10.1 Common Chronic Diseases in Long-Term Care
Key Takeaways
- Hypoglycemia is the diabetic emergency a CNA is most likely to witness: it comes on suddenly with shakiness, sweating, pallor, hunger, irritability, and confusion, and it requires the nurse immediately — never insulin, never blood glucose testing by the CNA in most facilities.
- For a resident with diabetes, inspect the feet daily, dry thoroughly between the toes, never cut toenails, never use heating pads or soak the feet, and report any redness, blister, crack, or open area at once.
- The stroke warning signs a CNA must act on are captured by BE FAST — Balance loss, Eyes/vision change, Face drooping, Arm weakness, Speech difficulty, Time to call for help immediately.
- In congestive heart failure, weight gain of two to three pounds in a day, new or worsening ankle and leg edema, shortness of breath lying flat, and a moist cough are early decompensation signs the CNA reports before the resident becomes acutely short of breath.
- Residents with COPD often breathe most easily sitting upright and leaning forward on an overbed table (the orthopneic position); oxygen flow rate is set by the nurse or provider, and a CNA never adjusts the liter flow.
Common Chronic Diseases in Long-Term Care
Disease Process is one of the twelve published North Dakota subject areas, worth five questions. The handbook defines it as "questions dealing with the stages of disease(s) and/or the theory of disease(s) and the detection, prevention, or treatment of disease(s)."
A CNA does not diagnose and does not treat. What a CNA does — and what these questions test — is recognize what a condition looks like when it worsens, adapt daily care to the disease, and report the right observation to the right person at the right time.
1. Diabetes Mellitus
Diabetes is a disorder of glucose regulation. Type 1 results from little or no insulin production and always requires insulin; Type 2, far more common in older adults, involves insulin resistance and is managed with diet, oral medication, and often insulin as well.
The two emergencies, side by side
| Hypoglycemia (low blood sugar) | Hyperglycemia (high blood sugar) | |
|---|---|---|
| Onset | Sudden — minutes | Gradual — hours to days |
| Common causes | Too much insulin, a skipped or vomited meal, unusual exertion | Too little insulin, illness or infection, overeating, stress |
| Skin | Cold, clammy, sweaty, pale | Hot, dry, flushed |
| Behavior | Shaky, irritable, anxious, sudden confusion, staggering | Drowsy, weak, lethargic |
| Other | Hunger, headache, rapid pulse, blurred vision | Extreme thirst, frequent urination, fruity/acetone breath, deep rapid breathing, nausea |
| Progression | Loss of consciousness, seizure | Diabetic ketoacidosis, coma |
[!WARNING] Cold and clammy — needs some candy. Hot and dry — sugar high. This mnemonic is worth memorizing, but the action is the same for both: tell the nurse immediately. Hypoglycemia moves fastest and is the one you are most likely to witness during morning care or after a resident refuses breakfast. Do not give food or fluids to a resident who is not fully alert and able to swallow.
Daily diabetic care the CNA owns
- Meals: serve on time and report exactly how much was eaten. A resident who received insulin and then ate 20% of the tray is heading for hypoglycemia, and only your documentation makes that visible.
- Foot care: inspect the feet every day. Wash with mild soap and warm water, rinse, and dry thoroughly between the toes. Apply lotion to the tops and bottoms of the feet but not between the toes, where moisture breeds fungus and maceration. Report any redness, blister, callus, crack, ingrown nail, corn, or open area immediately.
- Never cut or trim the toenails of a resident with diabetes — nail care is done by a nurse or podiatrist.
- Never apply heating pads, hot water bottles, or hot soaks to the feet; neuropathy means the resident cannot feel a burn.
- Ensure shoes fit and socks are seamless, clean, and dry; check inside shoes for debris before they go on.
- Report new numbness, tingling, or burning in the feet (peripheral neuropathy) and any change in vision.
2. Cerebrovascular Accident (Stroke)
A stroke is a sudden interruption of blood flow to part of the brain — ischemic (a clot, the large majority) or hemorrhagic (a bleed). Brain tissue dies quickly, so recognition speed determines the resident's outcome.
+-----------------------------------------------------------------------------+
| BE FAST - STROKE WARNING SIGNS |
| |
| B - BALANCE ---> Sudden loss of balance, coordination, or dizziness |
| E - EYES ---> Sudden trouble seeing in one or both eyes, double |
| vision |
| F - FACE ---> Facial droop; ask the resident to smile - is it even? |
| A - ARMS ---> Arm weakness; ask them to raise both arms - does one |
| drift down? |
| S - SPEECH ---> Slurred, garbled, or absent speech; cannot repeat a |
| simple sentence |
| T - TIME ---> Note the TIME symptoms started and get the nurse |
| IMMEDIATELY. Do not leave the resident. Do not give |
| food, drink, or medication. |
+-----------------------------------------------------------------------------+
Other sudden signs include a severe unexplained headache, sudden confusion, and sudden numbness on one side. A transient ischemic attack (TIA) produces the same signs, resolves within minutes to hours, and is a warning of an impending stroke — it is reported with exactly the same urgency.
Post-stroke care overlaps heavily with hemiplegia care: dress the affected side first, transfer toward the strong side, protect the affected shoulder, watch for dysphagia at every meal, and support communication if aphasia is present.
3. Congestive Heart Failure
In heart failure the heart cannot pump effectively, so fluid backs up. Left-sided failure backs fluid into the lungs; right-sided failure backs it into the body.
| Left-sided signs | Right-sided signs |
|---|---|
| Shortness of breath, worse lying flat (orthopnea) | Dependent edema — ankles, feet, and lower legs, or the sacrum in a bedbound resident |
| Waking at night gasping for air | Abdominal distension and fullness |
| Moist or frothy cough | Distended neck veins |
| Restlessness, anxiety, fatigue | Rapid weight gain |
What the CNA reports — before the crisis
- Daily weight taken the same way each time. A gain of 2 to 3 pounds in a day or about 5 pounds in a week signals fluid retention and is reported even if the resident feels fine.
- New or worsening ankle, foot, or sacral edema; shoes or socks that no longer fit; a ring that has become tight.
- Increasing shortness of breath, especially on lying flat, or needing more pillows than usual.
- A new moist cough, or pink frothy sputum (report urgently).
- Strict adherence to any fluid restriction and accurate intake and output recording.
- Elevate the head of the bed for comfort; assist with repositioning and avoid prolonged dependent leg positioning.
4. Chronic Obstructive Pulmonary Disease
COPD covers chronic bronchitis and emphysema — chronically obstructed airflow, usually from long-term smoking. Residents work hard to breathe all day, and the work of breathing burns calories they often cannot afford.
- Positioning: most COPD residents breathe best sitting upright, frequently in the orthopneic position — leaning forward over an overbed table with the arms supported.
- Pursed-lip breathing — inhale through the nose, exhale slowly through pursed lips — keeps small airways open longer and is worth encouraging.
- Energy conservation: cluster care, allow rest between activities, place frequently used items within reach, and let the resident set the pace.
- Nutrition: offer small, frequent, high-calorie meals; a full stomach pushes on the diaphragm. Rest before meals.
- Oxygen: the CNA checks that tubing is not kinked, that the cannula sits properly, and that the resident's ears and nares are protected — but the liter flow rate is a medical order that a CNA never adjusts. Oxygen supports combustion; enforce no-smoking and no-open-flame rules in the room.
- Report: any change in the color, amount, or thickness of sputum; increased confusion or restlessness (an early sign of low oxygen); a bluish tint to lips or nail beds (cyanosis); or breathing that is harder than this resident's normal.
5. Arthritis, Osteoporosis, Parkinson's Disease, and Cancer
| Condition | What it is | Key CNA implications |
|---|---|---|
| Osteoarthritis | Wear-and-tear cartilage loss in weight-bearing joints | Pain and stiffness worst after inactivity; encourage gentle ROM and activity; allow extra time in the morning; apply heat or cold only as ordered |
| Rheumatoid arthritis | Autoimmune inflammation, typically symmetrical in small joints | Morning stiffness lasting an hour or more; joints may be hot and swollen; never force a swollen joint through ROM; adaptive utensils preserve independence |
| Osteoporosis | Loss of bone density; bones become porous and brittle | Fracture risk during ordinary care. Turn and transfer gently with a full lift sheet and adequate help; never pull on limbs; fractures can occur before the fall rather than because of it; encourage weight-bearing activity as ordered |
| Parkinson's disease | Progressive loss of dopamine-producing neurons | Resting tremor, muscle rigidity, bradykinesia (slow movement), shuffling festinating gait, stooped posture, mask-like face, small handwriting, soft speech. High fall and aspiration risk; allow far more time; adaptive utensils and weighted cups; never rush or startle |
| Cancer | Uncontrolled cell growth, treated with surgery, chemotherapy, radiation | Chemotherapy causes fatigue, nausea, hair loss, mouth sores, and immunosuppression — infection precautions matter enormously. Provide gentle oral care with a soft brush or foam swab; do not wash off radiation site markings; handle irradiated skin gently with no lotions or powders unless ordered; report new bruising or bleeding |
[!IMPORTANT] The single most transferable idea in this whole subject area: the CNA's job in chronic disease is observation and reporting. You are with the resident more hours than anyone else in the building. A one-day weight jump, a foot blister, a slightly slurred word, a cough that turned moist — those are the observations that prevent hospitalizations, and they are only useful if you report them the shift you see them.
A resident with type 2 diabetes who received insulin before breakfast ate only a few bites. Mid-morning she becomes shaky, pale, sweaty, and unusually irritable. What should the CNA do?
Which foot-care action is appropriate for a resident with diabetes?
During breakfast a resident's face suddenly droops on the right, her speech becomes slurred, and she cannot hold her fork. What is the CNA's priority action?
A resident with congestive heart failure has gained three pounds since yesterday's weight and her ankles are more swollen than usual, although she says she feels fine. What should the CNA do?