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Activities of Daily Living (ADLs)

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Last Update: December 12, 2019.

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, Allied Health, and Interprofessional Team 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, Allied Health, and Interprofessional Team 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.

Questions

To access free multiple choice questions on this topic, click here.

Instrumental Activities of Daily Living

Figure

Instrumental Activities of Daily Living. Contributed by the US National Library of Medicine (NIH, 2017)

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