, the index of ADL has reported levels of agreement ranging from 86 percent to 64 percent in certain frail long-term-care populations(2-4). Functional ability in elders has become Synonymous with ADL ability. To some extent, t'unctional ability usually is measured on a version.of Katz's original work(5). Using a framework such as Katz's index is especially helpful in planning the frequency and type of assistance a patient needs. Those who need help with more
complex functions, such as bathing and dressing, generally need help at certain isolated times during the day; those at greater levels of dependency need help more often.
Systematic Care Planning Approaching self-care deficit diagnoses with a framework in mind provides ready-made outcome criteria for your long-term plan of care. The inherent order of self-care deficits helps you know what to expect and how to plan for it: A patient who is totally dependent in all six ADL areas, but has the potential for recovering some ADL function, is more likely to begin to feed himself before he can bathe or dress without assistance. The following case demonstrates how acute-care nurses can use functional assessment data to begin a treatment plan that can follow the patient into post-hospital care.
Time Out for Healing Rita Ward, 82 years old, had been admitted to the hospital many times because of chronic gastrointestinal problems. Early one morning, Ms. Ward came to the emergency room coughing and short of breath. She complained of difficulty breathing at night for the past week and was expectorating thick, yellow sputum. She was admitted with medical diagnoses of congestive heart failure and chronic atrial fibrillation. Ms. Ward was no stranger to the nurses. They all knew her as a "feisty" and determined woman who had always worked hard to get out of the hospital and back home. This time, though, profound dyspnea and fatigue had reduced her independence strikingly. On admission, she was at functional level 6 on the Katz index. It's not unusual for the staffs and the patient's ideas about recovering ADL function to differ. In Ms. Ward's case, the staffplanned to help her back to functional level 2 (dependent in bathing and dressing), then to discharge her With a referral to a home health agency for help with personal care during her post-hospital recuperation.
The nurses agreed that Ms. Ward had reached the point in her life where she would need intermittent, long-term assistance with at least some aspects of personal care if she expected to remain at home. Ms. Ward had her own ideas about what to expect. The first morning, she got up and wore herselfout trying to bathe and dress before her physician arrived. Although the nurses wanted her on bed rest for 24 hours, Ms. Ward refused to use the bedside commode and insisted on going to the bathroom herself. It took them two days to convince her that they were not trying to "make her an invalid" or "put her in a nursing home."
bladder control program in place for him. Strategies to help Mr. Sawyer avoid "accidents" of incontinence became a major part of the nursing plan. In each shift report, the care plan was evaluated, and any necessary changes were implemented immediately. With the staffs interventions, Mr. Sawyer was able to remain continent and feed himself for about three weeks. One evening, he began to deteriorate rapidly. Although-every, one, including Mr. Sawyer, was prepared for his death, the grief was intense for the nurses who'd worked so closely with him to give him the quality of death he wanted.
Room for Flexibility
A patient recovering ADL function is more likely to be able to feed himself before he can bathe or dress without assistance. Once Ms. Ward understood the rationale behind the nurses" plan for gradual recovery of ADL independence, her care progressed smoothly.
Quality of Death Of course, not every long-term patient can recover ADL function. Mike Sawyer was 90 years old when he was transferred from the hospital to the nursing home with cancer of the pancreas. On admission, he was at functional level 4 on the Katz index. Mr. Sawyer knew he was dying and asked only that the nurses "'take care of me while I die." Mr. Sawyer wanted to remain continent and feed himself as long as possible. So the nursing staff focused their energy on helping him retain those two ADL functions (a theoretically sound decision based on the hierarchy of ADL). Mr. Sawyer's daily treatments, visiting time, and other activities were paced so that he would have the energy to feed himself and the appetite to eat. The nurses put a rigid bowel and
It makes no theoretical or practical sense to expect a patient who needs to be spoon fed to dress himself. Nor does it make sense to stand back and allow any superficial goals of the unit (efficient execution of routines) or of the patient (looking nice for the physician) circumvent theoretically sound strategies for recovering ADL function. Keeping in mind the natural order of ADL functioning can make your care plan more appropriate for the situation. Reimbursement at the national level seems to be moving toward basing payment on outcomes of care and not simply on process, or what was done to the patient. An outcome reimbursement system shifts the spotlight onto nurses to articulate exactly how interventions for self-care deficits actually help maintain or improve a patient's functioning. A functional assessment system can help us document the outcome of care.
References I. Staff of the Benjamin Rose Hospital, Cleveland. OH. Mulfidisciplinary sludies of illness in aged persons. A new classification of functional status in activities of daily living. J.Chronic Dis. 9:55-62. Jan. 1959. 2. Katz, S., and others. Studies of illness in the aged. The index ofADL. JAMA 183:914-919, Sept. 21, 1963. 3. Katz, S,, and others. Progress in the development of the index of ADL. Gerontologist 10:20-30, Spring 1970. 4. Travis, S. S., and McAuley, W. J. Deviance from the ADL hierarchy in a long term care population. Gerontologist 25:26, Oct. 1985. 5. German, P. S. Measuring functional disability in the older population. Am.J.Public llealth 71: I 1971199, Nov. 1981.
Geriatric Nursing
M a r c h / A p r i l 1990 7 3
SHIRLEY S. TRAVIS Patient's ability to bathe, dress, toilet and feed himself, transfer from one place to another, and stay continent can make the crucial difference between remaining at home and being admitted to a nursing home for long-term care. Is it any wonder that basic self-care is the focal point of long-term care placement decisions?
A
T h e ADL Index Comes Full Circle
The first attempt to classify patients by functional status rather than medical diagnoses dates back to the mid 1950s. A research group led by Sidney Katz constructed the "Index of Independence in Activities of Daily living," dubbed the "Index of ADL"(I). (See "Rating Functional Ability'at right.) The index provided the first way to quantitatively measure the progressive loss of ADL abilities as well as the return to independence in response to rehabilitation. The Index of ADL assigns a patient to one of six functional levels.. I have adapted the Index by assigning numbers ranging from 0 for independent Shirley S. Travis, RN, PhD, is ~/n associate professor of family and child development at the Virginia Polytechnic Institute and State University, Blacksburg, VA.
72 Geriatric Nursing March/April 1990
to 6 for totally dependent, based on the patient's abilities in bathing, dressing, toileting, transferring, continence, and feeding himself. In the index, feeding, continence, and transferring are considered to reflect simple biological functioning(2). By contrast, bathing, dressing, and toileting involve not only locomoter and neurological functioning but are also influenced by learning and culture(2). Over the years, Katz's research
RATING FUNCTIONAL ABILITY(2) Level O: Independent Level 1: Dependent bathing Level 2: Oependent bathing and dressing Level 3: Dependent bathing, dressing, and totleting Level 4: Dependent bathing, dressing, toileting, and transferring Level 5: Dependent bathing, dressing, toileting, transferring, and maintaining continence Level 6: Dependent bathing, dressing, toileting, transferring, maintaining continence, and feeding
teams have matched rehabilitation of elders to their scores on the index's hierarchy of ADLs. Some patients do not fit the hierarchy, however. In addition, the problem with a two-category (dependent-independent) rating scale is that the independent range of behaviors is very narrowly defined. With continence, for example, the patient must be in control of urination and bowel movements. All other behaviors, including occasional "accidents," are classified as dependent. It.is the task of the professional nurse to determine if the cause of the divergent pattern, for example, incontinence, is correctable. • • Although not a perfect predictor of patterns of functional decline and recovery, the index of ADL has reported levels of agreement ranging from 86 percent to 64 percent in certain frail long-term-care populations(2-4). Functional ability in elders has become Synonymous with ADL ability. To some extent, t'unctional ability usually is measured on a version.of Katz's original work(5). Using a framework such as Katz's index is especially helpful in planning the frequency and type of assistance a patient needs. Those who need help with more
complex functions, such as bathing and dressing, generally need help at certain isolated times during the day; those at greater levels of dependency need help more often.
Systematic Care Planning Approaching self-care deficit diagnoses with a framework in mind provides ready-made outcome criteria for your long-term plan of care. The inherent order of self-care deficits helps you know what to expect and how to plan for it: A patient who is totally dependent in all six ADL areas, but has the potential for recovering some ADL function, is more likely to begin to feed himself before he can bathe or dress without assistance. The following case demonstrates how acute-care nurses can use functional assessment data to begin a treatment plan that can follow the patient into post-hospital care.
Time Out for Healing Rita Ward, 82 years old, had been admitted to the hospital many times because of chronic gastrointestinal problems. Early one morning, Ms. Ward came to the emergency room coughing and short of breath. She complained of difficulty breathing at night for the past week and was expectorating thick, yellow sputum. She was admitted with medical diagnoses of congestive heart failure and chronic atrial fibrillation. Ms. Ward was no stranger to the nurses. They all knew her as a "feisty" and determined woman who had always worked hard to get out of the hospital and back home. This time, though, profound dyspnea and fatigue had reduced her independence strikingly. On admission, she was at functional level 6 on the Katz index. It's not unusual for the staffs and the patient's ideas about recovering ADL function to differ. In Ms. Ward's case, the staffplanned to help her back to functional level 2 (dependent in bathing and dressing), then to discharge her With a referral to a home health agency for help with personal care during her post-hospital recuperation.
The nurses agreed that Ms. Ward had reached the point in her life where she would need intermittent, long-term assistance with at least some aspects of personal care if she expected to remain at home. Ms. Ward had her own ideas about what to expect. The first morning, she got up and wore herselfout trying to bathe and dress before her physician arrived. Although the nurses wanted her on bed rest for 24 hours, Ms. Ward refused to use the bedside commode and insisted on going to the bathroom herself. It took them two days to convince her that they were not trying to "make her an invalid" or "put her in a nursing home."
bladder control program in place for him. Strategies to help Mr. Sawyer avoid "accidents" of incontinence became a major part of the nursing plan. In each shift report, the care plan was evaluated, and any necessary changes were implemented immediately. With the staffs interventions, Mr. Sawyer was able to remain continent and feed himself for about three weeks. One evening, he began to deteriorate rapidly. Although-every, one, including Mr. Sawyer, was prepared for his death, the grief was intense for the nurses who'd worked so closely with him to give him the quality of death he wanted.
Room for Flexibility
A patient recovering ADL function is more likely to be able to feed himself before he can bathe or dress without assistance. Once Ms. Ward understood the rationale behind the nurses" plan for gradual recovery of ADL independence, her care progressed smoothly.
Quality of Death Of course, not every long-term patient can recover ADL function. Mike Sawyer was 90 years old when he was transferred from the hospital to the nursing home with cancer of the pancreas. On admission, he was at functional level 4 on the Katz index. Mr. Sawyer knew he was dying and asked only that the nurses "'take care of me while I die." Mr. Sawyer wanted to remain continent and feed himself as long as possible. So the nursing staff focused their energy on helping him retain those two ADL functions (a theoretically sound decision based on the hierarchy of ADL). Mr. Sawyer's daily treatments, visiting time, and other activities were paced so that he would have the energy to feed himself and the appetite to eat. The nurses put a rigid bowel and
It makes no theoretical or practical sense to expect a patient who needs to be spoon fed to dress himself. Nor does it make sense to stand back and allow any superficial goals of the unit (efficient execution of routines) or of the patient (looking nice for the physician) circumvent theoretically sound strategies for recovering ADL function. Keeping in mind the natural order of ADL functioning can make your care plan more appropriate for the situation. Reimbursement at the national level seems to be moving toward basing payment on outcomes of care and not simply on process, or what was done to the patient. An outcome reimbursement system shifts the spotlight onto nurses to articulate exactly how interventions for self-care deficits actually help maintain or improve a patient's functioning. A functional assessment system can help us document the outcome of care.
References I. Staff of the Benjamin Rose Hospital, Cleveland. OH. Mulfidisciplinary sludies of illness in aged persons. A new classification of functional status in activities of daily living. J.Chronic Dis. 9:55-62. Jan. 1959. 2. Katz, S., and others. Studies of illness in the aged. The index ofADL. JAMA 183:914-919, Sept. 21, 1963. 3. Katz, S,, and others. Progress in the development of the index of ADL. Gerontologist 10:20-30, Spring 1970. 4. Travis, S. S., and McAuley, W. J. Deviance from the ADL hierarchy in a long term care population. Gerontologist 25:26, Oct. 1985. 5. German, P. S. Measuring functional disability in the older population. Am.J.Public llealth 71: I 1971199, Nov. 1981.
Geriatric Nursing
M a r c h / A p r i l 1990 7 3