Chronic Physical Conditions and Pain Management

Chronic Physical Conditions and Pain Management

Domain V on the Delaware Prometric exam includes residents living with long-term physical changes: bowel and bladder problems, special nutrition routes, oxygen therapy, fragile skin, and pain. These topics also appear in everyday nursing-home practice under DHCQ-regulated care. The CNA does not “treat” chronic disease the way a nurse or physician does. You implement the care plan, protect safety, notice change early, and give the licensed nurse a clear picture so interventions can start before a small problem becomes sepsis, aspiration, hypoxia, or a stage-worsening pressure injury.

Chronic illness often stacks on normal aging: slower gut motility, thinner skin, reduced thirst awareness, and more medication side effects. Maslow’s hierarchy still guides priorities—airway and oxygen needs, toileting dignity, nutrition, pain relief advocacy, and belonging when illness isolates people.

Elimination Changes: Incontinence, Constipation, and Ostomies

Urinary and bowel incontinence

Incontinence is loss of bladder or bowel control. Causes include infection, mobility limits, cognitive impairment, medications, and sphincter weakness—not “laziness.” CNA care focuses on:

• Prompt response to call lights and toileting schedules on the care plan
• Privacy, respect, and matter-of-fact attitude (shame deepens depression)
• Thorough perineal care after episodes; clean, dry skin; barrier cream only as directed
• Correct brief size and timely changes—never “wait until the end of the shift” if soiled
• Observation of urine/stool: color, amount, odor, blood, mucus, frequency
• Hydration encouragement unless restricted; report signs of UTI (burning if reported, frequency, foul urine, new confusion in older adults)

Never scold a resident for incontinence. Never restrict fluids as a CNA “solution” to reduce wet beds.

Constipation and diarrhea

Older adults and immobile residents are high risk for constipation. Clues: hard stools, straining, bloating, reduced appetite, irritability, or no bowel movement within the resident’s normal pattern. Report absences of stool per facility bowel protocol, abdominal hard distention, vomiting, or severe pain—possible impaction or obstruction needs nursing assessment. Encourage ordered fluids, fiber foods if diet allows, and mobility/ambulation as able. Do not give laxatives; that is a nursing/medication role.

Diarrhea risks dehydration and skin breakdown. Count episodes, note blood or black stool, maintain skin care, use infection-control practices if infectious cause is possible, and report promptly.

Colostomy and ileostomy observation

Some residents have a surgically created stoma and pouch. CNAs who are facility-trained may assist with pouch emptying or changes only as allowed by training, policy, and assignment. Universal CNA duties include:

• Observing stoma color (healthy stomas are typically moist and pink/red—report pale, dark, or dusky appearance)
• Noting output amount and character; report bleeding, severe skin irritation around the stoma, pouch leaks, or resident distress
• Protecting dignity and odor control without showing disgust
• Not irrigating colostomies or performing skilled procedures outside training

Nutritional Changes: Restrictions, Nausea, Tubes, and IVs

Chronic disease brings therapeutic diets (sodium restriction, carbohydrate control, pureed texture, thickened liquids). The CNA verifies the tray against the diet order, sits residents upright for meals when allowed, uses aspiration precautions for dysphagia, and reports poor intake, choking, pocketing food, or new nausea.

Nausea, vomiting, and appetite loss

Offer oral care, remove strong odors, serve preferred allowed foods in smaller amounts, and keep the head elevated after vomiting as appropriate. Measure and report emesis characteristics. Watch for dehydration: dry mouth, poor intake, concentrated urine, dizziness.

Tube feeding and IV therapy—observe, protect, report

Enteral tubes (NG, gastrostomy/PEG) and intravenous lines are nursing-managed devices. Delaware CNA scope does not include independently inserting tubes, starting IVs, adjusting pump rates, or deciding feeding formulas. Within facility training you may:

• Keep the head of bed elevated (often 30–45°) during and after feedings as ordered to reduce aspiration risk
• Avoid pulling on tubing; secure loose clothing; report if the tube is dislodged
• Report pump alarms, resident coughing, cyanosis, vomiting, abdominal distention, or residual concerns the nurse evaluates
• Provide mouth care (NPO residents still need oral hygiene)
• For IVs: report redness, swelling, pain, wet dressings, or blood in tubing; do not disconnect or restart IV pumps

If a tube comes out, do not reinsert; cover/protect per policy, stay calm, and get the nurse immediately.

Oxygen Safety and Observation

Many residents use oxygen by nasal cannula or mask for chronic lung disease or acute need. Oxygen supports life but is a fire accelerant and a medical therapy licensed staff control.

CNA oxygen safety rules

• No smoking, candles, or open flames near oxygen; enforce “Oxygen in Use” precautions
• Avoid petroleum-based products around the nose if facility policy restricts them; use approved lubricants only
• Keep tubing free of kinks; check that the cannula is in the nostrils and that ears/cheeks are not skin-broken from tubing pressure
• Secure portable cylinders upright; never allow tanks to fall or be stored in heat
• Know where shutoffs are for fire response per facility training
• Do not change the ordered flow rate—if the resident seems short of breath, cyanotic, anxious, or the tank is empty, report to the nurse; only licensed staff adjust oxygen
• Observe respiratory rate, color, cough, sputum, and pulse oximetry only if trained and assigned—still report, do not “fix” the number by changing O₂

On exam items, the wrong answer is almost always “turn the oxygen up to help” without a nurse.

Skin Integrity and Pressure Ulcer Concepts for Reporting

Chronic immobility, moisture, poor nutrition, and friction create pressure injuries (pressure ulcers). Domain III covers prevention in depth; Domain V expects you to recognize and report skin failure related to health change.

Teaching concepts (staging language is for communication; the nurse stages formally):

• Stage-type observations you may describe factually: intact skin with non-blanchable redness; blister or partial-thickness open area; deeper open wound with visible tissue; dark, hard, or maroon areas that may indicate deep tissue injury; wounds covered with eschar that cannot be staged until cleared by nursing
• Never massage reddened bony prominences
• Reposition per care plan (commonly at least every 2 hours in bed)
• Keep skin clean and dry; manage incontinence quickly
• Report new redness that does not fade, open areas, drainage, odor, or pain over pressure points the same shift

Your documentation should describe what you see (location, size estimate if trained, color, drainage)—not a self-assigned medical stage if policy reserves staging for licensed staff. The exam cares that you escalate early.

Pain: Location, Scale, Behavior, and Advocacy

Pain may be acute (fracture, post-op) or chronic (arthritis, neuropathy, cancer). Older adults may underreport pain, and residents with dementia may show behavior instead of words: guarding, grimacing, moaning, resisting care, rocking, sudden aggression, or change in usual routine.

What to include in a pain report

1. Location — where it hurts; radiates?
2. Intensity — facility pain scale (0–10) or approved behavioral scale
3. Quality — sharp, dull, burning, cramping (use the resident’s words)
4. Timing — onset, constant vs intermittent, after movement or dressing change
5. Aggravating/alleviating factors — what makes it better or worse
6. Associated signs — nausea, sweating, vital sign changes if you are assigned to take them
7. Effect on function — cannot bear weight, refuses therapy, cannot sleep

CNAs do not choose pain medication or increase doses. You report promptly, position for comfort, use nonpharmacologic supports allowed on the care plan (repositioning, quiet environment, warm blanket if safe, distraction, hand-holding if welcomed), and reassess after nursing intervention when asked.

Cultural and spiritual factors shape how people express pain—some are stoic; some are vocal. Believe the resident’s report; do not say “it can’t hurt that much.”

Integrating Chronic Care on the Exam and on the Unit

Prometric Domain V items often combine themes: a resident on oxygen who is short of breath, a PEG tube with coughing during feeding time, a reddened coccyx, or a grimacing resident who denies “being a bother.” The scoring logic is consistent: safety first, stay in scope, report complete observations, protect dignity. Delaware CNAs who master chronic physical observation become the nurse’s most reliable early-warning system—and that is exactly what specialized care questions measure.