Category: Clinical Corner

FIM (Functional Independence Measure)

FIM

Functional Independence Measure

Scoring Basics

  • Seven and 5 mean no helper
  • 6 and below require a helper
  • 6 The patient needs an assistive device, need extra time or there is a safety risk that they can manage.
  • 5 The patient needs setup assistance; no physical contact. Eg. TLSO or ted hose;
  • 4 The patient performs 75% or more of the effort and requires no more than touching. Minimum Assistance
  • 3 The patient performs less than 50% of the task or maximum assist.
  • 2 The patient is performing less than 25% or total assist. Also, anytime the patient needs more than 2 people, even if the level of assistance is touching.
  • 1 The patient performs less than 10% or dependent.

An objective measure of the burden of care.

If a patient refuses care and the clinician performs the entire task for the patient, the patient is dependent on that task in that instance become dependent. A score of 7 is appropriate for this instance. On the other hand, if the patient refuses to perform a task and the clinician does not perform the task, the task is deemed not assessed and a score of 0 is appropriately assigned.

Scenario

Suppose a patient did not have a bowel movement during a clinician’s shift, the burden of care for that task is none or independent; therefore a score of 7 is assigned.  If a nurse has to give a patient medication for bowel movement or control, a score of 6 is appropriate. While, if a nurse has to give a medication that requires contact like a suppository, a score of 4 is assigned.

Remember that the score has to reflect the patient’s actual performance. Also, the score can only be assigned when the task is performed in a realistic, close to actual environment as possible. For instance, a simulated bath will not include the one element that makes the task realistic – water.

When reasonable time is taken into account;  sometimes to differentiate between a score of 7 and 6, the time comparison is not against another patient; rather,  it is against the clinician (a typical person performing the same task.)

In bathing; if the patient requires help with more than 2 body parts level of assistance is 80% based on the 10 body part concept. Assisting with this task brings their level of assistance to at least a 3

Bowel and Bladder

A measure of the Level of assistance and frequency of accidents.

Is it possible for a patient who is incontinent to have a score of 7 or independent? Yes! As long as the device(s) they use to collect urine or feces is completely managed by the patient, making the burden of care independent.  By the same token, a patient who is continent can have an accident that requires cleanup raising the level of care.

Note that if the pt is having renal dialysis there is no burden of care or 7.

  • 7 Control bladder, never incontinent;
  • 6 The patient needs a device by manages the device independently. The device can be a urinal, bedpan, the catheter etc. Medication can also make a pt 6. Patient empties the urinal
  • 5. Urinal or bedpan, patient empties the collecting device independently.
  • 4. Includes touching like positioning the urinal or bedpan. helping to apply an external catheter.
  • 3. Can change the brief more than 50% of the times. Rolling one direction.
  • 2. Can change the brief less than 50% of the times. Rolling both directions.
  • 1. Dependent.

If a patient is on a 2hr voiding program; the patient becomes dependent for bladder because their sphincter control is managed by the clinician.

Bowel Control

  • 7 Control bladder, never incontinent;
  • 6 The patient needs a device by manages the device independently. Medications like suppositories, or digital stimulation performed independently.
  • 5. Bedpan, patient empties the collecting device independently.
  • 4. Includes touching like positioning the bedpan.
  • 3. Can change the brief more than 50% of the times. Rolling one direction.
  • 2. Can change the brief less than 50% of the times. Rolling both directions.
  • 1. Dependent.

 

Wheelchair

We need to score based on whether the patient will be primarily walking or using a wheelchair at discharge. At times they are going to use both in which case the lower score is an appropriate measure.

If the clinician changes the DC disposition from saying walking to wheelchair mobility as opposed to walking later during the care, changing the wheelchair score at admission is necessary.

The score is the distance traveled, how much help and the mode of locomotion.

Distance; 

Max is 150′

50-149′

Less than 50′

This is measured as walking without a rest break. Measurement starts after any rest breaks.

A patient may not go longer with a less restrictive device.

  • 7.  The patient can walk without an assistive device 150′ without assistance.
  • 6.  The patient can walk 150′  but needs an assistive device or needs additional time, or there is a safety concern that the pt can manage.
  • 5. The patient can walk Modified Independent or Independent but cannot go the full 150′. Supervision.
  • 4. Contact Guard and walk at least 150′.
  • 3. Help to advance a foot, or correcting balance and walk at least 150′.
  • 2. Can go at least 50′ but less than 150′. Max Assistance.
  • 1. Less than 50′  or need 2 people.

Wheelchair

  • 6. Propel 150′  turnaround maneuver around the bed, chair or toilet and navigate a 3% grade.

Eating 

Use of utensils to bring food to the mouth, drinking from a glass.  IV fluids and IV meds score are 1. Chewing and swallowing;

  • 7. Completely independent.
  • 6. Need additional time or use an assistive device like dentures. but they perform the entire activity independently.
  • 5. If the clinician is opening up containers or cutting up food.
  • 3. If the patient can feed themselves 50% of the meal.
  • 1. If the nurse manages the patient’s tube feeding
  • Grooming includes 
  1. Open containers are set up
  2. Dentures are an assistive device

Patient Transfers

Transferring a patient from one surface to another;  also referred as transfers is an essential part of patient care. In physical therapy, it is also a measurable goal in a patient’s plan of care.  A physical therapist and or occupational therapist are trained to assess the best option to transfer a patient. Initially, transferring a patient is for the purposes of reducing the risk of secondary impairments and/or diseases resulting from the deconditioning that results from immobility. Later, transfer training is implemented with the specific goal of improving a patient’s independence.

Let’s explore the first reason for transfers;  To Improve mobility and independence.

Considering that every patient has a baseline activity level, also referred to the prior level of function;  interventions provided by the physical and occupational therapist are to restore the patient’s mobility to this level of performance. Nonetheless, the prior level of function may not be optimal for activities of daily living, in which case, therapists will try to improve the baseline to improve functional movement and safety while moving. In essence, the goal of therapy is to improve the current mobility status of a patient to suit a patient’s social, recreational, employment role. Also, the goal is to restore the patient to their baseline function.

In hospitals, where patients are typically being treated for an acute illness, the goal of therapy is to one, prevent or retard physical mobility complications like weakness and loss of range of motion. In addition, the goal is to improve function by addressing muscle weakness, treating wounds, educating patients how to safely mobilize and assessing their ability to perform activities of daily living safely. Lastly, the goal of therapy is to determine the most appropriate discharge location given the patient’s medical diagnosis, prognosis, current presentation, social support, and cognitive state. Therapists work closely with physicians, case managers, and social workers to determine the discharge location that is most appropriate for a patient.