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Overview

Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged to a nursing home setting (Fortinsky, Covinsky, Palmer, & Landefeld, 1999), increased morbidity and mortality, increased rehabilitation costs, and decreased functional recovery.  The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity and nonelective rehospitalizations (Gill et al., 2004).  

The promotion of function is a basic gerontological tenet, and functional status is a key determinant of quality of life for older adults (Boltz, Capezuti, Shabbat, & Hall, 2010).  Although the acute care setting, with its focus on correcting the admitting medical problem, typically prioritizes nursing tasks such as medication administration, coordination of care, and documentation over the promotion of function as a clinical outcome, there is growing awareness of the need to attend to the functional status of the hospitalized older adult (Nolan & Thomas, 2008).  Older adults themselves expect that an acute care stay will not result in functional decline but instead lead to the resumption of normal roles and activities posthospitalization (Boltz, Capezuti, Shabbat, & Hall, 2010).

Nursing Standard of Practice Protocol: Function-Focused Care (FFC) Interventions

Marie Boltz, Barbara Resnick, and Elizabeth Galik

Evidence-Based Content - Updated August 1, 2013

I. GOAL: The following protocol has been designed to help nurses collaborate with the interdisciplinary team to implement interventions that maximize the older adult’s functional abilities and performance. This protocol can be used in combination with the protocol Assessment of Physical Function.

II. OBJECTIVE: As stated in the Age-Related Changes in Health Protocol, to restore or maximize physical functioning, prevent or minimize decline in ADL function, and plan for transitions of care.

III. BACKGROUND
A. Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill et al., 2010).

B. Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999), increased mortality (Boyd et al., 2005; Rozzini et al, 2005), increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2008; Boyd et al., 2005; Gill et al., 2004; Volpato et al., 2007). The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity, and nonelective rehospitalizations (Gill et al., 2004).

C. Functional decline may result from the acute illness and can begin preadmission (Fortinsky et al., 1999) and continue after discharge (Sager et al., 1996). Baseline function serves as a useful benchmark when developing discharge goals (Covinsky et al., 2003; Fortinsky et al., 1999; Sager et al., 1996; Wakefield & Holman, 2007).

D. Patient risk factors for functional decline include prehospitalization functional loss; the presence of two or more comorbidities; taking five or more prescrip-
tion medications; having had a hospitalization or emergency room visit in the previous 12 months (McCusker et al., 2002); depression (Covinsky et al., 1997); impaired cognition, including delirium (Inouye et al., 1999; Narain et al., 1988); pain (Reid et al., 2005); nutritional problems; adverse medication effects (Graf, 2006); fear of falling (Boltz, Capezuti, & Shabbat, 2010); low self-efficacy and outcome expectations (McAuley et al., 2006; Resnick, 2002); and attitudes toward functional independence and views on hospitalization (Boyd, Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, & Hall, 2010; Brown et al., 2007).

E. Bed rest results in loss of muscle strength and lean muscle mass (Kortebein et al., 2007; Kortebein et al., 2008), decreased aerobic capacity (Kortebein et al., 2008), diminished pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper et al., 1988; Hoenig & Rubenstein, 1991). Care processes that curtail mobility such as the use of restraints and tethering devices (Boltz, Capezuti, & Shabbat, 2010; Graf, 2006; King, 2006) are associated with low mobility, higher rate of ADL decline (Brown et al, 2004; Zisberg et al., 2011), new institutionalization, and death (Brown et al., 2004).

F. Interdisciplinary rounds support promotion of function by addressing functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility (McVey et al., 1989).

G. Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz, Capezuti, & Shabbat, 2010; Resnick, 2004).

H. FFC educational intervention on medical–surgical units have shown improvements in knowledge and outcome expectations associated with function-
promoting care (Resnick et al., 2011).

IV. FUNCTION-FOCUSED CARE INTERVENTIONS

A. Hospital care systems and processes

1. Evaluation of leadership commitment to rehabilitative values (Boltz, Capezuti, & Shabbat, 2010; Resnick, 2004).
2. Interdisciplinary rounds that address functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan
for progressive mobility (McVey et al., 1989).
3. Well-defined roles, including areas of accountability for assessment and follow-through for function-promoting activities (Jacelon, 2004; Resnick
et al., 2011).
4. Method of evaluating communication of patient needs among staff (Boyd, Capezuti, & Shabbat, 2010).
5. Process of disseminating data (e.g., compliance with treatment plans and functional outcomes; Boyd, Capezuti, & Shabbat, 2010).

B. Policy and procedures to support function promotion

1. Protocols that minimize adverse effects of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative-hypnotic agents) contribute
to positive functional outcomes (Kleinpell, 2007).
2. Supporting policies: identification and storage of sensory (e.g., glasses, hearing aids/amplifiers) and mobility devices and other assistive devices (Boyd,
Capezuti, & Shabbat, 2010; St. Pierre, 1998).
3. Discharge policies that address the continuous plan for function promotion (Boyd, Capezuti, & Shabbat, 2010; Boyd, Capezuti, Shabbat, & Hall,
2010)

C. Physical design

1. Toilets, beds, and chairs at appropriate height to promote safe transfers and function (Capezuti et al., 2008).
2. Functional and accessible furniture and safe walking areas with relevant/interesting destination areas (Gulwadi & Calkins, 2008; Ulrich et al., 2008)
and with distance markers (Callen et al., 2004).
3. Adequate lighting, nonglare flooring, door levers, and hand rails (including in the patient room; Gulwadi & Calkins, 2008; Ulrich et al., 2008).
4. Large-print calendars and clocks to promote orientation (Kleinpell, 2007).
5. Control of ambient noise levels (Gabor et al., 2003).

D. Education of nursing staff, and other members of the interdisciplinary team (e.g., social work, physical therapy), regarding

1. the physiology, manifestations, and prevention of hospital-acquired deconditioning (Boyd, Capezuti, & Shabbat, 2010; Gillis et al., 2008; Resnick
et al., 2011; Weitzel & Robinson, 2004);
2. assessment of physical capability (Resnick, Cayo et al., 2009; Resnick et al., 2011);
3. rehabilitative techniques and use of adaptive equipment (Weitzel & Robinson, 2004; Resnick et al., 2011; Resnick, Cayo et al., 2009);
4. interdisciplinary collaboration (Resnick et al., 2011; Resnick, Cayo et al., 2009);
5. engagement in decision making (Boltz, Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, & Hall, 2010; Jacelon, 2004); and
6. communication that motivates are associated with a function-promoting philosophy (Boltz, Capezuti, & Shabbat, 2010; Gillis et al., 2008; Jacelon,
2004; Weitzel & Robinson, 2004).

E. Education of patients and families regarding FFC (Resnick, Cayo, et al., 2009), including the benefits of FFC, the safe use of equipment, and self-advocacy
(Boltz, Capezuti, Shabbat & Hall, 2010)

F. Clinical Assessment and interventions

1. Assessment of physical function and capability (baseline, at admission and daily) and cognition (at a minimum daily; Boltz, Capezuti, & Shabbat,
2010; Covinsky et al., 2003; Fortinsky et al., 1999; Sager et al., 1996; Wakefield & Holman, 2007).
2. Establishing functional goals based on assessments and communication with other members of the team and input from patients (Resnick, Cayo,
et al., 2009; Resnick et al., 2011; Resnick, Gruber-Baldini, et al., 2009; Resnick et al., 2007; Resnick & Simpson, 2003).
3. Social assessment: history, roles, values, living situation, and methods of coping (Boltz, Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, &
Hall, 2010).
4. Addressing risk factors that impact goal achievement (e. g., cognitive status, anemia, nutritional status, pain, fear of falling, fatigue, medications and
drug side effects such as somnolence) by the interdisciplinary team to optimize patient participation in functional and physical activity (Boltz et al.,
in press; Resnick, Cayo, et al., 2009; Resnick et al., 2011; Resnick, Gruber-Baldini, et al., 2009; Resnick et al., 2007; Resnick & Simpson, 2003).
5. Development of discharge plans that include carryover of functional interventions, and addressing the unique preferences and needs of the patient
(Nolan & Thomas, 2008).

V. EXPECTED OUTCOMES

A. Patients will

1. Be discharged, functioning at their maximum level.

B. Providers can demonstrate

1. Competence in assessing physical function and devloping an individualized plan to promote function, in collaboration with the patient and interdisciplinary team.
2. Physical and social environments that enable optimal physical function for older adults.
3. Individualized discharge plans.

C. Institution will experience

1. A reduction in incidence and prevalence of functional decline.
2. Reduction in the use of physical restraints, prolonged bed rest, Foley catheters.
3. Decreased incidence of delirium and other advserse events (pressure ulcers and falls).
4. An increase in prevalence of patients who leave hospital at their baseline or with improved functional status.
5. Physical environments that are safe and enabling.
6. Increased patient satisfaction.
7. Enhanced staff satisfaction and teamwork.

VI. RELEVANT PRACTICE GUIDELINES

Several resources are now available to guide adoption of evidence-based nursing interventions to enhance function in older adults.
1. Agency for Healthcare Research and Quality, National Guideline Clearinghouse; http://www.guideline.gov/
2. McGill University Health Centre. Research & Clinical Resources for Evidence Based Nursing (EBN); http://www.muhc-ebn.mcgill.ca/
3. National Quality Forum; http://www.qualityforum.org/Home.aspx
4. Registered Nurses Association of Ontario. Clinical Practice Guidelines Program; http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID
5. University of Iowa Hartford Center of Geriatric Nursing Excellence (HCGNE). Evidence-Based Practice Guidelines; http://www.nursing.uiowa.edu/hartford/
nurse/ebp.htm

Topics

Function-Focused Care (FFC) Interventions
Want to Know More
Transitional Care
Assessing Cognitive Function
Heart Failure: Early Recognition and Treatment
Advance Directives
Prevention of Catheter-Associated Urinary Tract Infection Prevention
Atypical Presentation
Delirium
Dementia
Depression
Elder Mistreatment and Abuse
Ethnogeriatrics and Cultural Competence for Nursing Practice
Falls
Frailty and its Implications for Care
Function
Medication
Family Caregiving
Hydration Management
Iatrogenesis
Sleep
Mealtime Difficulties
Age Related Changes
Nutrition in the Elderly
Oral Healthcare in Aging
Pain
Palliative Care
Physical Restraints
Pressure Ulcers and Skin Tears
Sensory Changes
Sexuality Issues in Aging
Substance Abuse
Healthcare Decision Making
Urinary Incontinence
Evidence-Based Practice
Critical Care
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