10.1 Cardiovascular, Respiratory & Endocrine Conditions

Cardiovascular, Respiratory & Endocrine Conditions

Chronic medical diseases represent the leading causes of functional impairment, hospitalization, and mortality among residents in long-term care, skilled nursing, and assisted living facilities across Arizona. Certified Nursing Assistants (CNAs) and Licensed Nursing Assistants (LNAs) spend more direct bedside time with residents than any other member of the interdisciplinary healthcare team. Consequently, the nursing assistant serves as the primary frontline observer who detects subtle physiological changes, initiates emergency alerts, and carries out vital individualized comfort and disease-management care plans.

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|                 TRIAD OF MAJOR CHRONIC GERIATRIC CONDITIONS                 |
|                                                                             |
|   CARDIOVASCULAR              RESPIRATORY                 ENDOCRINE         |
|   - Coronary Artery Disease   - COPD (Emphysema/Bronch)   - Type 1 Diabetes |
|   - Myocardial Infarction     - Pneumonia (Aspiration)    - Type 2 Diabetes |
|   - Congestive Heart Failure  - Dyspnea / Hypoxia         - Hypoglycemia    |
|   - Hypertension / Angina     - Oxygen Safety Protocols   - Hyperglycemia   |
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1. Cardiovascular Disorders & CNA Interventions

The cardiovascular system (heart, blood vessels, and blood) delivers oxygen and essential nutrients to every cell in the body while removing metabolic waste products. Aging reduces arterial elasticity, thickens heart valves, and decreases cardiac output, predisposing older adults to severe cardiovascular pathology.

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|                    CARDIOVASCULAR PATHOLOGY & CNA ACTIONS                   |
|                                                                             |
|   CORONARY ARTERY DISEASE (CAD)                                             |
|   - Narrowed coronary arteries reduce myocardial blood supply (ischemia).   |
|   - Leads to Angina Pectoris (chest tightness/pain relieved by rest).       |
|   - CNA Care: Promote rest, minimize physical stress, report chest pain.    |
|                                                                             |
|   MYOCARDIAL INFARCTION (MI / HEART ATTACK)                                 |
|   - Complete occlusion of coronary artery causes myocardial cell necrosis.  |
|   - Crushing chest pain radiating to left arm/jaw, diaphoresis, dyspnea.    |
|   - CNA Care: Emergency! Stay with resident, call RN, sit upright.          |
|                                                                             |
|   CONGESTIVE HEART FAILURE (CHF)                                            |
|   - Inability of heart to pump sufficient blood; fluid pools in lungs/body. |
|   - Shortness of breath, dependent edema, fatigue, rapid weight gain.       |
|   - CNA Care: Daily morning weights, fluid restrictions, elevate legs.      |
|                                                                             |
|   HYPERTENSION (HTN)                                                        |
|   - Chronic elevated arterial pressure (BP >= 130/80 mmHg).                 |
|   - CNA Care: Strict BP monitoring, low-sodium diet, orthostatic safety.    |
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Coronary Artery Disease (CAD) & Angina Pectoris

• Pathophysiology: Atherosclerosis (buildup of fatty plaque along the arterial intima) narrows the lumen of the coronary arteries, restricting oxygenated blood delivery to the myocardium.
• Angina Pectoris: When the heart's demand for oxygen exceeds the restricted supply during exertion, emotional stress, or cold exposure, the resident experiences chest pain or pressure known as angina.
• Classic Presentation: Squeezing, pressure, or tightness in the substernal chest that may radiate to the left shoulder, left arm, neck, or jaw. In stable angina, pain typically subsides within minutes of rest or sublingual nitroglycerin administration.
• CNA Responsibilities:
  1. Have the resident stop all physical activity immediately and sit in a comfortable, upright position (Fowler's or semi-Fowler's).
  2. Immediately report the chest pain to the charge nurse.
  3. Never leave the resident unattended while awaiting the nurse.
  4. Note the exact time of onset, duration, character, and location of the pain.
  5. Obtain baseline vital signs (blood pressure, pulse, respirations, pulse oximetry) as directed by the nurse.

Myocardial Infarction (MI / Acute Heart Attack)

• Pathophysiology: Acute complete obstruction of a coronary artery (usually by a ruptured plaque and thrombus), resulting in irreversible ischemic necrosis (death) of myocardial tissue.
• Cardinal Symptoms:
  • Crushing, substernal chest pain, pressure, or "elephant sitting on the chest," not relieved by rest or nitroglycerin.
  • Radiation of pain to left arm, back, neck, jaw, or epigastric region.
  • Profuse cold sweating (diaphoresis), pallor, or cyanosis.
  • Dyspnea (shortness of breath), rapid shallow breathing, orthopnea.
  • Nausea, vomiting, lightheadedness, or sudden syncope (fainting).
• Atypical Presentations in Geriatric Residents, Women, and Diabetics: Elderly residents and diabetics may experience "silent MIs" with minimal chest pain, presenting instead with sudden severe fatigue, unexplained shortness of breath, acute confusion, or epigastric "indigestion."

[!CAUTION] CNA EMERGENCY PROTOCOL FOR SUSPECTED HEART ATTACK

1. STAY WITH THE RESIDENT: Never leave the resident alone.
2. CALL FOR HELP IMMEDIATELY: Use the emergency call bell or call loudly for the charge nurse to initiate emergency medical services (EMS/911).
3. POSITION FOR COMFORT: Assist the resident into a semi-Fowler's or high-Fowler's position to ease the work of breathing and decrease venous return to the heart.
4. LOOSEN RESTRICTIVE CLOTHING: Unbutton tight collars, belts, or waistbands.
5. ADMINISTER VITAL SIGNS MONITORING: Take BP, apical/radial pulse, and oxygen saturation immediately.
6. DO NOT GIVE FOOD OR FLUIDS: Keep the resident NPO (nothing by mouth) in case emergency cardiac catheterization or surgery is required.
7. SCOPE BOUNDARY: CNAs never administer nitroglycerin or aspirin unless working under specific certified medication technician authorizations and direct RN delegation.

Congestive Heart Failure (CHF)

• Pathophysiology: The diseased heart muscle weakens and cannot pump blood effectively to meet bodily metabolic needs.
  • Left-Sided Failure: Blood backs up into the pulmonary veins and capillaries, causing pulmonary congestion, pulmonary edema, dyspnea, orthopnea (inability to breathe while lying flat), and coughing up pink, frothy sputum.
  • Right-Sided Failure: Blood backs up into the systemic venous circulation, causing peripheral dependent edema (swelling in feet, ankles, and sacrum), jugular vein distention (JVD), and ascites (abdominal fluid retention).

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|                      DAILY WEIGHT PROTOCOL FOR CHF RESIDENTS                |
|                                                                             |
|   1. SAME SCALE -------> Always use the exact same calibrated scale.        |
|   2. SAME TIME --------> Measure every morning at the exact same hour.      |
|   3. AFTER VOIDING ----> Weigh immediately after the resident voids urine.  |
|   4. BEFORE BREAKFAST -> Weigh before eating, drinking, or receiving fluids.|
|   5. SAME CLOTHING ----> Weigh in same type of gown or light clothing.      |
|   6. RECORD & REPORT --> Report weight gain > 2-3 lbs in 1 day or           |
|                          > 5 lbs in 1 week to the charge nurse immediately. |
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CNA Nursing Interventions for CHF:

• Daily Weight Accuracy: The single most sensitive clinical indicator of acute fluid retention is rapid weight gain. Follow the rigid daily weight protocol illustrated above.
• Positioning: Maintain the resident in a High-Fowler's position (60–90 degrees) to allow diaphragm expansion and reduce pulmonary venous pressure. Use extra pillows or an overbed cardiac table for support.
• Fluid Restriction Compliance: Strictly adhere to physician-ordered fluid restrictions (e.g., 1,500 mL/24 hours). Accurately record every milliliter of liquid intake (including ice chips, soups, gelatin, and coffee) and output on the I&O flowsheet.
• Low-Sodium (NAS) Diet Enforcement: Ensure the resident receives a "No Added Salt" (NAS) diet to prevent sodium-induced water retention. Discourage adding table salt or eating high-sodium processed foods.
• Anti-Embolism Stockings (TED Hose): Apply prescribed TED hose before the resident gets out of bed in the morning while legs are least swollen. Remove every shift to inspect skin for redness or breakdown.

Hypertension (HTN)

• Clinical Definition: Persistent systemic blood pressure measurement of 130/80 mmHg or higher. Known as the "silent killer" because it frequently produces no overt symptoms until target-organ damage occurs (stroke, kidney failure, heart failure).
• Orthostatic Hypotension Safety: When hypertensive residents take antihypertensive medications, rapid positional changes can cause sudden blood pressure drops upon standing. CNAs must always have residents dangle their legs over the edge of the bed for 1–2 minutes before standing, and monitor for dizziness, lightheadedness, or blurred vision.

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2. Chronic Respiratory Disorders & Oxygen Therapy Safety

The respiratory system delivers ambient oxygen to the alveoli for capillary gas exchange and expels carbon dioxide. Chronic respiratory diseases severely impair oxygenation, cause chronic dyspnea, and require rigorous nursing assistant vigilance.

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|                  RESPIRATORY PATHOLOGIES & CLINICAL SIGNS                   |
|                                                                             |
|   CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)                              |
|   - Chronic Bronchitis: Chronic airway inflammation, excessive mucus, cough.|
|   - Emphysema: Destruction of alveolar walls, loss of elastic recoil, air   |
|     trapping, "barrel chest", chronic carbon dioxide retention.             |
|   - CNA Care: Pursed-lip breathing, High Fowler's/Orthopneic positioning,   |
|     small frequent meals, never adjust oxygen flow rate without RN order.   |
|                                                                             |
|   PNEUMONIA (ASPIRATION / INFECTIOUS)                                       |
|   - Acute lung inflammation with alveolar exudate/consolidation.            |
|   - Fever, chills, productive cough (green/rust sputum), tachypnea, hypoxia.|
|   - CNA Care: Upright 90 deg during all meals, monitor O2 saturation.       |
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Chronic Obstructive Pulmonary Disease (COPD) Management

• Understanding Hypoxic Drive: In healthy individuals, elevated blood carbon dioxide ($CO_2$) triggers the urge to breathe. In chronic COPD residents with persistent high $CO_2$ levels, the brain adapts and switches to relying on low blood oxygen levels (hypoxic drive) to stimulate breathing. Administering excessive oxygen flow rates can suppress this respiratory drive, leading to respiratory depression or arrest.
• Pursed-Lip Breathing: An effective technique that residents with COPD use to prolong exhalation, increase airway pressure, and prevent alveolar collapse. CNAs should coach residents: "Inhale slowly through your nose for 2 counts, then exhale gently through puckered lips for 4 counts."
• Orthopneic Positioning: Residents with severe COPD frequently breathe easiest leaning forward over an overbed table cushioned with pillows. This posture maximizes diaphragmatic descent and chest expansion.

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|               RESPIRATORY POSITIONING & COMFORT MATRIX                      |
|                                                                             |
|   HIGH FOWLER'S (60°–90°)        ORTHOPNEIC (OVERBED TABLE)                 |
|   +--------------------------+   +--------------------------------------+   |
|   | Resident sits upright in |   | Resident sits at bedside leaning     |   |
|   | bed with head elevated   |   | forward onto overbed table cushioned |   |
|   | 60 to 90 degrees.        |   | with pillows.                        |   |
|   | Relieves abdominal organ |   | Maximizes chest cavity expansion and |   |
|   | pressure on diaphragm.   |   | lung capacity during acute dyspnea.  |   |
|   +--------------------------+   +--------------------------------------+   |
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Pneumonia & Aspiration Prevention

• Pneumonia: An infection of one or both lungs where alveoli fill with pus and fluid. Geriatric residents are exceptionally susceptible due to weakened immune defenses and diminished cough reflex.
• Aspiration Pneumonia: Occurs when food particles, liquids, saliva, or vomitus are inhaled into the bronchial tree and lungs.
• CNA Aspiration Prevention Protocols:
  • Maintain the resident in a strict upright 90-degree High-Fowler's position during all oral intake (meals, snacks, medications, sips of water).
  • Ensure the resident remains upright for at least 30 to 60 minutes after eating.
  • Strictly observe speech therapist dietary orders (e.g., pureed foods, honey-thick liquids).
  • Offer small bites (1/2 teaspoon), feed slowly, and allow the resident to swallow twice between bites.
  • Stop feeding immediately if coughing, choking, wet gurgling voice, or watery eyes occur, and notify the nurse.

Strict Oxygen Therapy Safety Rules for CNAs

Oxygen supports combustion—it is not explosive itself, but it makes any fire burn much faster and hotter.

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|                     OXYGEN SAFETY RULES FOR NURSING ASSISTANTS              |
|                                                                             |
|   [!] PRESCRIBED DRUG ---> Oxygen is a medical drug ordered by physician.   |
|                            CNAs NEVER change, titrate, or adjust flow rate. |
|   [!] NO SMOKING --------> Prominently post "NO SMOKING / OXYGEN IN USE"    |
|                            signs outside room and on bedside wall.          |
|   [!] NO OPEN FLAMES ----> Prohibit matches, lighters, candles, open flames |
|                            within 10-15 feet of oxygen delivery systems.    |
|   [!] NO PETROLEUM ------> NEVER use petroleum jelly, Vaseline, or oil-     |
|                            based chapstick (use water-soluble K-Y jelly).   |
|   [!] STATIC & ELECTRICAL->Use 100% cotton blankets; ensure all electrical  |
|                            devices (razors, fans) are properly grounded.    |
|   [!] TANK SAFETY -------> Secure portable oxygen cylinders upright in      |
|                            approved metal carts or wall-mounted brackets.   |
|   [!] SKIN INTEGRITY ----> Check behind ears, cheekbones, and nares for     |
|                            pressure injury every shift; maintain pad guards.|
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[!IMPORTANT] OXYGEN CANNULA & SKIN CARE PROTOCOL

• Ensure nasal prongs curve downward and inward toward the nasal passages.
• Inspect the skin behind both ears and around the nostrils at least once per shift for redness, indentation, or friction breakdown.
• Verify that the oxygen flowmeter ball or dial matches the exact physician-ordered liters per minute (L/min) on the care plan. If the flow rate is incorrect or the resident complains of severe dyspnea, notify the nurse immediately—never adjust the dial yourself.
• Check that the humidifier bottle contains sterile/distilled water and is bubbling gently.

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3. Endocrine Disorders: Diabetes Mellitus & Metabolic Emergencies

The endocrine system consists of glands that secrete hormones into the bloodstream to regulate metabolism, growth, and homeostasis. Diabetes Mellitus is the most common and clinically impactful endocrine disorder encountered in long-term care.

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|                       TYPES OF DIABETES MELLITUS                            |
|                                                                             |
|   TYPE 1 DIABETES (AUTOIMMUNE)        TYPE 2 DIABETES (INSULIN RESISTANT)   |
|   - Pancreas produces NO insulin      - Pancreas produces insufficient      |
|     due to autoimmune destruction       insulin or body cells resist it.    |
|     of beta cells in islets.          - 90–95% of geriatric diabetes cases. |
|   - Requires daily insulin injections - Managed by diet, exercise, oral     |
|     for survival.                       antidiabetic agents, or insulin.    |
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Acute Metabolic Emergencies: Hypoglycemia vs. Hyperglycemia

A Certified Nursing Assistant must memorize the distinguishing characteristics, rapid onset, and life-saving interventions for both acute diabetic emergencies.

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|              HYPOGLYCEMIA vs. HYPERGLYCEMIA DIFFERENTIATION                 |
|                                                                             |
|   HYPOGLYCEMIA (INSULIN SHOCK)        HYPERGLYCEMIA (DIABETIC COMA / DKA)   |
|   "Cold and Clammy, Need Some Candy"  "Warm and Dry, Sugar is High"         |
|                                                                             |
|   - Blood Glucose: < 70 mg/dL         - Blood Glucose: > 200–300 mg/dL      |
|   - Onset: SUDDEN (minutes)           - Onset: GRADUAL (hours to days)      |
|   - Skin: Pale, cool, clammy, sweating- Skin: Warm, flushed, dry            |
|   - Neurological: Shaky, trembling,   - Neurological: Drowsy, lethargic,    |
|     dizzy, irritable, confused, slurred weak, confused, stupor             |
|   - Respiration: Normal or shallow    - Respiration: Deep, rapid (Kussmaul) |
|   - Breath Odor: Normal               - Breath Odor: Fruity, sweet acetone  |
|   - Cardinal Signs: Hunger, headache  - Cardinal Signs: The 3 "P's":        |
|                                         Polyuria (excess urination)         |
|                                         Polydipsia (excess thirst)          |
|                                         Polyphagia (excess hunger)          |
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CNA Actions in Diabetic Emergencies

1. Hypoglycemic Crisis:
   • Immediate Notification: Report to the charge nurse instantly.
   • Conscious Resident: If the resident is conscious and able to swallow safely, and if directed by the nurse or care plan, provide 15 grams of fast-acting simple carbohydrate (4 oz orange juice, 4 oz regular soda, 3–4 glucose tablets, or 1 tablespoon honey).
   • Unconscious or Dysphagic Resident: Never put fluids or food into the mouth of an unresponsive or choking resident. Position them on their side to prevent aspiration and summon the nurse for emergency intramuscular glucagon or IV dextrose administration.
2. Hyperglycemic Crisis:
   • Immediately report findings to the charge nurse.
   • Assist the nurse with blood glucose testing and vital signs collection.
   • Encourage water consumption if ordered and resident is alert.

Rigid Diabetic Foot Care Protocol

Diabetic peripheral neuropathy (loss of nerve sensation) and peripheral arterial disease (poor blood circulation) make the feet of diabetic residents vulnerable to severe infections, non-healing pressure ulcers, and lower extremity amputations.

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|                     DIABETIC FOOT CARE PROTOCOL FOR CNAs                    |
|                                                                             |
|   1. DAILY INSPECTION ---> Inspect all surfaces of feet, heels, and between |
|                            toes daily for redness, blisters, cuts, or sores.|
|   2. WARM WATER WASH ----> Wash feet daily using mild soap and warm water   |
|                            (95°F–105°F); test temperature with bath thermo. |
|   3. THOROUGH DRYING ----> Pat dry gently with a soft towel; ensure the skin|
|                            BETWEEN THE TOES is completely dry.              |
|   4. MOISTURIZE PROPERLY-> Apply lotion to heels and soles to prevent cracks|
|                            [!] NEVER APPLY LOTION BETWEEN THE TOES!         |
|   5. PROPER FOOTWEAR ----> Ensure clean, seamless, dry cotton socks and     |
|                            supportive, closed-toe shoes; NEVER GO BAREFOOT. |
|   6. NAIL CARE RESTRICTION>[!] CNAs MUST NEVER CLIP OR TRIM DIABETIC TOENAILS|
|                            (Podiatrist or RN care only).                    |
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[!CAUTION] CRITICAL DIABETIC FOOT CARE PROHIBITIONS FOR CNAs

• NEVER USE SCISSORS OR CLIPPERS: In Arizona and under standard long-term care regulations, CNAs are strictly forbidden from clipping, trimming, or digging at the toenails of a diabetic resident. Even a microscopic nick can lead to gangrene and amputation. Toenails must be filed gently or referred to a licensed podiatrist or RN.
• NEVER APPLY LOTION BETWEEN TOES: Moisture trapped between toes creates a dark, warm breeding ground for fungal and bacterial infections (maceration and tinea pedis), leading to skin breakdown.
• NEVER APPLY DIRECT HEAT: Do not apply heating pads, hot water bottles, or hot soaks to diabetic feet due to reduced thermal sensation and high risk of severe third-degree burns.