9.2 Common Chronic Conditions in Long-Term Care

9.2 Common Chronic Conditions in Long-Term Care

Most older adults in long-term care manage concurrent chronic conditions. Chronic illnesses persist over time, differ in course and treatment, and often need ongoing monitoring. Some remain stable or improve with care; do not predict every resident's decline from a diagnosis alone. Certified nursing assistants (CNAs) spend extensive hours observing, bathing, ambulating, and feeding residents with chronic illnesses. Mastering these conditions enables CNAs to provide safe care and recognize acute decompensation early.

Cardiovascular Conditions: Hypertension, CAD, MI & Heart Failure

• Hypertension (HTN): Sustained blood pressure elevation (systolic ≥ 130 mm Hg or diastolic ≥ 80 mm Hg). Arteriosclerosis frequently produces isolated systolic hypertension. CNAs measure blood pressure routinely with correct cuff sizing, resting the resident 5 minutes prior. Report outside assigned limits and for a new baseline change; urgent symptoms require immediate escalation regardless of the exact number.
• Coronary Artery Disease (CAD) & Myocardial Infarction (MI): Plaque narrowing coronary arteries causes ischemia (angina). Thrombus occlusion causes myocardial infarction. Crucially, older adults often present with atypical MI symptoms: acute dyspnea, sudden confusion, extreme weakness, diaphoresis, nausea, or epigastric discomfort ("silent MI"), rather than classic crushing chest pain. Report unexplained dyspnea or diaphoresis immediately.
• Congestive Heart Failure (CHF): Inability of the heart to pump sufficient blood volume. Left-sided failure causes pulmonary congestion (exertional dyspnea, orthopnea requiring multiple pillows or a recliner, crackles, persistent cough, pink frothy sputum). Right-sided failure causes systemic venous congestion (dependent edema in feet, ankles, sacrum, jugular venous distention, ascites, rapid weight gain).
  • CNA Protocols for CHF: Daily weight tracking detects early fluid retention. Weigh the resident on the same scale, at the same time every morning (before breakfast), in similar clothing, after voiding. Immediately report a weight gain of 2 to 3 pounds in 24 hours, or 5 pounds in one week. Follow prescribed fluid restrictions, record Intake and Output (I&O) in milliliters, serve low-sodium meals, and elevate swollen legs.
• Peripheral Vascular Disease (PVD): Peripheral Artery Disease (PAD) involves narrowed arterial lumens, causing cool, pale, shiny, hairless skin on lower legs, diminished pedal pulses, and intermittent claudication (calf cramping during walking relieved by rest). Dangling legs relieves ischemic pain; elevation worsens it. Chronic Venous Insufficiency (CVI) causes venous stasis, warm swollen bronze skin, and weeping ulcers. Elevating legs above heart level promotes venous return.

Respiratory Conditions: COPD & Oxygen Therapy Protocols

Chronic Obstructive Pulmonary Disease (COPD) involves chronic airflow limitation:

• Emphysema & Chronic Bronchitis: Emphysema destroys alveolar walls and elastic recoil, trapping air in hyperinflated alveoli ("barrel chest", exertional dyspnea). Chronic bronchitis involves chronic bronchial inflammation and excessive mucus, defined as a productive cough for at least 3 months per year for 2 consecutive years.
• Supportive Techniques: The tripod position (leaning forward on a cushioned overbed table) expands thoracic volume. Pursed-lip breathing (inhaling 2 counts through nose, exhaling 4 counts through pursed lips) creates positive end-expiratory pressure, preventing bronchiolar collapse and releasing trapped CO2.
• Oxygen Safety Rules: Oxygen is a physician-prescribed drug. Do not independently initiate, change, or discontinue prescribed oxygen outside a specifically authorized protocol. Oxygen prescriptions are individualized. Some patients are vulnerable to carbon-dioxide retention, but COPD does not mean everyone relies on a "hypoxic drive." Do not withhold emergency help or assume a low saturation is acceptable. Report severe breathlessness, unusual drowsiness, cyanosis, or a low/unexpected reading immediately. CNAs post "Oxygen in Use - No Smoking" signs, secure cylinders upright, verify nasal prongs curve downward into nares, inspect ears/cheeks for pressure injuries, and use only water-soluble lubricants (petroleum jelly is flammable and strictly prohibited).

Neurological Conditions: CVA & Parkinson's Disease

• Cerebrovascular Accident (CVA / Stroke): Interruption of cerebral blood flow from a thrombus/embolus (ischemic, ~87%) or ruptured vessel (hemorrhagic, ~13%).
  • FAST Screening: Face drooping; Arm weakness; Speech difficulty; Time (note onset time and report immediately; "time is brain").
  • Post-Stroke Care: Dress the affected (weak) side first; undress the unaffected (strong) side first ("Dress the weak, undress the strong"). For expressive aphasia (Broca's), use yes/no questions and picture boards. For receptive aphasia (Wernicke's), use gestures and visual cues. For dysphagia, seat upright at 90° for meals and 30 minutes after, provide prescribed the exact ordered drink consistency, using IDDSI levels when specified, feed on the unaffected side, and check for pocketing in the weak cheek. For unilateral neglect, cue the resident to scan the paralyzed side.
• Parkinson's Disease: Dopamine depletion in the substantia nigra producing four cardinal signs: (1) resting "pill-rolling" tremor; (2) muscle rigidity ("cogwheel" resistance); (3) bradykinesia (slow movement, freezing); (4) postural instability (impaired balance, high fall risk). Manifestations include shuffling festinating gait, mask-like facies, soft voice, and dysphagia. CNAs clear tripping hazards, use the therapist's individualized gait/freezing cues, allow extra time for ADLs, provide weighted utensils, and offer fiber and fluids for constipation.

Musculoskeletal Conditions: OA, RA, Osteoporosis & Hip Precautions

• Osteoarthritis (OA) vs. Rheumatoid Arthritis (RA): OA is a degenerative "wear-and-tear" disease of articular cartilage affecting weight-bearing joints asymmetrically; morning stiffness lasts < 30 minutes, pain worsens with activity, and joints display crepitus and Heberden's nodes. RA is an autoimmune systemic disorder of synovial membranes affecting joints symmetrically; morning stiffness lasts > 1 hour, systemic fatigue occurs, and deformities (swan-neck, ulnar drift) develop.
• Osteoporosis: Severe bone demineralization causing brittle bones and pathological fractures (hip, vertebrae, wrist). Kyphosis causes height loss. CNAs execute fall prevention and handle limbs gently.
• Hip Arthroplasty Precautions: To prevent dislocation after posterior hip replacement: (1) Avoid hip flexion > 90° (use raised toilet seats, reachers); (2) Avoid adduction past midline (never cross legs/ankles; keep an abductor wedge pillow between legs in bed); (3) Avoid internal rotation (keep toes pointed straight/outward); (4) Avoid trunk twisting (pivot the whole body during transfers).

Endocrine Conditions: Diabetes Mellitus & CNA Foot Care

Type 1 diabetes involves autoimmune beta-cell destruction with absolute insulin deficiency. Type 2 diabetes involves peripheral insulin resistance and progressive secretory defect.

• Possible Low or High Glucose: Symptoms overlap and skin temperature cannot diagnose glucose level. Hypoglycemia often means below 70 mg/dL, but the resident's individualized threshold may differ. Shaking, sweating, confusion, weakness, or unusual behavior requires immediate nurse notification and glucose checking by authorized personnel. If the resident is alert, can swallow safely, and the treatment protocol authorizes it, provide the specified fast carbohydrate; a common example is 15–20 grams, followed by a glucose recheck after 15 minutes. Do not give oral food, drink, or candy to an unconscious person or someone who cannot swallow safely. Activate emergency response; authorized clinicians provide the appropriate medication. Hyperglycemia reporting thresholds are individualized. Vomiting, deep rapid breathing, fruity breath, severe dehydration, or altered consciousness can indicate a crisis and need urgent help, rather than a routine later report.

• CNA Diabetic Foot Care Protocol: Neuropathy and arterial disease make diabetic feet vulnerable to ulcers and amputation: (1) Inspect tops, soles, heels, and between toes daily under bright light; (2) Wash daily with mild soap and lukewarm water (within the approved temperature limit, measured appropriately; avoid soaking); (3) Pat dry gently, ensuring spaces between toes are completely dry; (4) Apply lotion to tops and soles only—NEVER between toes (trapped moisture breeds infection); (5) Do not independently trim high-risk diabetic toenails; refer needs to the nurse/podiatrist under the plan; (6) Ensure clean seamless socks and properly fitted shoes are worn; never permit barefoot walking.

Sources checked October 16, 2026

NIDDK hypoglycemia; South Dakota advance directives and medical orders; NIA end-of-life comfort.