Activities of Daily Living (ADLs)


Article Author:
Peter Edemekong
Deb Bomgaars


Article Editor:
Shoshana Levy


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/11/2019 1:47:36 PM

Introduction

The activities of daily living (ADLs) are both essential and routine aspects of self-care. The six essential ADLs includes the ability to be able to independently eat, dress, walk or transfer from one position to another, bathe, and toilet, and maintaining bowel and bladder continence. Independent adults generally can manage activities of daily living so that they can successfully live without assistance from outside caregivers or significant others. Inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life; possibly serving as criteria to consider home care assistance or placement in assisted living, skilled care, or long-term care. Placement in a facility due to declining ADL's is often a difficult decision made collaboratively by the patient, significant others, and the healthcare team.   [1][2][3]

Instrumental activities of daily living (IADLs) are another factor to consider when assessing independence. IADL's assess a person’s ability to live independently and thrive. IADLs include companionship and mental support, transportation and shopping, planning and preparing meals, managing the household, managing medications, communicating with others, and managing finances. 

Nurses are often the first to note when patients' functionality declines during hospitalization; therefore, routine screening of ADLs is imperative and nursing assessment of ADL's is performed on all hospitalized patients.  Hospitalization for an acute or chronic illness may influence a person’s ability to meet personal goals and sustain independent living. Chronic illnesses progress over time, resulting in a physical decline that may lead to a loss of ability to perform ADL's.

Function

More than half of the American population age 65 years old or older are placed in skilled or long-term care facilities due to diminished ability to accomplish ADLs. The first signs of diminished functionality is lack of capacity to accomplish basic self-care activities (feeding, grooming, dressing, bathing, walking, toileting, ability to transfer from bed to a wheelchair or walking).  Aside from being able to perform ADLs, patients also need to be able to perform necessary instrumental activities of daily living, for example, managing their finances, medications, shopping, or preparing meals (Wiener et al. 1990).

Decline or impairment in physical function arises from many conditions. Musculoskeletal, neurological, circulatory, or sensory conditions can lead to decreased physical function leading to impairment in ADL's. A cognitive or mental decline can also lead to impaired ADL's.  Severe cognitive fluctuations in dementia patients have a significant association with impaired engagement in activities of daily living that negatively affect the quality of life. Social isolation can lead to impairment in instrumental activities of daily living.  Other factors such as side effects of medications, social isolation, or the patient's home environment can influence the ability to perform ADL's. Clinicians and nurses must be aware of the many influences on ADL's and be prepared to intervene. 

Placement in a care facility is an option for patients and their significant others. Though many placements at care facilities are short-term, most patients end up staying longer than a year due to inability to perform more than two of the six ADLs.[4]

Issues of Concern

In an effort to assess independence during activities of daily living nurses assess patient status, plan, and intervene appropriately. Aging is a natural process that may present a decline in the functional status of patients; thus assessment of ADL's is an important aspect of routine patient assessment. 

Patient falls are a serious and mostly preventable issue to consider in all patients, but especially in relation to ADL's[5].  Impaired ability to ambulate, transfer, and bathe can lead to accidental falls.  Additionally, fear of incontinence can lead to a careless rush to get to the bathroom; leading to a risk of falls.  Increased risk of falls is a central concern for older adults. There is an increased mortality rate among individuals who have more than one incidence of falling and the most at-risk group of individuals include those 65 years old and older who tend to have the worse prognosis after experiencing a fall. Assessment of fall risk and intervention to prevent falls is important for every patient.  [5]

Independent living is highly encouraged and advocated in American society, and many aging individuals fear a loss of autonomy. Nurses, social workers, and primary care providers collaborate to define the individual patient’s ability to perform ADL's before placement. Other issues to consider before placement in assisted living or nursing home as opposed to independent living at home include a patient’s ability to cook and clean their homes, shop, use of public transportation or drive. It is important for a provider to address a patient’s general medical condition when determining his/her level of accomplishing functional capabilities that otherwise ensure independent living and personal care. Nurses are encouraged to routinely assess patients’ ease in performing ADLs during every patient encounter.

Clinical Significance

Nurses need to communicate patient ability to perform ADL's with providers so that the health care team and their families can discuss if patients meet pre-defined criteria to either continue living in their homes or be placed in assisted living, skilled care, or nursing home facilities. A patient’s inability to perform ADLs as well as IADLs constitutes a disability that often requires further assessment, such as measurement of functionality which then becomes a significant predictor of being admitted into an assisted facility or nursing home depending on variable factors that pertain to the individual patient (United States National Library of Medicine, 2017).

Depending on the level of assistance required, as well as presenting comorbidities, most patients and significant others work with the health care team to care for loved ones at home. Significant others often hire in-home nurses or unlicensed assistive personnel to provide continuous care and to support patient ADLs. Depending on the severity of the patient's impairment, most home health nurses complete assessments to make plans for improvements, help with medication administration, and bring resources to assist with independence. Unlicensed assistive personnel help with bathing, light housekeeping, shopping, and activity to support the patient's desire for continued independent living.

Other Issues

Cost of home care, skilled care, assisted living, and nursing homes is a concern for many families.  Not all supportive care is covered by Medicare or private insurance, thus leading to financial concerns for patients and significant others.  The high cost of care may lead to decisions that preclude patients from receiving the care required to support ADL's.  [6]

Access to care can also be an issue. Often lower socioeconomic groups or disadvantaged persons have difficulty accessing quality care for seniors.  Access can be difficult due to transportation, distance, and availability.   [7]

Enhancing Healthcare Team Outcomes

All healthcare workers, including providers, nurses, physical therapy, and occupational therapy should collaborate to assess the functionality of patients before discharge. Patients who are unable to perform activities of daily living may require further rehabilitation or assistance at home. The inability to dress or toilet can lead to poor quality of life. Difficulty ambulating or transferring can lead to falls and further decline. Difficulty in eating independently can lead to poor nutrition, dehydration, and further weakness.  Appropriate referrals to OT, PT, and dieticians should be considered.  Assessment of functionality should become routine practice for all patients as it can affect people of all ages. An interprofessional team communicating and collaborating together will provide the best patient evaluation and discharge with good follow up care. The nursing staff should report to the medical team concerns in regards to patients unable to complete ADLs. The clinical team assists in directing the nursing home health and social work coordinators to make sure patients receive the care they need. The home health nursing staff needs to provide ongoing monitoring and reporting back to the clinical team should increased deficiency of ADLs occur.   [Level V]

Nursing Actions and Interventions

Nurses should regularly access the activities of daily living (ADLs) because they are the basic tasks that must be accomplished every day for an individual to thrive. The assessment should include:

  • Personal hygiene - bathing, grooming, oral, hair, and nail care
  • Continence management - ability to properly use the bathroom
  • Dressing - ability to select and wear proper clothes
  • Feeding - ability to feed themselves or needs assistance
  • Ambulating - ability to change from one position to the other and walk independently

Nurses also commonly assess Instrumental activities of daily living (IADLs); evaluating a person’s ability to live independently and thrive. IADLs include:

  • Companionship and mental support - reflects on the help needed to keep a person in a positive frame of mind
  • Transportation and shopping -  independently procure meals and supplies
  • Planning and preparing meals - shopping and storing groceries
  • Managing household - cleaning, removing trash and clutter, doing laundry, and folding clothes
  • Managing medications - filling prescriptions, keeping medications up to date, taking medications on time, and in the right dosages
  • Communicating with others - by phone or email
  • Managing finances - maintaining bank balances and checkbooks and paying bills

Other related assessments include: Fall risk assessment, depression assessments, and mental status assessment. 

Appropriately assessing, planning, intervening, and evaluating ADLs and IADLs can mean the difference between independent aging and needing daily assistance.

Nursing Monitoring

Nurses assess ADLs and IADLs daily in all hospitalized patients. There are many tools included in daily shift assessments, but all nurses should be aware of each patient's needs for assistance in managing ADL's.  When a patient is at risk for a change in ADLs or IADLs, the nurse should assist patients and report to the interprofessional team members so that a new plan of care can be established.

Possible NANDA nursing diagnoses include: Altered health maintenance, defined as a "State in which an individual has no physiological or psychological energy enough to resist or complete required or desired daily activities". Other possible nursing diagnoses include: risk of injury, activity intolerance, social isolation, or ineffective family coping.


  • Image 5801 Not availableImage 5801 Not available
    Contributed by the US National Library of Medicine (NIH, 2017)
Attributed To: Contributed by the US National Library of Medicine (NIH, 2017)

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Activities of Daily Living (ADLs) - Questions

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Which of the following physiological functions is not considered a part of daily living activities?



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What is the best way to assess the respiratory status of a patient performing their activities of daily living?



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A physical therapist is evaluating activities of daily living for a patient after coronary artery bypass grafting. What is most important during evaluation and treatment?



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A 35-year-old male patient is seen by a physical therapist after a total knee arthroplasty. What is the most appropriate intervention?



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A patient has had total hip arthroplasty and is only allowed toe touch weight bearing. Which of the following ADL techniques is appropriate?



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An OT plans to use a functional skills training approach to teach a patient with severe cognitive deficits how to brush her teeth. Select the appropriate method.



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A patient has had total hip arthroplasty and is demonstrating ADLs for her OT prior to discharge. The patient puts on her shoes using a long handled shoe horn while bending 90 degrees at the hips. What should the therapist do?



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A 17-year-old male with juvenile idiopathic arthritis has reduced range of motion at his elbows and shoulders making shaving difficult. What is the best adaptation?



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A young patient has neurological deficits and does not learn new skills or retain skills learned during occupational therapy (OT). What would be the best solution to improve function with activities of daily living (ADLs)?



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What is the best adaptive device to assist with oral hygiene activities for a patient with C7-C8 quadriplegia?



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Which assessment tool is best for assessing patients with dementia for the performance of activities of daily living?



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A patient with a below the knee amputation is in therapy for activities of daily living. Which of the following is most important?



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A patient is returning home after a stroke and a home evaluation reveals that the patient cannot reach the toilet tissue without problems with balance. What is the best option?



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Which of the following would not inhibit negative motor responses for a patient with excess tone preventing activities of daily living participation?



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A patient with dementia is having problems with activities of daily living. What is the intervention least likely to improve independence?



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A patient is involved in a motor vehicle accident and has a cast on the left arm and a full leg cast. Which of the following activities of daily living will the patient be able to do independently?



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When teaching activities of daily living to a patient with a transfemoral amputation, what is the most important goal?



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Which of the following activities of daily living would be most difficult for a patient with ankylosing spondylitis?



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Which test would be best to test patient balance during ADLs?



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Which of the following assesses the degree of assistance required for bathing, dressing, toileting, transfer, continence, and feeding?



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Which of the following activities of daily living assessment question is most relevant and important during a follow-up visit with the primary care provider?



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Activities of daily living include all of the following actions to promote personal well-being and comfort except which one?



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You are the nurse caring for an 81-year-old male who was admitted to the hospital with a diagnosis of Parkinson disease. Which of the following assessment findings indicate a deficit in activities of daily living (ADL’s)? Select all that apply.



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A 72-year-old female with a history of dementia, osteoarthritis, and hypertension is being examined. Initial assessment reveals an unkempt, extremely thin elderly female. The patient is disoriented to time and place but follows simple commands. Vital signs are as follows: blood pressure 140/88mmHg, temperature 97.5 degrees Fahrenheit, pulse 96 beats per minute, respirations 20 per minute. Gait is unsteady; she needs assistance for balance. On physical exam, there is a large purple bruise on her left forearm that the family says resulted from the patient stumbling when using the bathroom. Which of the following is the immediate priority?



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Your patient is an elderly male with orthostatic hypotension. Which of the following ADL’s would you anticipate will require assistance?



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You have assessed ADL's on your patient and have found several deficits. Your patient desires independence in order to avoid placement in a nursing home. Which of the following interventions will assist a patient in maintaining independence in performing ADL’s?



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You are caring for a 75-year-old male. His family is concerned about his ability to remain in his own home after hospitalization. Therefore, you will assess the instrumental activities of daily living. Which of the following questions would you ask to assess IADL's (Select all that apply)?



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Activities of Daily Living (ADLs) - References

References

Walter CS,Hengge CR,Lindauer BE,Schaefer SY, Declines in motor transfer following upper extremity task-specific training in older adults. Experimental gerontology. 2018 Dec 15;     [PubMed]
Parmar MC,Saikia N, Chronic morbidity and reported disability among older persons from the India Human Development Survey. BMC geriatrics. 2018 Dec 7;     [PubMed]
Turnbull GS,Scott CEH,MacDonald DJ,Breusch SJ, Return to activity following revision total hip arthroplasty. Archives of orthopaedic and trauma surgery. 2018 Dec 7;     [PubMed]
Abrahamson K,Hass Z,Arling G, Shall I Stay or Shall I Go? The Choice to Remain in the Nursing Home Among Residents With High Potential for Discharge. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2018 Oct 26;     [PubMed]
Wong MM,Pang PF, Factors Associated with Falls in Psychogeriatric Inpatients and Comparison of Two Fall Risk Assessment Tools. East Asian archives of psychiatry : official journal of the Hong Kong College of Psychiatrists = Dong Ya jing shen ke xue zhi : Xianggang jing shen ke yi xue yuan qi kan. 2019 Mar     [PubMed]
Damukaitis C,Schirm V, Program planning for long-term care: meeting the demand for nursing services. Nursing homes and senior citizen care. 1989 Nov     [PubMed]
Gorges RJ,Sanghavi P,Konetzka RT, A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles. Health affairs (Project Hope). 2019 Jul     [PubMed]

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