ASSESSMENT OF THE FRAIL ELDERLY CLIENT

Aging involves an overall general decline in tissues throughout the body. This decline reaches about 50% by the time a
person is age 80 or older. However, decline in tissue mass does not necessarily correlate with functional decline.

Body systems that are affected by functional changes related to aging:

A. Skin, hair, and nails:

 Gradual replacement of elastic collagen in skin with more fibrous tissue and the loss of subcutaneous tissue.
 Scalp, axillary, and pubic hair gradually becomes thinner and coarser. Loss of hair pigment is the cause of
graying.
 Toenails usually thicken, but fingernails may become thin and split. They may also appear yellowish and dull.

B. Eyes and vision:

 Decreased tear production by the lacrimal glands results in dry eyes.
 Some older adults also experience excessive tearing.
 The lens loses elasticity; decreased ability to change shape (presbyopia).
 Cataracts most commonly affect people after age 55.
 With age, there is an overall decrease in the size of the pupil and its ability to dilate in the dark.

C. Ears and hearing:

 Structural changes in the outer ear begin in middle adulthood.
 The earlobes elongate, and the pinna increases in length and width. The hairs become coarser.
 Cerumen production decreases, leading to dryness and the increased tendency toward impaction.
 Presbycusis or hearing loss occurs.

D. Head and neck:

 Facial wrinkles are prominent.
 Cervical curvature may increase due to kyphosis of the spine.
 Dowager’s hump may occur.

E. Mouth and throat:

 Periodontal disease, swallowing abnormalities, and dry mouth contribute to nutritional problems.
 The major cause of xerostomia (dry mouth) in the elderly is from using medications that have anticholinergic
effects (see Display 30-2).

F. Nose and sinuses:

 Olfactory function gradually decreases with aging and may lead to a decreased ability to detect odors.
 Allergic rhinitis, vasomotor rhinitis, and infectious sinusitis are common problems in the elderly.

G. Thorax and lungs:

 The decrease of collagen and elastin associated with aging causes the lungs to recoil less during expiration. This
increases the energy needed for breathing and requires the active use of accessory muscles.

H. Heart and blood vessels:

 Heart failure is the leading cause of hospitalization, and coronary artery disease is the leading cause of death in
the elderly.

I. Breasts:
 The aged breasts, particularly in women, are often described as pendulous. This is because fat and elastic tissue
decreases and the existing tissue becomes more fibrotic.

J. Abdomen:
 With advancing age, abdominal structures undergo changes in size and function.

K. Genitalia:
 Women:
o Because reproductive and breast tissues depend on estrogen for growth, many atrophic changes begin
in women at menopause.
  Men:
o The decline in testosterone production brings about similar atrophic changes in men (penis and testes
size decreases, scrotum hangs lower).

L. Anus, rectum, and prostate:

 Although constipation is not a normal process of aging, factors relating to the aging process may contribute to it.
 Lower gastrointestinal (GI) bleeding must be investigated and must always be suspected when an older person is
anemic or complains of weakness and fatigue.
 BPH is the benign growth of the prostate from exposure to androgen hormones. It occurs in 80% of men over
age 70.

M. Musculoskeletal system:
 The structural changes of the musculoskeletal system illustrate very clearly how difficult it is to differentiate
physiologic changes of aging from those of disease or disuse.
 Bone loss, muscle weakness, joint disease may occur.

N. Nervous system:
 Starting in early adulthood, a predicted loss of several thousand neurons a day occurs. The brain shrinks, the
sulci widen, and neurotransmitter levels change.
 Discuss gait and mental and emotional status related to aging.

Physical Examination

There is often a fine line between deterioration of function from aging and deterioration from disease. For this reason, it
is crucial to integrate the subjective, functional, and physical assessments. The significance of a physical finding is often
determined by the effect it has on the person’s level of comfort and ability to function. A medical pathology should be
suspected whenever any physical or functional change has occurred suddenly (days to weeks).

Preparing the Client

Most importantly, the examiner must take care to approach the frail elderly client without assumptions with regard to
mental status or physical ability. It is essential that the frail elderly person be approached as an individual, that
adjustments be made to accommodate the client’s specific functional limitations, and that the nurse be sensitive to the
client’s need for privacy as well as his or her wishes for caregiver to remain in the room during all or parts of the
assessment.

Some modifications and techniques appropriate for an examination of the frail elderly person include:
 Keep the temperature of the room warmer than may be comfortable for younger adults.
 Eliminate background noise as much as possible.
 When interacting with an elderly client, remember that it may be more acceptable to be more formal than
informal. For example, address the client by first name only if the client specifically requests that you do so.
 Keep your voice volume down even if you anticipate the client has difficulty hearing. Speaking clearly and at a
moderate pace is more beneficial in cases of hearing loss. Remember to face the client when speaking with him
or her.
 Do not assume that the client cannot answer questions if he or she has a cognitive impairment. However, if the
impairment has significantly impaired function or verbal expression, give only one-step directions and avoid
questions that require two responses. The cognitively impaired elderly person with few remaining verbal
abilities may have no or only minimal loss of the ability to comprehend non-verbal cues.
 If you need to question caregivers or collateral sources to validate or clarify information, avoid consulting them
in the presence of the client.
 Elderly people with physical disabilities may need assistance with dressing and with parts of the examination.
Allow additional time in deference to the client’s need for independence as well as your need to know how
much the client can do independently.

Equipment

In addition to the equipment needed for performing a complete adult physical examination, the following items will be
needed for assessing the functional capacity of the frail elderly adult:
 Newspaper or book and lamp light for vision testing
 Lemon slice or mint for sense of smell test
 Pudding or food of pudding consistency and spoon for swallowing examination. A teacup may also be used
  Food and fluid diary sheets or forms
 Two or three pillows for client comfort and positioning
 Straight-backed chair for “Get Up and Go” test

Physical Assessment

Skin and Hair

 Inspect and palpate skin lesions. Wear gloves when palpating lesions. Note whether lesions are flat or raised,
palpable or non-palpable. Also note odor, size, and exudates, if any.
 Normal findings include:
o Lentigenes / Liver spots: hyperpigmentation in sun-exposed areas appear as brown, pigmented, round
or rectangular patches.
o Venous lakes: reddish vascular lesions on ears or other facial areas resulting from dilation of small, red
blood vessels.
o Skin tags: acrochordons, flesh-colored pedunculated lesions.
o Seborrheic keratoses: tan, brown, or reddish, flat lesions commonly found on fair-skinned person in
sun-exposed areas.
o Cherry angiomas: small, round, red spots.
o Senile purpura: vivid purple patches (lesion should not blanch to touch)
 Note color, texture, integrity, and moisture of skin and sensitivity to heat or cold (it should be somewhat
transparent, pale, skin with an overall decrease in body hair on lower extremities is normal. Dry skin is common;
skin may wrinkle and dent when pinched).
 Inspect and palpate hair and scalp (thinning and graying of scalp, axillary, and pubic hair are normal; some
women may have mild hair growth on upper lip).

Head and Neck

 Inspect head and neck for symmetry and movement. Observe facial expression.
o Normal findings include:
 Atrophy of face and neck muscles
 Reduced ROM of head and neck
 Shortening of neck due to vertebral degeneration and development of “buffalo hump” at top of
cervical vertebrae

Mouth and Throat

 Inspect the gums and buccal mucosa for color and consistency (decreased salivary gland secretion is commonly
seen in the elderly client; gums and mucosa should be pink and without swelling, bleeding, or lesions).
 If the client is wearing dentures, inspect them for fit. Then ask the client to remove for the rest of the oral
examination (resorption of gum ridge commonly results in poorly fitting dentures).
 Examine the tongue. Observe symmetry and size (the tongue should be pink and moist).
 Observe the client swallowing food or fluids (a mild decrease in swallowing ability is normal).
 Depress the posterior third of the tongue, and note gag reflex (gag reflex is slightly sluggish in some older
adults).

Nose and Sinuses

 Inspect the nose for color and consistency (nose and nasal passages are not inflamed , and skin and mucous
membranes are intact; nose may seem more prominent on face because of loss of subcutaneous fat).
 Evaluate the sense of smell. Have the client close the eyes and smell a common substance, such as mint, lemon,
or soap (client has slightly diminished sense of smell and ability to detect odors).
 Test nasal patency by asking the client to breathe while blocking one nostril at a time (client can breathe with
reasonable ease).
 Palpate the frontal and maxillary sinuses for consistency and to elicit possible pain (area is free of lesions and
pain).

Eyes and Vision

 Inspect eyes, eyelids, eyelashes, and conjunctiva. Also observe eye and conjunctiva for dryness, redness, tearing,
or increased sensitivity to light and wind (the skin around the eyes becomes thin, and wrinkles appear normally
with age; eyelids close easily, and eyelashes turn outward; client may have some dryness resulting from
diminished tear production that occurs with aging).
 Inspect the cornea and lens. Also ask the client when he or she last had an eye and vision examination (an arcus
senilis, a cloudy or grayish ring around the iris, and decreased pigment in iris are age-related changes).
  Inspect the pupils. With a penlight or a similar device, test papillary reaction to light (overall decrease in size of
pupil and ability to dilate in dark and constrict in light may occur with advanced age; this results in poorer night
vision and decreased tolerance to glare).
 Test vision. Ask the client to read a newspaper or magazine. Use only room lighting for the initial reading. Use
task lighting for a second reading (impaired near vision is indicate of presbyopia / farsightedness, a common
finding in older adults; also common are slight decreases in peripheral vision and difficulty in differentiating blues
from greens).

Ears and Hearing

 Inspect the external ear. Observe shape, color, and hair growth. Also look for lesions or drainage (hairs may
become coarser and thicker in the external ear, especially in men; earlobes may be pendulous).
 Perform an otoscopic examination to determine quantity, color, and consistency of cerumen (cerumen
accumulation increases).
 Perform the voice-whisper test, a functional examination to detect obvious (conversation) hearing loss. Instruct
the client to put a hand over one ear and to repeat the sentence you say. Stand approximately 2 feet away from
the client and whisper a sentence. (The inability to hear high-frequency sounds or to discriminate a variety of
simultaneous sounds from degeneration of the hair cells of the inner ear and is called presbycusis).

Thorax and Lungs

 Inspect shape of thorax. Note respiratory rate, rhythm, and quality of breathing.
o Normal findings include:
 Increase in normal respiratory rate of 16 to 25.
 Increased reliance on diaphragmatic breathing and increased work of breathing related to the
anatomic changes in the costal cartilage, respiratory muscles, and lung tissue.
 Percuss lung tones as you would in a younger adult (in general, the normal sound to percussion is the same in an
older adult—resonant. However, in the presence of structural changes such as kyphosis or a slight barrel hest,
resonance may increase).
 Auscultate lung sounds as you would in a younger adult (vesicular sound should be heard over all areas of air
exchange. However, because lung expansion may be diminished, it may be necessary to emphasize taking deep
breaths with the mouth open during the exam. This may be very difficult for those with dementia).

Heart and Blood Vessels

A. Blood Pressure
 Take blood pressure to detect actual or potential orthostatic hypotension and, therefore, the risk for falling.
Measure pressure with the client in lying, sitting, and standing positions. Also measure pulse rate. Have the
client lie down for 5 min; take the pulse and BP; at 1 min, take pulse and BP after client is sitting and again at 1
min after client stands. If dizziness occurs, instruct client to sit a few minutes before attempting to stand up from
a supine or reclining position. Any client with BP exceeding 160/90 mmHg should be referred to the health care
provider for follow up (an elderly person’s baroreceptor response to positional changes is slightly less efficient.
BP increases as elasticity decreases in arteries with proportionately greater increase in systolic pressure resulting
in a widening of pulse pressure).

B. Exercise Tolerance
 Measure activity tolerance. Evaluate, either review results of stress testing or by observing the client’s ability to
move from a sitting to a standing position or to flex and extend fingers rapidly (the maximal heart rate with
exercise is less than in a younger person. The HR will also take longer to return to its pre-exercise rate; normally,
the rise in a pulse rate should be no greater than 10 to 20 bpm; baseline rate within 2 minutes).

C. Pulses
 Determine adequacy of blood flow by palpating the arterial pulses in all locations (carotid, brachial, radial,
femoral, popliteal, posterior tibial, and dorsalis pedis) for strength and quality (proximal pulses may be easier to
palpate due to loss of supporting surrounding tissue. However, distal lower extremity pulses may be more
difficult to feel or even nonpalpable. The dorsalis pedis pulse is absent in approximately 20% of older persons).

D. Arteries and Veins

 Auscultate he carotid, abdominal, and femoral arteries (no unusual sounds should be heard).
 Evaluate arterial and venous sufficiency of extremities. Elevate the legs above the level of the heart and observe
color, temperature, size of the legs, and skin integrity (hair loss occurs normally with advanced age and cannot
be used singly as an indicator of arterial insufficiency).
  Inspect and palpate veins while client is standing (prominent, bulging veins are common. Varicosities are
considered a problem only if ulcerations, signs of thrombophlebitis, or cords, are present. Cords are nontender;
palpable veins having a rubber tubing consistency).

E. Heart
 Inspect ad palpate the precordium (the precordium is till and without thrills, heaves, or visible, palpable
pulsations, noted exception may be the apex of the heart if close to the surface).
 Auscultate heart sounds (extra heart sounds, low-intensity systolic murmur and an S4, result from normal age-
related calcification of heart valves and vessels and fibrotic changes in the heart muscle).

Breast
 Inspect and palpate breast and axillae. When viewing axillae and contour of breasts, assist a client with arthritis
to raise the arms over the head. Do this gently and without force and only if it is not painful for the client.
 If the breast are pendulous, assist the client to lean slightly so the breasts hag way from the chest wall, enabling
you to best observe symmetry and form (the breasts of elderly women are often described as pendulous due to
the atrophy of breast tissue and the forward thrust of the client brought about by kyphosis; decreases in fat
composition and increase in fibrotic tissue ay make the terminal ducts feel more fibrotic and palpable as linear,
spoke-like strands; nipples may retract due to loss in musculature. Unlike nipple retractions due to a mass,
nipples retracted because of aging can be everted with gentle pressure; skin intact without lesions or rashes).

Abdomen

A. Nutritional Status
 Elderly clients typically report gastrointestinal problems related not only to elimination but also to diet and
nutrition. Therefore, measure and record the client’s height and weight, noting weight changes and problems
with swallowing or chewing.
 Review laboratory test values (CBC, Vit. B12, Cholesterol, Albumin, and Prealbumin levels).
 In addition, compile a 24-hour food and fluid diary noting food preferences an cravings, vitamin and food
supplement intake, and dietary restrictions (e.g. salt), (antral cells and intestinal villi atrophy, and gastric
production of hydrochloric acid decreases with age).

B. Hydration Status
 Because muscle mass decreases and fatty tissues increase, the elderly client is at increased risk for dehydration.
Evaluate hydration status as you would nutritional status. Begin with accurate serial measurements of weight,
careful review of laboratory test findings (serial serum sodium level, hematocrit, osmolality, BUN level, and
urine-specific gravity), and a 2 to 3-day diary of fluid intake and output (normal findings include stable weight
and stable mental status).

C. Motility
 Assess GI motility and auscultate bowel sounds (5 to 30 sounds/min are heard).
 Determine absorption or retention problems in elderly clients receiving enteral feedings (less than 100ml
residual is a normal finding for intermittent).
 Inspect and percuss abdomen in same manner as for younger adults (liver, pancreas, and kidneys normally
decrease in size, but the decrease is not generally appreciable upon physical examination).
 Palpate the bladder (ask client to empty bladder before the examination). If the bladder is palpable, percuss from
symphysis pubis to umbilicus. If the client is incontinent, postvoid residual content may also need to be measured
(empty bladder is not palpable or percussable).

Genitalia

A. Female
 Inspect external genitalia. Assist the client into the lithotomy positions. Inspect the urethral meatus and vaginal
opening (pubic hair is usually sparse, and labia are flattened; clitoris is decreased in size).
 Ask the client to cough while in the lithotomy position (no leakage of urine occurs).
 Test for prolapse. Ask the client to bear down while you observe the vaginal opening (no prolapsed is evident).
 Perform a pelvic examination. Put on disposable gloves and use a small speculum if the vaginal opening has
narrowed with age. Use lubrication on speculum and hand because natural lubrication is decreased (vaginal
secretions should be white, clear, and odourless; the vaginal epithelium is thinner, drier, ad may be pale and
shiny; atrophic changes are intensified by infrequent intercourse; because the ovaries, uterus, and cervix shrink
with age, the ovaries may not be palpable).
  Test pelvic muscle tone. Ask the woman to squeeze muscles while the examiner’s finger is in the vagina. Assess
perineal strength by turning fingers posterior to the perineum while the woman squeezes muscles in the vaginal
area (the vaginal wall should constrict around the examiner’s finger, and the perineum should feel smooth).

B. Male
 Inspect the male genital area with the client in standing position if possible (pubic hair is thinner. Scrotal skin is
slightly darker than surrounding skin and is smooth and flaccid in the older man. Penis and testicular size
decreases).
 Observe and palpate for inguinal swelling or bulges suggestive of hernia in the same manner as for a younger
male (no swelling or bulges is present).
 Auscultate the scrotum if a mass is detected; otherwise palpate the right and left testicle using the thumb and
first two fingers (no detectable sounds or masses are present).

Anus, Rectum, and Prostate

 Inspect the anus and rectum (the anus is darker than the surrounding skin; bluish, grapelike lumps at the anus
are indicators of hemorrhoids).
 Put on gloves to palpate the anus and rectum. Also palpate the prostate in the male client (the prostate is
normally soft or rubbery-firm and smooth, and the median sulcus is palpable).

Musculoskeletal System
 Observe the client’s posture and balance when standing, especially the first 3 to 5 seconds (client stands
reasonably straight with feet positioned fairly widely apart to form a firm base of support. This stance
compensates or diminished sense of proprioception in lower extremities. Body usually bends forward as well).
 Observe the client’s gait by performing the timed “Get Up and Go” test (widening of pelvis and narrowing of
shoulders).
1. Have the client rise from a straight-backed armchair, stand momentarily, and walk about 3m toward a
wall.
2. Ask the client to turn without touching the wall and walk back to the chair, then turn around and sit
down.
3. Using a watch or clock with a second hand, time how long it takes the client to complete the test.
4. Score performance on a 1-5 scale: 1 = normal; 2 = very slightly abnormal; 3 = mildly abnormal; 4 =
moderately abnormal; 5 = severely abnormal.

Client walks steadily without swaying, stumbling, or hesitating during the walk. The client does not appear to be
at risk of falling. Elderly clients without impairments in gait or balance can complete the test within 10 seconds.

 Inspect the general contour of limbs, trunk, and joints. Palpate wrist and hand joints (enlargement of the distal,
interphaleal joints of the fingers, called Heberden’s nodes, are indicators of degenerative joint disease / DJD, a
common age-related condition involving joints in the hips, knees, and spine as well as the fingers).
 Test ROM. Ask client to touch each finger with the thumb of the same hand, to turn wrists up toward the ceiling
and down toward the floor, to push each finger against yours while you apply resistance, and to make a fist and
release it (there is full ROM of each joint and equal bilateral resistance).
 Similarly assess ROM and strength of shoulders (left) and elbows (right); (there is full ROM and equal strength of
each joint).
 Assess hip joint for strength and ROM in the same manner as for a younger adult (intact flexion, extension, and
internal and external rotation).
 Inspect and palpate knees, ankles, and feet. Also assess comfort level particularly with movement (flexion,
extension, rotation); (the common problems associated with the aged foot, such as soreness and aching, are
most frequently due to improperly fitting footwear).
 Inspect client’s muscle bulk and tone (atrophy of the hand muscles may occur with normal aging).

Neurologic System

A. Mental Status
 Assess the elderly client’s mental status including level of consciousness, orientation, judgment and insight,
short-term and long-term memory. Ability to recall events or data and to calculate are core elements of a
mental status exam. (An explanation to the Mini-Mental Status Examination is presented in page 613-614). The
test is used in various settings as a screening tool to measure insight, judgment, calculation ability, short-term
and long-term as well as recall (there is no observable change in cognition or motor function in the absence of
disease; the usual loss of neurons and brain mass as well as increased response time seen in advanced age does
not manifest as any abnormality; date and time may become a less significant indicator of orientation for the
 older person who lacks a routine, relies on others for the daily routine, or has significant deficits in vision or
hearing; a slight decline in short-term memory is common with aging).
 Observe for tremors and involuntary movements (resting tremors increase in the aged. In the absence of an
identifiable disease process, they are not considered pathologic).

B. Sensory System
 Test sensation to pain, temperature, touch position and vibration as you would for a younger adult (touch and
vibratory sensations may diminish normally with aging).
 Assess positional sense by using the Romberg test as presented in page 622. The exceptions to the test are
clients who must use assistive devices such as a walker (there is minimal swaying without loss of balance).

FUNCTIONAL ASSESSMENT TESTS

1. INSTRUMENTAL ACTIVITIES OF DAILY LIVING

 used to measure abilities associated with living independently in the community
 includes assessment of these ADLs: ability to use telephone, shopping, food preparation, housekeeping,
laundry, mode of transportation, responsibility for own medications, ability to handle finances
 A score is assigned for each category and then totalled. Total score can range from 8-28. The higher the score,
the more independent the client is.

2. KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

 The index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring,
continence, and feeding.
 Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full
function, 4 indicate moderate impairment, and 2 or less indicates severe functional impairment.

Activities Independence Dependence

Points (1 or 0) (1 Point) (0 Points)
NO supervision, direction or personal assistance WITH supervision, direction, personal
assistance or total care

BATHING (1 POINT) Bathes self completely or needs help in (0 POINTS) Need help with bathing more
Points: __________ bathing only a single part of the body such as the than one part of the body, getting in or
back, genital area or disabled extremity out of the tub or shower. Requires total
bathing

DRESSING (1 POINT) Get clothes from closets and drawers (0 POINTS) Needs help with dressing self
Points: __________ and puts on clothes and outer garments complete or needs to be completely dressed.
with fasteners. May have help tying shoes.

TOILETING (1 POINT) Goes to toilet, gets on and off, arranges (0 POINTS) Needs help transferring to the
Points: __________ clothes, cleans genital area without help. toilet, cleaning self or uses bedpan or
commode.

TRANSFERRING (1 POINT) Moves in and out of bed or chair (0 POINTS)Needs help in moving from
Points: __________ unassisted. Mechanical transfer aids are bed to chair or requires a complete
acceptable transfer.

CONTINENCE (1 POINT) Exercises complete self control over (0 POINTS) Is partially or totally
Points: __________ urination and defecation. incontinent of bowel or bladder

FEEDING (1 POINT) Gets food from plate into mouth (0 POINTS) Needs partial or total help
Points: __________ without help. Preparation of food may be done by with feeding or requires parenteral
another person. feeding.

Total Points = ______________

6 = High (patient independent)
0 = Low (patient very dependent)

3. BARTHEL INDEX

 Consists of 10 items that measure a person's daily functioning specifically the activities of daily living and
mobility.
 Include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet,
bathing, walking on level surface, going up and down stairs, dressing, continence of bowels and bladder.

THE Patient Name: ___________________________

BARTHEL Rater Name: ___________________________
INDEX Date: ___________________________

Activity Score

FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent ______

BATHING
0 = dependent
5 = independent (or in shower)
______
GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided) ______

DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.) ______

BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent ______

BLADDER
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent ______

TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping) ______

TRANSFERS (BED TO CHAIR AND BACK)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent ______

MOBILITY (ON LEVEL SURFACES)

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards ______
STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent ______

TOTAL (0–100): ______

DEFINITION AND DISCUSSION OF SCORING

1. Feeding

10 = Independent. The patient can feed himself a meal from a tray or table when someone puts the food within his
reach. He must put on an assistive device if this is needed, cut up the food, use salt and pepper, spread butter,
etc. He must accomplish this in a reasonable time.

5 = Some help is necessary (with cutting up food, etc., as listed above).

2. Moving from wheelchair to bed and return

15 = Independent in all phases of this activity. Patient can safely approach the bed in his wheelchair, lock brakes, lift
footrests, move safely to bed, lie down, come to a sitting position on the side of the bed, change the position of the
wheelchair, if necessary, to transfer back into it safely, and return to the wheelchair.

10 = Either some minimal help is needed in some step of this activity or the patient needs to be reminded or supervised
for safety of one or more parts of this activity.

5 = Patient can come to a sitting position without the help of a second person but needs to be lifted out of bed, or if he
transfers with a great deal of help.

3. Doing personal toilet

5 = Patient can wash hands and face, comb hair, clean teeth, and shave. He may use any kind of razor but must put in
blade or plug in razor without help as well as get it from drawer or cabinet. Female patients must put on own makeup, if
used, but need not braid or style hair.

4. Getting on and off toilet

10 = Patient is able to get on and off toilet, fasten and unfasten clothes, prevent soiling of clothes, and use toilet paper
without help. He may use a wall bar or other stable object for support if needed. If it is necessary to use a bed pan
instead of a toilet, he must be able to place it on a chair, empty it, and clean it. Patient needs help because of imbalance
or in handling clothes or in using toilet paper.

5. Bathing self

5 = Patient may use a bath tub, a shower, or take a complete sponge bath. He must be able to do all the steps involved
in whichever method is employed without another person being present.

6. Walking on a level surface

15 = Patient can walk at least 50 yards without help or supervision. He may wear braces or prostheses and use crutches,
canes, or a walkerette but not a rolling walker. He must be able to lock and unlock braces if used, assume the standing
position and sit down, get the necessary mechanical aides into position for use, and dispose of them when he sits.
(Putting on and taking off braces is scored under dressing.)

10 = Patient needs help or supervision in any of the above but can walk at least 50 yards with a little help.

6a. Propelling a wheelchair

5 = If a patient cannot ambulate but can propel a wheelchair independently. He must be able to go around corners, turn
around, maneuver the chair to a table, bed, toilet, etc. He must be able to push a chair at least 50 yards. Do not score
this item if the patient gets score for walking.

7. Ascending and descending stairs

10 = Patient is able to go up and down a flight of stairs safely without help or supervision. He may and should use
handrails, canes, or crutches when needed. He must be able to carry canes or crutches as he ascends or descends stairs.

5 = Patient needs help with or supervision of any one of the above items.

8. Dressing and undressing

10 = Patient is able to put on and remove and fasten all clothing, and tie shoe laces (unless it is necessary to use
adaptations for this). The activity includes putting on and removing and fastening corset or braces when these are
prescribed. Such special clothing as suspenders, loafer shoes, dresses that open down the front may be used when
necessary.

5 = Patient needs help in putting on and removing or fastening any clothing. He must do at least half the work himself.
He must accomplish this in a reasonable time. Women need not be scored on use of a brassiere or girdle unless these
are prescribed garments.

9. Continence of bowels

10 = Patient is able to control his bowels and have no accidents. He can use a suppository or take an enema when
necessary (as for spinal cord injury patients who have had bowel training).

5 = Patient needs help in using a suppository or taking an enema or has occasional accidents.

10. Controlling bladder

10 = Patient is able to control his bladder day and night. Spinal cord injury patients who wear an external device and leg
bag must put them on independently, clean and empty bag, and stay dry day and night.

5 = Patient has occasional accidents or cannot wait for the bed pan or get to the toilet in time or needs help with an
external device.

A score of 0 is given in all of the above activities when the patient cannot meet the criteria as defined above.

SAMPLE DOCUMENTATION:
> 5’3”, 122 lbs
 > No orthostatic HPN (lying=150/85, HR=88; sitting=148/84, HR=90; standing=148/84, HR=90); RR=22
> Independent in transfers and uses a walker for ambulating
> Has pill-rolling tremor at rest
> Soft systolic murmur
> Absent pedal pulses
> Soft, non-distended abdomen
> No pedal edema
> Toenails thick and yellowish
> No skin ulcerations or discoloration on lower extremities
> With slight accumulation of dry ear wax on outer ear
> Has no noted difficulties in conversation

APPROPRIATE NURSING DIAGNOSES:

Wellness:
Readiness for enhanced effective caregiving
Risk:
 Risk for ineffective family coping related to emotional conflicts secondary to chronic illness of parent
 Risk for social isolation related to inability to communicate effectively
 Risk for imbalanced nutrition, less than body requirements related to dysphagia
 Risk for constipation related to decreased physical mobility
 Risk for loneliness related to changing role and decreasing functional status
Actual:
 Diversional activity deficit related to impaired mobility
 Fatigue related to compromised circulatory system
 Grieving related to debilitating effects of chronic illness
 Ineffective protection related to decreased immunity
 Activity intolerance related to weakness or pain
 Bathing self-care deficit related to impaired physical functioning

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