2.6: Functional Health

Functional health involves the assessment of the client’s physical and mental capacity to participate in day-to-day activities. It includes assessment of:

• Activities of Daily Living (ADL) as illustrated in Figure 2.7 are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).
• Instrumental Activities of Daily Living (iADL) as illustrated in Figure 2.8 are more complex daily tasks that allow clients to function independently (e.g., managing finances, paying bills, purchasing and preparing meals, managing one’s household, taking medications, facilitating transportation). Assessment of iADL may be particularly important to inquire about with adolescents or young adults who have just moved into their first place and clients who are older and/or have disabilities.

Figure 2.7: Activities of daily living

 

Figure 2.8: Instrumental activities of daily living

It is important to assess functional health because the data collected could expose an opportunity for preventive action and health promotion, palliation, or assistance. Because health extends beyond the absence of disease, it is important to consider broader dimensions of health as a holistic and complete assessment.

You may start this section of the interview by saying, “Next, I would like to ask you some questions related to your day-to-day life and factors that affect your ability to function in your day-to-day life.” Table 2.6 outlines possible questions and statements to apply to the various sub-categories of functional health, along with some considerations. For interview demonstrations, see Film Clip 2.4 about elimination and Film Clip 2.5 about substance use.

Film Clip 2.4: Interview demonstrating assessment of elimination

Film Clip 2.5: Interview demonstrating assessment of substance use

Table 2.6: Functional health assessment

Items	Questions and Statements	Considerations
Nutrition Refers to food and fluid intake, financial ability to purchase food, time and knowledge to prepare and make meals, and appetite or change in appetite. You also want to elicit data related to a client’s usual diet and goals related to their nutrition. Additionally, you need to probe so that an adequate amount of detail is obtained. Take action This is an opportune time to engage in health promotion discussions about healthy eating. It is also important to be aware of risks for malnutrition and obesity, specifically assessing for patterns of rapid and excessive weight loss or weight gain.	Tell me about your diet. What foods do you eat? What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.) What have you consumed in the last 24 hours? Is this typical of your usual eating pattern? Do you purchase and prepare your own meals? Tell me about your appetite. Have you had any changes in your appetite? Do you have any goals related to your nutrition? Do you have the financial capacity to purchase the foods you want to eat? Do you have the knowledge and time to prepare the meals you want to eat?	The types of questions asked and the level of detail required depends on the developmental age or health of the client. Infants: Breast milk or formula, amount, frequency, supplements, problems and introductions of new foods. Pregnant women: nutritional intake and presence of nausea and vomiting, intake of folic acid, iron, omega-3 fatty acids, vitamin D, and calcium. Older adults or clients with disabling illnesses: Ability to purchase and cook their food, decreased sense of taste, ability to chew or swallow foods, loss of appetite, enough fibre and nutrients.
Elimination Refers to the removal of waste products through the urine and stool. Healthcare providers refer to urinating as “voiding.” Stool is referred to as a “bowel movement.” You want to assess urine concentration, frequency, and odour. For stool, you want to assess frequency, colour, and consistency. You want to use terminology that clients understand. Thus, you may find yourself using less medicalized terms, such as “pee” and “poo” when speaking with some clients. Take action Findings that require further investigation include pain or difficulty upon urination, blood in the stool, melena (black, tarry stool), constipation; diarrhea, excessive laxative use.	How often do you urinate each day? What colour is it (amber, clear, dark)? Have you noticed a strong odour? How often do you have a bowel movement? What colour is it (brown, black, grey)? Is it hard or soft? Do you have any problems with constipation or diarrhea? If so, how do you treat it? Do you take laxatives or stool softeners?	Toilet training takes several months, occurs in several stages, and varies from child to child. It is influenced by culture and depends on physical and emotional readiness, but most children are toilet trained between 18 months and three years. Constipation and diarrhea are common symptoms associated with aging and medication usage. Thus, health promotion is needed in this area particularly related to safe food preparation, drinking enough water, sufficient activity, and fibre intake (e.g., fruits and vegetables). Clients may experience nausea and abdominal pain with constipation and diarrhea.
Sleep and rest Refer to a client’s pattern of rest and sleep and any associated routines or aids. Although it varies for everyone, it is suggested that people should get approximately eight hours of sleep per night. Take action Findings that require further investigation include disruptive sleep patterns and reliance on sleeping pills or other sedative medications.	Tell me about your sleep routine. Probes How much do you sleep? Do you wake up at all? Do you feel rested when you wake? What do you do before you go to bed? (e.g., use the phone, watch TV, read) Do you take any sleep aids? Do you have any rests during the day?	Disruption in sleep patterns can occur across the lifespan. Assessing sleep patterns and routines will contribute to collaborative interventions. The use of social media and phones prior to bed can disrupt sleep patterns. Pain and stress can also disrupt sleep patterns
Mobility, activity, exercise Mobility refers to a client’s ability to move around (e.g., sit up, sit down, stand up, walk). Activity and exercise refer to informal and/or formal activity (e.g., walking, swimming, yoga, strength training). Note: In addition to exercise, it is important to assess activity because some people may not engage in exercise but still have an active living lifestyle (e.g., walking to school, working in a physically demanding job). Take action Findings that require further investigation include insufficient aerobic exercise and strength training and identified risk for falls.	Tell me about your ability to move around. Do you have any problems sitting up, standing up or walking? Do you use any mobility aids (e.g., cane, walker, wheelchair)? Tell me about the activity and/or exercise that you engage in. What type? How frequent? For how long?	Type of mobility and activity depends on developmental age and a client’s health and illness status. With infants, it is important to assess their ability to meet specific developmental milestones at each well baby visit. Mobility can become problematic for clients who are ill or are aging and can result in self-care deficits. Thus, it is important to assess how their mobility is affecting their ADL.
Violence and trauma There are many types of violence, including abuse and neglect, physical, sexual, psychological, and financial. Trauma can be a result of violence or other distressing events in a life. Take action Collaborative intervention with the client is required when violence and trauma are identified. In Ontario, you are legally mandated to report suspected cases of child abuse or neglect to a children’s aid society. You are also legally mandated to report suspected cases of elder abuse when the client resides in a long-term care or retirement home to the Ministry of Health and long-term care director. You are also required to report to the College of Nurses of Ontario if you suspect that a nurse has abused or sexually abused a client. At any time, if you or the client is in immediate danger, call the police.	Many clients experience violence or trauma in their lives. Can you tell me about any violence or trauma in your life? How has it affected you? Tell me about the ways you have coped with it. Have you ever talked with anyone about it before? Would you like to talk with someone?	People respond in different ways to trauma. It is important to use a trauma-informed approach  when caring for clients who have experienced trauma. For example, a client may respond to the situation in a way that seems unfitting (such as laughter, ambivalence, denial). This does not mean the client is lying; such a response could be symptoms of trauma. To reduce the effects of trauma, it is important to include social and psychological assessments of recent traumatic events (e.g., sudden loss, near-death experience, gravely ill child) and, more importantly, collaborative interventions to support clients experiencing trauma. The gendered and racialized experience of violence and trauma are important to assess. In addition to children, people with disabilities, and elderly people, there are other cohorts who are more at risk and respond to violence and trauma based on their identity.
Relationships and resources Refer to influential relationships in the client’s life, whether positive or negative. Take action Findings that require further investigation include indications that a client does not have any meaningful relationships or has “negative” or abusive relationships in their lives. Sometimes the action involves providing a safe space for the client to talk about their experiences and working with them to identify goals.	Tell me about the most influential relationships in your life. Tell me about the relationships you have with your family. Tell me about the relationships you have with your friends. Tell me about the relationships you have with any other people. Probes How do these relationships influence your day-to-day life? Your health and illness? Who are the people that you talk to when you require support or are struggling in your life?	It is not the number of social contacts, but the social interconnectedness and meaning in relationships that is most important. Some clients can have a lot social contacts but not describe any of them as meaningful. When clients feel isolated or lack meaning in their relationships, it can influence their physical and mental health making them feel fatigued, sad or depressed, and make them eat more or eat less.
Intimate and sexual relationships Refer to sexual feelings, attractions, and preferences toward other people. It involves a combination of emotional connection and, physical companionship (holding hands, hugging, kissing) and sexual activity. It is also linked with a person’s identity and part of their physical and mental health. Take action Assess further if a client describes, or if you observe, a partner who is controlling, reinforces stereotypical gendered roles (domineering), acts jealous or possessive, or has volatile moods. Although you are not legally responsible for reporting abuse in the adult context, it is important to fully assess and work with the client in developing a safety plan.	I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships. Tell me about the ways that you ensure your safety when engaging in intimate and sexual practices. Do you have any concerns about your safety?	Gender is a social construction that exists along a continuum. It is a way of being with other people and not a binary . Gender is different than sexuality. It is important to be attentive to your language and expectations related to gendered roles within a relationship and not make assumptions about things such as who drives, who takes care of the children, or who earns the family income within a relationship.
Substance use Refers to the intake of alcohol, tobacco products (e.g., smoking, chewing tobacco), cannabis, or any illegal drugs (e.g., cocaine, heroin, meth, inhalants, fentanyl). Assess the type, frequency, quantity, patterns, making a distinction between use and abuse. Substance misuse typically constitutes a disruption in everyday function because of a dependence on a substance (e.g., loss of employment, deterioration of relationships, loss of home or precarious living circumstances). Take action Action is needed if clients indicate that they have a problem with substance use or show signs of dependence, addiction, or binge drinking.	To better understand a client’s overall health, I ask everyone about substance use such as tobacco, herbal shisha, alcohol, cannabis, and illegal drugs. Do you or have you ever used any tobacco products (e.g., cigarettes, pipes, vaporizers, hookah)? If so, how much? When did you first start? If you used to use, when did you quit? Do you drink alcohol or have you ever? If so, how often do you drink? How many drinks do you have when you drink? When did you first start drinking? If you used to drink, when did you quit? Do you use or have you used any cannabis products? If so, how do you use them? How often do you use them? When did you first start using them? Do you purchase them from a regulated or unregulated place? If you used to use cannabis, when did you quit? Do you use any illegal drugs? If so, what type? How often do you use them? Tell me about the ways that you ensure your safety when using any of these substances. Have you ever felt you had a problem with any of these substances? Do you want to quit any of these substances? Have you ever tried to quit?	It is important to use a non-judgmental approach when assessing a client’s use of substances so they feel accepted and not stigmatized. Substance use can affect people of all ages. Binge drinking is a health issue that sometimes affects adolescents and young adults. Also, use of some substances can influence the effectiveness of prescription medication.
Environmental health and home/occupational/school health Environmental health refers to the safety of a client’s physical environment, which is a determinant of health. Examples include exposure to community violence, air pollution, and insect infestations. This may include health and safety in the school and workplace (e.g., hazardous materials, noise, body mechanics). Take action Findings that require further investigation include a client being exposed to unsafe environments. This includes prolonged exposure to second- and third-hand cigarette smoke, which is particularly hazardous for children (e.g., smoking in vehicles with children in the car).	Tell me about any factors in your environment that may affect your health. Do you have any concerns about how your environment is affecting your health? Tell me about your home. Do you have any concerns about safety in your home or neighbourhood? Tell me about your workplace and/or school environment. What activities are you involved in or what does your day look like?   Note: These questions will help you determine if probing, detailed questions are needed. For example, if a student or an office worker indicates they are on the computer most of the day, you may need to probe about ergonomics. If a client is working in a healthcare setting, you may need to probe about hazardous materials.	It is important to understand exposure to environmental hazards as nuanced. Not all exposure is the same. For example, during pregnancy, a client may be more attentive to environmental exposures. Some municipalities have banned pesticide use as even small dose exposure can have long-term health effects. It is important to ask about clean and safe water, more so in particular areas than others.
Self-concept and self-esteem Self-concept refers to all the knowledge a person has about themselves that makes up who they are (i.e., their identity). Self-esteem refers to a person’s self-evaluation of these items as being worthy or unworthy. It is best to assess these items toward the end of the interview because you will already have collected data that potentially contributes to an understanding of the client’s self-concept and self-esteem. Take action Findings that require further investigation include a client having low self-esteem, which can be inextricably related to mental health and wellness. Indeed, a criterion for diagnosing mental illness includes low-self-esteem, which can contribute to illnesses such as depression and anxiety.	The factors that contribute to self-concept and self-esteem vary from person to person, so it is assessed best by using open-ended statements. You may need to prompt a client’s responses by saying, “Tell me more” or “Please explain.”   Tell me what makes you who you are. Are you satisfied about where you are in your life? Can you share with me your life goals?	The factors that influence a client’s self-concept vary from person to person. Often these items involve valued elements of life such as talents, education, accomplishments, family, friends, career, stability and financial status, and spirituality and religion.
Other iADL Refers to more complex daily tasks that allow clients to function independently. Take action Findings that require further investigation include risk for falls in the home for clients with mobility limitations. These falls can occur while the client is trying to take care of their home (e.g., when cleaning or cooking). A previous history of falls is an important predictor of future falls. If the client reports a fall at home, brainstorm with them to identify hazards in the home (e.g., loose rugs, wet floors, socks without traction) and strategies for safety (e.g., mobility devices, removing tripping hazards, installing handrails).	Tell me about how you take care of yourself and manage your home. Do you have sufficient finances to pay your bills and purchase food, medications, and other needed items? Do you have any current or future concerns about being able to function independently?	Avoid making assumptions about a client based on their age. It is important to maintain an optimistic view and work collaboratively with the client.

Test Yourself

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