10.1 Cardiovascular & Respiratory Chronic Conditions

Cardiovascular & Respiratory Chronic Conditions

Cardiovascular and respiratory diseases represent the leading causes of morbidity, hospitalization, and mortality in geriatric and long-term care populations. Because the circulatory and respiratory systems operate in tight physiological synergy to supply cellular oxygen and eliminate carbon dioxide, impairment in one system rapidly destabilizes the other. Certified Nursing Assistants (CNAs) provide over 80% of direct bedside observation and must rapidly recognize early signs of cardiopulmonary decompensation, implement comfort positioning, support therapeutic dietary and fluid regimens, and enforce strict oxygen therapy safety protocols.

+-----------------------------------------------------------------------------+
|                 CARDIOPULMONARY DISORDERS & CNA CARE SUMMARY                |
|                                                                             |
|   [HYPERTENSION (HTN)]   ---> 'Silent Killer' / Asymptomatic; Sodium Limit  |
|                               Orthostatic BP: Dangle on bed edge 1-2 min    |
|   [CORONARY ARTERY/CAD]  ---> Plaque Narrowing; Angina (Relieved by Rest/NTG)|
|   [MYOCARDIAL INFARCTION]---> Crushing Chest Pain, Left Arm/Jaw, Diaphoresis|
|                               Atypical in Women/Elderly: Fatigue, Heartburn |
|                               EMERGENCY: Push Call Light, High Fowler's!    |
|   [HEART FAILURE (CHF)]  ---> Left: LUNGS (Crackles, Dyspnea, Orthopnea)    |
|                               Right: BODY (Pitting Edema, JVD, Ascites)     |
|                               Daily Morning Weight: Alert >=2-3 lbs/24 hours|
|   [COPD / EMPHYSEMA]     ---> Barrel Chest, Tripod Position, Pursed-Lip Br. |
|                               Low-Flow Oxygen (1-2 L/min); Activity Pacing  |
|   [TUBERCULOSIS (TB)]    ---> Mycobacterium tuberculosis; Airborne Droplets |
|                               Night Sweats, Hemoptysis, Weight Loss         |
|                               AIRBORNE PRECAUTIONS: N95 Respirator & AIIR   |
|   [OXYGEN THERAPY SAFETY]---> CNA NEVER Adjusts Flow Rate (Nurse Only!)     |
|                               Prongs Curve DOWN; Water-Based Lubricant ONLY |
|                               NO Petroleum Jelly / Vaseline (Combustion Risk)|
+-----------------------------------------------------------------------------+

1. Hypertension (HTN): The "Silent Killer" & Orthostatic Precautions

Pathophysiology & Diagnostic Thresholds

Hypertension (HTN) is a chronic medical condition characterized by persistent elevation of systemic arterial blood pressure ($Systolic \ge 130\text{ mmHg}$ or $Diastolic \ge 80\text{ mmHg}$). Under current American Heart Association (AHA) and clinical guidelines:

• Normal Blood Pressure: Systolic $<120\text{ mmHg}$ and Diastolic $<80\text{ mmHg}$.
• Elevated Blood Pressure: Systolic $120\text{ to }129\text{ mmHg}$ and Diastolic $<80\text{ mmHg}$.
• Stage 1 Hypertension: Systolic $130\text{ to }139\text{ mmHg}$ or Diastolic $80\text{ to }89\text{ mmHg}$.
• Stage 2 Hypertension: Systolic $\ge 140\text{ mmHg}$ or Diastolic $\ge 90\text{ mmHg}$.
• Hypertensive Crisis: Systolic $>180\text{ mmHg}$ and/or Diastolic $>120\text{ mmHg}$ (immediate emergency).

+-----------------------------------------------------------------------------+
|                         HYPERTENSION CLINICAL PROFILE                       |
|                                                                             |
|   [PRIMARY RISK FACTORS] ---> Aging, Arteriosclerosis, High Sodium Intake,  |
|                               Obesity, Sedentary Lifestyle, Chronic Stress  |
|   [TARGET ORGAN DAMAGE]  ---> Stroke (Brain), MI (Heart), Nephrosclerosis   |
|                               (Kidneys), Retinopathy (Eyes)                 |
|   [WARNING SIGNS]        ---> Occipital Headaches, Epistaxis (Nosebleeds),  |
|   (WHEN SEVERE)               Dizziness, Blurred Vision, Tinnitus           |
|   [CNA CARE MEASURES]    ---> Accurate BP Measurement, Low-Sodium DASH Diet,|
|                               Orthostatic Dangling Protocol, Immediate Alert|
+-----------------------------------------------------------------------------+

Hypertension is universally termed the "silent killer" because millions of individuals experience zero physical symptoms for years while sustained high intravascular pressure progressively destroys delicate vascular endothelial beds, accelerating atherosclerosis, kidney failure, cerebral aneurysms, and left ventricular hypertrophy.

Orthostatic (Postural) Hypotension & The Dangling Protocol

Many hypertensive residents receive antihypertensive medications (e.g., beta-blockers, ACE inhibitors, diuretics) that blunt the autonomic vascular constriction reflex upon standing, causing orthostatic hypotension.

• Definition: A sudden drop in systolic blood pressure of $\ge 20\text{ mmHg}$ or a drop in diastolic blood pressure of $\ge 10\text{ mmHg}$ within 3 minutes of assuming an upright sitting or standing posture.
• Symptoms: Sudden dizziness, lightheadedness, blurred/dimmed vision, feeling faint (presyncope), and syncope (loss of consciousness), creating an extreme fall risk.
• The CNA Dangling Protocol:
  1. Before transferring or ambulating a resident from a supine (bed) position, assist them into a seated position on the edge of the bed.
  2. Allow the resident's feet to dangle flat on the floor or stool for 1 to 2 full minutes.
  3. Ask the resident: "Do you feel dizzy or lightheaded?"
  4. Observe facial color for sudden pallor.
  5. Only proceed with standing and transfer once the resident confirms complete stability and normal equilibrium. If dizziness occurs, assist the resident back into a recumbent bed position immediately and notify the charge nurse.

2. Coronary Artery Disease (CAD), Angina Pectoris & Myocardial Infarction

+-----------------------------------------------------------------------------+
|                        CORONARY ARTERY DISEASE SPECTRUM                     |
|                                                                             |
|   [ATHEROSCLEROSIS]      ---> Lipid plaques narrow coronary arteries        |
|                                      |                                      |
|                                      v                                      |
|   [ANGINA PECTORIS]      ---> Transient myocardial ischemia (<15 min)       |
|                               Relieved by rest and nitroglycerin (NTG)      |
|                                      |                                      |
|                                      v                                      |
|   [MYOCARDIAL INFARCTION]---> Complete arterial occlusion & muscle necrosis |
|                               Unrelieved by rest/NTG; EMERGENCY!            |
+-----------------------------------------------------------------------------+

Coronary Artery Disease (CAD) & Angina Pectoris

Coronary Artery Disease (CAD) occurs when the coronary arteries supplying oxygenated blood to the myocardium become narrowed and hardened by atherosclerotic plaques. When myocardial oxygen demand exceeds available supply (such as during physical exertion, emotional agitation, or exposure to cold), the resident experiences Angina Pectoris (cardiac chest pain).

• Characteristics of Angina: A sensation of squeezing, heaviness, tightness, or burning behind the sternum; may radiate to the left shoulder, jaw, or neck. It typically lasts 3 to 5 minutes (rarely $>15\text{ minutes}$) and is relieved promptly by physical rest and sublingual nitroglycerin (NTG).
• CNA Action for Angina:
  1. Stop all resident physical activity immediately.
  2. Place the resident in a seated position (Semi-Fowler's or Fowler's position) to reduce venous return and lower myocardial oxygen demand.
  3. Push the call light to summon the licensed nurse immediately for sublingual nitroglycerin administration.
  4. Stay with the resident, provide calm reassurance, and measure vital signs.

Myocardial Infarction (MI / Heart Attack): Classic vs. Atypical Presentations

A Myocardial Infarction (MI) is an acute, life-threatening medical crisis occurring when a coronary artery is completely occluded by a thrombus, resulting in prolonged ischemia and irreversible necrosis (cellular death) of cardiac muscle fibers.

+-----------------------------------------------------------------------------+
|                   CLASSIC VS. ATYPICAL HEART ATTACK SYMPTOMS                |
|                                                                             |
|   [CLASSIC PRESENTATION]                    [ATYPICAL PRESENTATION]         |
|   (Standard / Male Profile)                 (Women, Diabetics, Elderly)     |
|   - Crushing, heavy, substernal pain        - Unexplained profound fatigue  |
|     ("elephant sitting on chest")           - Epigastric burning / heartburn|
|   - Radiation to left arm, neck, jaw,       - Sudden shortness of breath    |
|     throat, or back                           without overt chest pain      |
|   - Profuse cold diaphoresis                - Nausea, vomiting, indigestion |
|   - Severe dyspnea, nausea, dizziness       - Acute confusion / delirium    |
|   - Feeling of impending doom               - Ashen pallor, mild dizziness  |
+-----------------------------------------------------------------------------+

Detailed Comparison Table: Angina Pectoris vs. Acute Myocardial Infarction

CNA Emergency Action Protocol for Suspected Acute MI:

1. ACTIVATE EMERGENCY SYSTEM & NEVER LEAVE: Press the emergency call button or call out loudly for help. Never leave the resident unattended.
2. Position for Hemodynamic Relief: Place the resident in High Fowler's position (head of bed elevated $60^\circ\text{ to }90^\circ$) to reduce venous return to the heart, lower cardiac workload, and maximize thoracic expansion.
3. Loosen Restrictive Clothing: Immediately unbutton tight collars, loosen belts, and remove restrictive garments.
4. Provide Calm Reassurance: Anxiety triggers sympathetic catecholamine release (adrenaline), driving up heart rate and oxygen consumption. Speak in a quiet, steady, reassuring voice.
5. Retrieve Emergency Equipment: Obtain the vital signs cart, pulse oximeter, and facility Automated External Defibrillator (AED) as directed by the nurse.
6. Scope Boundary: Never attempt to give oral fluids, food, or unauthorized medications unless explicitly directed by the licensed nurse.

3. Congestive Heart Failure (CHF): Left vs. Right Decompensation & Daily Weight Monitoring

Congestive Heart Failure (CHF) is a chronic, progressive cardiovascular syndrome in which the weakened myocardium cannot pump a sufficient volume of blood to meet the metabolic and oxygenation demands of body tissues, causing fluid and hydrostatic pressure to back up into the lungs and systemic venous circulation.

+-----------------------------------------------------------------------------+
|               CONGESTIVE HEART FAILURE: LEFT VS. RIGHT PATHOLOGY            |
|                                                                             |
|   [LEFT-SIDED HEART FAILURE]          [RIGHT-SIDED HEART FAILURE]           |
|   "L" = LUNGS                         "R" = REST OF BODY                    |
|   - Left ventricle fails              - Right ventricle fails               |
|   - Blood backs up into lungs         - Blood backs up into systemic veins  |
|   - Pulmonary edema & crackles        - Dependent peripheral pitting edema  |
|   - Shortness of breath (Dyspnea)     - Jugular Venous Distention (JVD)     |
|   - Orthopnea (needs 2-3 pillows)     - Ascites & abdominal distension      |
|   - Paroxysmal nocturnal dyspnea      - Hepatomegaly (enlarged liver)       |
|   - Pink, frothy sputum (CRISIS!)     - Sudden rapid weight gain            |
+-----------------------------------------------------------------------------+

Clinical Comparison Matrix: Left-Sided vs. Right-Sided Heart Failure

Mandatory CNA Clinical Care Protocols for CHF:

1. Daily Morning Weight Monitoring (The Ultimate Clinical Indicator):

   • Fluid retention accumulates long before visible peripheral edema appears. A gain of 1 liter ($1,000\text{ mL}$) of fluid equals approximately $2.2\text{ pounds } (1\text{ kg})$.
   • Standardized Weighing Rules:
     • Weigh the resident every morning immediately after their first void.
     • Weigh before breakfast (fasting state).
     • Use the exact same calibrated scale each day.
     • Ensure the resident wears the exact same type of light clothing without heavy shoes or robes.
     • Record the measurement immediately in the medical record.
   • The Critical Weight Alert Threshold:

     [!IMPORTANT] CHF Weight Escalation Rule: A sudden weight gain of $\ge 2\text{ to }3\text{ pounds in 24 hours}$ or $\ge 5\text{ pounds in 1 week}$ represents acute intravascular and interstitial fluid overload. The CNA must verbally report this finding to the charge nurse immediately.

2. Strict Fluid Restrictions:

   • Residents with CHF are commonly ordered on strict daily fluid allowances (e.g., $1,200\text{ to }1,500\text{ mL/24 hours}$).
   • The CNA must divide fluid allowances across shifts (typically $50%$ on day shift, $33%$ on evening shift, remainder on night shift).
   • Record every milliliter of oral fluid intake (water, coffee, tea, soup, gelatin, ice cream, ice chips counted as $50%$ liquid volume).
   • Remove large water pitchers from the bedside if the resident tends to drink uncontrollably.

3. Low-Sodium Nutritional Support:

   • Strictly enforce prescribed Low-Sodium (2-gram sodium) diets. Sodium acts as an osmotic sponge, causing severe fluid retention. Ensure no table salt shakers are on meal trays.

4. Therapeutic Positioning:

   • Position the resident in Fowler's or High Fowler's position to ease breathing.
   • Elevate swollen lower extremities on pillows above heart level when seated in a chair to facilitate venous return, ensuring no direct pressure is placed behind the popliteal space (knee crease).

4. Chronic Respiratory Conditions: COPD, Pneumonia, Asthma & Tuberculosis

+-----------------------------------------------------------------------------+
|                       RESPIRATORY PATHOLOGY OVERVIEW                        |
|                                                                             |
|   [COPD / EMPHYSEMA]     ---> Chronic Obstruction, Loss of Alveolar Elasticity|
|                               Barrel Chest (1:1 AP), Tripod Position, Pursed|
|                               Low-Flow Oxygen (1-2 L/min) via Nasal Cannula |
|   [PNEUMONIA]            ---> Acute Lung Parenchyma Infection & Exudate,     |
|                               Fever/Chills, Rust/Purulent Sputum, Tachypnea |
|                               Atypical Presentation in Elderly: Confusion!  |
|   [BRONCHIAL ASTHMA]     ---> Reversible Airway Spasms, Expiratory Wheezing  |
|   [TUBERCULOSIS (TB)]    ---> Mycobacterium tuberculosis; Airborne Droplets |
|                               Night Sweats, Hemoptysis, Weight Loss         |
|                               AIRBORNE PRECAUTIONS: N95 Respirator & AIIR   |
+-----------------------------------------------------------------------------+

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive, irreversible respiratory disorder characterized by persistent airflow limitation. It encompasses two primary pathological entities that frequently coexist:

1. Chronic Bronchitis: Chronic inflammation and swelling of the mucous membranes lining the bronchi and bronchioles, characterized by excessive mucus production, goblet cell hyperplasia, and a chronic productive cough for at least 3 consecutive months per year for 2 consecutive years ("blue bloaters").
2. Pulmonary Emphysema: Permanent destruction and hyperinflation of the alveoli, loss of elastic lung recoil, and collapse of small bronchioles during exhalation, resulting in severe chronic air trapping ("pink puffers").

Key Clinical Features & CNA Interventions for COPD:

• Barrel Chest: Chronic alveolar hyperinflation expands the rib cage, producing a rounded, barrel-shaped thoracic cavity where the anterior-posterior (AP) diameter equals the transverse diameter ($1:1\text{ ratio}$, compared to the normal $1:2\text{ ratio}$).
• Tripod Positioning: Assist the resident to lean forward with their arms braced on their knees or resting across an overbed table cushioned with pillows. This position drops the diaphragm downward, enhances lung expansion, and recruits accessory sternocleidomastoid and intercostal muscles.
• Pursed-Lip Breathing: Coach the resident to inhale slowly through the nose for 2 seconds, then exhale slowly through puckered/pursed lips for 4 seconds (as if gently flickering a candle flame). This creates positive back-pressure within the airways, preventing premature bronchiolar collapse and releasing trapped carbon dioxide ($CO_2$).
• Low-Flow Oxygen Principle ($1\text{ to }2\text{ L/min}$): Residents with advanced COPD retain chronic carbon dioxide, shifting their primary breathing drive from hypercapnia ($CO_2$ elevation) to hypoxemia (low blood $O_2$ levels, known as the hypoxic drive). Administering high concentrations of oxygen can eliminate their stimulus to breathe, precipitating respiratory arrest. Supplemental oxygen must strictly remain at prescribed low flow rates (typically $1\text{ to }2\text{ L/min}$ via nasal cannula).
• Activity Pacing: Structure morning care and ADLs with scheduled rest intervals to avoid severe exertional dyspnea.

Pneumonia

Pneumonia is an acute infection and inflammatory consolidation of the alveolar spaces and bronchioles, causing alveoli to become plugged with purulent exudate, inflammatory cells, and fibrin.

• Classic Clinical Signs: High fever, shaking chills, tachypnea ($>20\text{ bpm}$), pleuritic chest pain on deep inspiration, and a productive cough with thick rust-colored (characteristic of Streptococcus pneumoniae), dark green, or yellow purulent sputum.
• The Atypical Geriatric Presentation: In elderly residents, pneumonia frequently presents without overt fever or cough. The hallmark presentation is sudden acute confusion (delirium), progressive lethargy, anorexia, tachypnea, and sudden functional decline.
• CNA Care: Maintain head of bed elevated in Fowler's position, encourage fluid intake to thin viscous bronchial secretions (if not on cardiac/renal fluid restrictions), assist with deep breathing and coughing exercises, and immediately report any sputum changes.

Asthma

Asthma is a chronic inflammatory disorder of the airways characterized by episodic, reversible bronchospasms, mucosal edema, and hypersecretion of thick, tenacious mucus triggered by allergens, cold air, exercise, respiratory infections, or stress.

• Signs: High-pitched musical expiratory wheezing, severe dyspnea, chest tightness, nonproductive coughing, and tachypnea.
• CNA Care: Elevate head of bed to High Fowler's, maintain a quiet and calm environment, and notify the charge nurse immediately for administration of prescribed rescue bronchodilator inhalers (e.g., albuterol).

Tuberculosis (TB) & Airborne Isolation Standards

Tuberculosis (TB) is a chronic, contagious bacterial granulomatous infection caused by the acid-fast bacillus Mycobacterium tuberculosis, primarily attacking lung tissue.

• Transmission: Transmitted via tiny airborne droplet nuclei ($<5\text{ micrometers}$) generated when an infected individual coughs, sneezes, speaks, or sings. These microscopic droplets remain suspended in the air for hours.
• Clinical Manifestations:
  • Persistent productive cough lasting longer than 3 weeks.
  • Hemoptysis (expectoration of blood or blood-streaked sputum).
  • Drenching night sweats (waking with soaked sleepwear and sheets).
  • Low-grade afternoon fevers and chronic chills.
  • Unexplained, progressive weight loss and profound anorexia.
  • Chronic physical fatigue and pleuritic chest pain.

+-----------------------------------------------------------------------------+
|                  TUBERCULOSIS AIRBORNE ISOLATION PROTOCOLS                  |
|                                                                             |
|   [AIRBORNE PRECAUTIONS] ---> Negative-Pressure Room (AIIR)                 |
|                               6 to 12 air changes/hr; Exhausted outdoors    |
|   [PPE REQUIREMENT]      ---> Fit-tested N95 RESPIRATOR (or PAPR)           |
|                               Must be donned BEFORE entering room           |
|   [ROOM ACCESS CONTROL]  ---> Door MUST remain closed at all times          |
|   [RESIDENT TRANSPORT]   ---> Limit transport; Resident MUST wear a         |
|                               SURGICAL MASK if transport is necessary       |
+-----------------------------------------------------------------------------+

[!IMPORTANT] TB Isolation Rules for the CNA:

1. The resident must be placed in a private Airborne Infection Isolation Room (AIIR) with negative air pressure.
2. Healthcare workers must wear a fit-tested N95 respirator mask (or Powered Air-Purifying Respirator, PAPR) that filters particles down to 0.3 microns. Standard surgical masks do NOT protect against airborne TB bacilli.
3. Don the N95 respirator before entering the room and remove it only after exiting and closing the door.
4. Keep the isolation room door closed at all times.
5. If the resident must leave the room for essential diagnostic testing, place a standard surgical mask on the resident during transport.

5. Oxygen Therapy Safety Guidelines & CNA Scope of Practice

Oxygen ($O_2$) is a classified medical drug prescribed by a licensed healthcare provider to correct arterial hypoxemia ($SpO_2 < 90%$). Because oxygen actively accelerates combustion, rigorous safety protocols and strict scope-of-practice boundaries govern its administration.

+-----------------------------------------------------------------------------+
|                     OXYGEN ADMINISTRATION & SAFETY RULES                    |
|                                                                             |
|   [CNA SCOPE LIMITATION] ---> CNA may NEVER adjust oxygen flow rate (LPM)   |
|                               or turn oxygen tanks on/off (Nurse Only!)     |
|   [NASAL CANNULA]        ---> Curved prongs MUST point DOWNWARD into nares  |
|                               Tubing loops over ears and tightens under chin|
|   [SKIN INSPECTION]      ---> Check RETROAURICULAR (behind ears) & CHEEKBONES|
|                               for pressure breakdown; apply foam padding    |
|   [COMBUSTION SAFETY]    ---> NO SMOKING / OXYGEN IN USE signs posted       |
|                               NO open flames, candles, or electrical sparks |
|                               WATER-BASED LUBRICANTS ONLY (K-Y Jelly)       |
|                               ABSOLUTELY NO PETROLEUM JELLY / VASELINE!     |
+-----------------------------------------------------------------------------+

CNA Scope of Practice & Equipment Standards:

1. Scope Boundary: Oxygen flow rate is ordered in liters per minute (e.g., $2\text{ L/min}$ via nasal cannula). The CNA is strictly prohibited from adjusting the flow meter, changing the flow rate, or initiating/discontinuing oxygen therapy. If the flow rate appears altered, the tubing is disconnected, or the resident requests a change, the CNA must notify the licensed nurse immediately.
2. Nasal Cannula Placement: Verify that the two curved prongs of the nasal cannula point downward into the resident's nostrils, following the natural anatomical curvature of the nasal passages. Loop the flexible plastic tubing snugly over both ears and adjust the sliding cinch comfortably under the chin without constricting the neck.
3. Skin Assessment & Pressure Sore Prevention: Continuous oxygen tubing creates localized mechanical pressure over fragile skin. The CNA must routinely inspect:
   • Behind the ears (retroauricular area): Vulnerable to Stage 1 and Stage 2 pressure injuries from cannula friction. Utilize foam tubing protectors or soft gauze pads behind the ears as directed by the nurse.
   • Cheekbones (malar eminences) & Upper Lip/Nares: Check for erythema, chafing, and skin irritation.

Fire Prevention & The Petroleum Prohibition:

• No Open Flames: Conspicuously post "NO SMOKING / OXYGEN IN USE" signs on the resident's entrance door and at the bedside. Strictly prohibit smoking, lighters, matches, candles, and open flames within the environment.
• Electrical Safety: All electrical equipment (radios, shavers, fans) must have 3-prong grounded plugs and undergo routine safety inspections. Avoid wool and synthetic fabrics that produce static sparks; use $100%$ cotton blankets.
• The Petroleum Prohibition (Critical Exam Concept):
  • Oxygen creates an oxygen-rich atmosphere where combustible hydrocarbons ignite at dramatically lower temperatures.
  • NEVER apply petroleum-based products (such as Vaseline, petroleum jelly, mineral oil, or petroleum lip balms) to the resident's nose, lips, or face while oxygen is in use.
  • Always utilize water-based, water-soluble lubricants (such as K-Y Jelly or water-soluble saline gels) to moisten dry mucous membranes and lips.
• Cylinder Safety: Portable oxygen cylinders must always be stored upright and securely latched in approved metal racks or transport carriers. Never leave freestanding oxygen tanks unsupported.