Sitting Standing and Transfers
| |
SITTING TO STANDING INSTRUCTIONS: Please stand up. Try not to use your hands for support. |
STANDING TO SITTING INSTRUCTIONS: Please sit down. |
TRANSFERS INSTRUCTIONS: Arrange chairs(s) for a pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair. |
4 |
able to stand without using hands and stabilize independently |
sits safely with minimal use of hands |
able to transfer safely with minor use of hands |
3 |
able to stand independently using hands |
controls descent by using hands |
able to transfer safely definite need of hands |
2 |
able to stand using hands after several tries |
sits independently but has uncontrolled descent |
able to transfer with verbal cueing and/or supervision |
1 |
needs minimal aid to stand or to stabilize |
sits independently but has uncontrolled descent |
needs one person to assist |
0 |
needs moderate or maximal assist to stand |
needs assistance to sit |
needs two people to assist or supervise to be safe |
Think:
- Hands
- Stability
- Assistance
- Supervison
AMTs
What is your age? |
. Give the patient an address, and ask him or her to repeat it at the end of the test e.g. 42 West Street |
What is the time to the nearest hour? |
What is the year? |
What is the name of the hospital or number of the residence where the patient is situated? |
Can the patient recognize two persons (the doctor, nurse, home help, etc.)? |
What is your date of birth? (day and month sufficient) |
. In what year did World War 1 begin? |
Name the present monarch/prime minister/president. |
Count backwards from 20 down to 1 |
A score of 6 or less suggests delirium or dementia, although further tests are necessary to
confirm
Barthel Part 1 Mobility
Transfers |
Independent |
| |
Needs minor help |
| |
Needs major help |
| |
Unable |
Mobility |
Independent (may use a stick) >50 yards |
| |
Walks with physical or verbal help of one other > 50 yards |
| |
Wheelchair independent > 50 yards |
| |
Immobile < 50 yards |
Stairs |
Independent |
| |
Needs help (other person, aid) |
| |
Unable |
|
|
Standing and Sitting
| |
STANDING UNSUPPORTED |
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED |
STANDING UNSUPPORTED ONE FOOT IN FRONT |
STANDING ON ONE LEG |
4 |
able to stand safely 2 minutes |
able to sit safely and securely 2 minutes |
able to place foot tandem independently and hold 30 seconds |
able to lift leg independently and hold >10 seconds |
3 |
able to stand 2 minutes with supervision |
able to sit 2 minutes with supervision |
able to place foot ahead of other independently and hold 30 seconds |
able to lift leg independently and hold = or >3 seconds |
2 |
able to stand 30 seconds unsupported |
able to sit 30 seconds unsupported |
able to take small step independently and hold 30 seconds |
tries to lift leg unable to hold 3 seconds but remains standing independently |
1 |
needs several tries to stand 30 seconds unsupported |
able to sit 10 seconds unsupported |
needs help to step but can hold 15 seconds |
tries to lift leg unable to hold 3 seconds but remains standing independently |
0 |
unable to stand 30 seconds unassisted |
unable to sit without support 10 seconds |
loses balance while stepping or standing |
tries to lift leg unable to hold 3 seconds but remains standing independently |
Risk Factor Checklist
Vision |
Dificulty seeing or finding way around |
Mobility |
Unsafe, impulsive, forgets aid |
Transfers |
Over=reaches, impusive |
Behaviours |
Agintation, confusion or non-compliant |
ADLs |
Riskptaking, unsafe equiment or footwear |
Environment |
Diffculties with orientation |
Nutrition |
Underweight/low appetite |
Contience |
Urgency, nocturia, accidents |
Barthel Part 1 ADLS
Cleaning |
Bathing |
Independent +10 |
| |
Needs Help +5 |
| |
Unable 0 |
Grooming |
Independent |
| |
Unable |
Dressing |
Independent |
| |
Needs Help |
| |
Unable |
Toileting |
Bowel Control |
Continent |
| |
Occasional Accident |
| |
Incontinent |
Bladder |
Continent |
| |
Occasional Accident |
| |
Incontinent |
Toilet Use |
Independent |
| |
Needs Help |
| |
Unable |
Feeding |
Independent |
| |
Needs Help |
| |
Unable |
|
|
Reaching
| |
REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING |
PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION |
4 |
can reach forward confidently >25 cm (10 inches) |
able to pick up slipper safely and easily |
3 |
can reach forward >12 cm safely (5 inches) |
able to pick up slipper but needs supervision |
2 |
can reach forward >5 cm safely (2 inches) |
unable to pick up but reaches 2-5cm (1-2 inches) from slipper and keeps balance independently |
1 |
reaches forward but needs supervision |
unable to pick up and needs supervision while trying |
0 |
loses balance while trying/requires external support |
unable to try/needs assist to keep from losing balance or falling |
Berg Balance Tests
| |
TURN 360 DEGREES |
TURNING TO LOOK BEHIND |
4 |
able to turn 360 degrees safely in 4 seconds or less |
looks behind from both sides and weight shifts well |
3 |
able to turn 360 degrees safely one side only in 4 seconds or less |
looks behind one side only other side shows less weight shift |
2 |
able to turn 360 degrees safely but slowly |
turns sideways only but maintains balance |
1 |
needs close supervision or verbal cueing |
needs supervision when turning |
0 |
needs assistance while turning |
needs assist to keep from losing balance or falling |
Falls Risk Assessment Tool
| |
Have you had a fall in the previous year? |
Are you taking four or more medications per day? Out of sedatives, anti-depresssants, parkinson's, diuretics, anti-hypertiensives and hypnotics |
Psycological (Anexity, depression, stroke, Parkisons, cooperation, insight or judgement) |
Have you had a stroke? Have you been diagnosed with Parkinson’s disease? |
Are you unable to stand up from a chair of knee height without using your arms? |
| |
0 in last 12 |
0 |
0 |
| |
0 or more in last 3 months |
1 |
mildly by 1 or more |
| |
one or more in last 3 months |
2 |
moderately by one or more |
| |
3 or more whilst ination |
>2 |
sever in one or more |
|
Created By
Metadata
Comments
No comments yet. Add yours below!
Add a Comment
Related Cheat Sheets
More Cheat Sheets by datamansam