Comprehensive Physical Assessment

INDIANA UNIVERSITY SCHOOL OF NURSING

B344: Comprehensive Physical Assessment:

Functional and Environmental Assessment of the Older Adult

Overview: The student will interview an older adult to obtain information about their functional abilities and disabilities, as well as their environment for safety concerns. The goal of this assessment is to identify the subject’s strengths as well as limitations, so that specific recommendations can be formulated to optimize health and safety and reduce the risk of functional declines. Note that this is an interview only, and does not include a physical examination. Be sure to omit any of the HIPAA personal identifiers such as name, date of birth, address, social security number etc. Assure the subject that all information obtained will be kept confidential, shared only with the course instructor, and that it will contain no information that would allow them to be identified.

Introduction

As with the other assignments, begin by introducing the paper, and your subject in general terms. Include their age and gender, the type of residence they live in (house, apartment, assisted living, etc.) and date of assessment. APA states the introduction of a document does not warrant a header.

Functional Assessment

Obtain information for the three domains of a functional assessment: activities of daily living (ADL’s), instrumental activities of daily living (IADL’s), and mobility.

Activities of Daily Living (ADL’s)

Bathing.

Are they able to climb in and out of a tub? Are there concerns about this?

Do they use any assistive devices such as a grab bar in the tub or shower chair?

Do they require any assistance with bathing or washing their hair?

Dressing. Are there any difficulties with gross movements such as pulling on clothes, or fine motor movements, such as buttoning, or tying shoes? With reaching over the head, such as when brushing the hair?

Toileting. Are they independent or is assistance required?

Are any assistive devices used, such as a raised toilet seat, or bedside commode?

Do they have any trouble getting to the bathroom ‘in time’? Is sleep interrupted by having to use the bathroom? If so, how many times a night usually?

Eating/feeding self. Is there any difficulty with:

Chewing or swallowing?

Handling utensils?

Are any assistive devices used?

Do they have dentures? If so, do they fit well enough to not limit chewing/swallowing?

Do they usually eat alone?

In general do they feel they are getting enough to eat?

How would they rate their appetite (in general- such as fair, poor, good)

Are they on any special diet? If so, describe.

Have they experienced an unintended weight loss?

Are there foods they avoid because they do not care for them, or do not tolerate them?

Do they take vitamin or mineral supplements? Herbal remedies?

Are they taking any medications that specifically relate to dietary concerns? Examples are diuretics such as Lasix and potassium, oral anticoagulants such as Coumadin and vitamin K foods;

Sleep/Rest. How would they describe their sleep pattern?

Do they take naps on most days?

Do they feel they have adequate energy to perform their daily tasks?

If they awaken during the night, what usually causes this?

Stress/Coping. What are the main stressors in their life? How do they cope with these?

Interpersonal Relationships. What is their marital status?

Does anyone else live in their home? Who? What people are they in regular contact with? Are there persons who they can call on for assistance if needed? Do they have a community of friends they can regularly socialize with such as a church group or community center?

Instrumental ADL’s

Housekeeping. Are they able to perform:

Heavy tasks such as vacuuming or scrubbing the floor? If not, is there someone else who takes care of these?

Light tasks such as dusting, washing dishes, doing laundry?

Do they have a washer and drier in the home?

Grocery shopping. How do they obtain their groceries? Are there any difficulties getting to store and back, carrying bags, etc.?

Meal preparation. Any limitations in the ability to cook? Who prepares the majority of meals in the home?

Obtaining medications (getting prescriptions filled, getting OTC meds). Any difficulty getting to the drug store? Are there financial concerns about being able to afford meds?

Taking daily medications. How do they manage their daily medications? Do they use any system to help them determine if doses have been taken, or to help with remembering what is due to be taken when? Are there times when they forget to take their meds? Are there times when they do not take meds because they feel they are not needed or because they caused adverse effects?

Communication. Any difficulty or limitations: Speaking? Hearing? Do they wear hearing aids? If so, do they work well for the client? Does the client seem to hear your normal conversational level of voice? Are there any difficulty with writing and reading?

Money management. Do they take care of their routine bills?

Any difficulties getting to the bank or getting bills taken care of?

Do they feel they have adequate insurance or medical assistance to be able to obtain needed medical services?

Memory functioning. Are there any difficulties in remembering: Daily meds? Doctors’ appointments? Family occasions or holidays? Tasks to be done?

Driving/Using public transportation:Do they drive? If not, is there someone else who can drive them if they need to get somewhere? Is public transportation available to them?

Using the telephone. Do they have a cell phone or portable phone? Any difficulty dialing numbers (fine motor skills, or ability to see numbers)? Any difficulty with hearing a caller?

Mobility

Ambulation. Are there any difficulties or limitations: Getting out of bed? Getting up from a chair? Walking about the house? Getting to the bathroom?Any difficulty with stairs? Are there steps or stairs inside the home? If so, how many? Are there any outside steps to get to the house?distance can they ambulate without difficulty? (e.g.: 1 block, 3 blocks, etc.)Any problems with balance? Have they experienced any falls? If so, how many times? Any resulting injuries? If there have been falls, does the person think they were due to a balance problem, lack of muscle strength, dizziness or an environmental hazard? Are any assistive devices used for ambulation (cane, walker)?

Activities/Exercise. What types of exercise do they get on a routine day? What leisure activities or hobbies do they enjoy?

Finally, are there any areas that they feel they need assistance or support with that they are not already receiving?

Based on this functional assessment, what are the subject’s strengths? What limitations do they have? Based on these, what recommendations would you make to this person to improve or maintain functional abilities?

Environmental Assessment

General Environment

Do they feel safe in their home and in their neighborhood? Are there any close neighbors

they could call on for a problem?

Determine if the following safety devices are present in the home: handrails for stairs, adequate lighting, working smoke detectors, scatter rugs have non-skid backing, easily accessible telephones, and grab bars in the tub/shower. Any other safety devices or hazards you noticed?

(Note: you do not need to inspect the entire house; you can ask about those things that are not in easy view of the assessment location.)

Recommendations Are there any recommendations you would make to improve safety in general, or to reduce the risk for falls?

Conclusion

Functional and Environmental Assessment of the Older Adult Rubric
Topics Exceeds Standard (points) Meets Standard

(points)

Below Standard (points) Comments
Introductory Paragraph*

10 8 6
Functional Assessment*

1. ADL’s

2. Instrumental ADL’s

3. Mobility

30 25 20
Environmental Assessment*

1. General Assessment

2. Recommendation

30 25 20
Conclusion*

5 4 3
Writing Guidelines

25 23 21
Total Points

 
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