Chapter Five: Specialized Care

Medical Term Hotlist

Advance directive

AIDS

Alzheimer’s disease

AMI

Angina

Arteriosclerotic

Aphasia

Carbohydrates

Cardiac arrest

Cheyne-Stokes respirations

Chronic illness

Colostomy

Comatose

Congestive heart failure

Coronary arteries

CPR

CVA

Cyanosis

Debilitated

Delusion

Dementia

Diabetes

Disoriented

DNR

Dyspnea

Dysuria

Edema

Emaciated

Embolus

Emesis

End of Life Issues

Enteral nutrition

Euthanasia

Flaccid

G tube

Grief process

Hallucination

Hemiplegia

Hemorrhage

Holistic health care

Hospice

Hyperglycemia

Hypertension

Hypoglycemia

Hypotension

Hypoxia

Incontinence

Infusion-IV therapy

Intubation

Ketones

KS

Malnutrition

Mechanical ventilator

Metastasis

Nares

Nocturia

NPO

Opportunistic disease

Oxygen

Palliative care

Paralysis

Paraplegia

Patient Self Determination Act (PSDA)

PCP (Pneumocystis Carinii Pneumonia)

Plaque

Polyuria

Postmortem care

Postoperative

Prosthesis

Quadriplegia

Reality orientation

Rescue breathing

Respiratory arrest

Respite care

Restraint

Role reversal

Seizure

Sensory overload

Sensory stimulation

Sexually transmitted disease/illness (STD/STI)

Shroud

Sputum

Stoma

Suffocation

Suicidal ideation

Sundowner’s Syndrome

Terminal illness

Thrombus

TIA

TPN

Tracheostomy

Tuberculosis (TB)

This chapter reviews specialized care for residents experiencing more severe physical problems and psychological issues, and those who are dying. The skills involved in specialized care of these residents are discussed in Chapter 6, “Clinical Skills Performance Checklists.”

Physical Problems

Physical problems reviewed in this section focus on acute and chronic conditions affecting major body systems.

Vision Impairment

Residents with hearing and vision problems are at high risk for injury, communication difficulties, and a potential for social isolation and loss of self-esteem. Common vision problems include chronic conditions such as glaucoma, a disease in which excessive pressure builds inside the eye that can cause blindness if left untreated. Cataracts, a clouding of the lens, prevents clear vision. Macular degeneration causes the loss of central vision while leaving side-to-side, or peripheral, vision intact. Diabetic retinopathy, a complication of diabetes, causes hardening of the arteries that carry blood and oxygen to the eye as well as damaging the retina. To ensure safety and security as well as improve their quality of life, it is important to assist residents with impaired vision by following these principles:

Knock before entering the resident’s room, identify yourself, and announce your entry.

Keep the resident informed of the placement of room furniture and belongings.

Arrange personal articles and other equipment and supplies within easy reach of the resident and encourage their use.

Keep the resident’s room clean, uncluttered, and safe.

Maintain adequate lighting.

To reduce glare, keep light sources behind the resident instead of behind you.

Maintain the resident’s bed in its lowest position.

Explain everything you are about to do for the resident, and alert the resident when you have completed each task.

Explain any extraordinary sounds in the environment.

Stay within the resident’s field of vision to enable the resident to focus on your face and voice.

Speak in a pleasant tone of voice.

Use a gentle touch to communicate.

When assisting the visually impaired resident to eat, open cartons or assist with feeding but encourage as much independence with eating as possible.

Use the hands of the clock to teach the resident the location of the foods on the plate.

Ensure that the resident can locate and touch the light before leaving the room.

Always announce when you are leaving the resident’s room and make the call light readily available.

Keep eyeglasses, magnifying glass, or other reading devices clean, in good repair, and readily available for the resident; report any damage or loss to the nurse immediately.

If assisting the resident to care for an artificial eye (also called a prosthesis), follow the facility’s procedure for removing, cleaning, and reinserting it.

Hearing Impairments

Residents with hearing disorders have trouble understanding speech, especially fast speech; they are also confused by noises, echoes, and hollow sounds. They have trouble understanding accented speech by persons for whom English is a second language because they often pronounce syllables and words differently. Although research indicates hearing loss does not directly affect the activities of daily living (ADLs) of hearing-impaired residents, they do report a loss of interest in socializing, which affects their quality of life.

Communication principles to remember when working with hearing-impaired residents include:

Placing yourself directly in front of the resident prior to beginning a conversation

Decreasing as much background noise as possible

Talking in a low tone and in an unhurried manner

Speaking clearly and distinctly

Keeping objects out of your mouth when you speak and not covering your mouth when talking

Making short statements but long enough to help give the resident a frame of reference; for example, “The chaplain from the First Street Church is coming for a visit today.”

Using sign language, finger spelling, teaching posters, note pads, white boards, or other visual aids to improve communication

Restricting conversation to one topic at a time, changing topics carefully, and giving the resident enough time to follow the change

For the resident who wears a hearing aid device, using the same communication techniques as with other hearing-impaired residents

Taking special care of hearing aids or other devices and following the facility’s procedure for cleaning and storage to prevent damage or accidental losses

Asking the resident to confirm his or her understanding of important information by repeating instructions

Residents with visual or hearing impairments might have other stronger senses to help offset their loss. For example, touch and smell might be stronger; for the visually impaired resident, the ability to hear might be more acute; for the hearing-impaired resident, sight might help compensate for the hearing loss. In all cases, you should encourage residents to use all the senses, called sensory stimulation, or the ability to use one’s senses. Likewise, excessive noise, sights, smells, and sounds can overly stimulate some residents. This is known as sensory overload and should be avoided, especially when the resident is suffering from undue physical or emotional stress or illness.

Speech Impairment

Remember some general principles for residents who might be dysphasic (have difficulty speaking). This condition can be due to a nervous system disorder such as a stroke (also called a cerebral vascular accident [CVA]), Parkinson’s disease, Alzheimer’s disease, or an injury that affects the speech center in the brain. Other causes of dysphasia might be a result of surgery to remove cancer from the mouth, oral cavity, tongue, or larynx (voice box) affecting speech. These residents might make sounds but cannot form words. Remember that they understand what you are saying because their speech problem has no effect on their intelligence. They often become frustrated by trying to speak clearly and require your patience as you listen to them. Do not hurry them or try to finish what you believe they are trying to say to you. Using assistive devices such as a white board, visual aids, and so on can help ease the frustration of the dysphasic resident who tries hard to communicate. Praise their efforts and encourage them to use every sense they can to convey their needs and actively participate in their daily activities.

Respiratory Problems

Residents might experience breathing problems that are short term, or acute, such as accidental choking, respiratory arrest, or shortness of breath (also called dyspnea) caused by an allergic reaction to a food or drug or by other medical conditions or illnesses. If left untreated, these acute conditions can become terminal. Respiratory complications can lead to hypoxia, or a lack of adequate supply of oxygen to the body tissues that damage the brain and the kidneys before other organs. Residents in respiratory distress will struggle to breathe and show signs of shock, which causes their skin to turn bluish in color (cyanosis), their blood pressure to fall (hypotension), and their pulse to rise (tachycardia). They will also become confused or combative as they lose oxygen to their brain. If this condition is not corrected, they will stop breathing, a condition called respiratory arrest. Respiratory arrest can occur very quickly if residents develop a life-threatening allergic reaction to a food, drug, or insect sting. If you see that the resident is not breathing, call for help and begin rescue breathing by delivering two long breaths by mouth to mouth or mask to mouth technique. Continue breathing for the resident at the rate of at least 12 breaths per minute until the resident resumes breathing or until you are relieved. For severe allergic reactions, the nurse will administer emergency drugs. Oxygen is a drug and, as such, must be administered by a licensed nurse. You can support the resident receiving oxygen by observing the resident’s response to oxygen therapy; that is, the rate, depth, and ease of his or her respirations, skin color, and alertness.

Residents may receive oxygen therapy for chronic diseases affecting the respiratory system, such as chronic obstructive lung disease (COPD), emphysema, or chronic bronchitis. These conditions cannot be reversed and result in a constant struggle to move air in or out of the lungs. Difficult bouts of productive coughing also occur, leaving the resident exhausted. PCP, a special type of pneumonia as a complication of Acquired Immunodeficiency Syndrome (AIDS), can be lethal. Other types of pneumonia can also become life threatening to residents already weakened by a chronic illness or condition that affects their ability to heal (referred to as debilitating). Surgery also poses a great risk for pneumonia in these residents.

Other considerations in caring for the resident receiving oxygen include the following:

Position the resident to make breathing as effortless as possible.

If confined to bed, change the resident’s position every two hours.

Provide mouth care to keep the resident’s mouth clean and moist.

Encourage frequent rest periods and arrange activities and care to promote rest.

Follow standard precautions for disposing of sputum.

Observe special precautions for active respiratory infections, including TB.

Observe and record any changes in sputum (changes could indicate infection or bleeding from the lungs).

Observe all safety precautions for the resident receiving oxygen.

Encourage fluids to help thin secretions; clear liquids are best for this purpose.

Encourage proper food intake to maintain nutrition and energy needs.

Provide careful skin care for residents receiving oxygen by any delivery method that uses tubing or with any appliance or equipment with edges that put pressure on the nose (nares), the top of the nose, cheeks, or ears.

Keep face masks clean and placed snugly to ensure oxygen delivery.

Maintain water in wall oxygen reservoir to keep delivered air moist. Change water according to facility protocol.

If receiving oxygen via portable tank, do not drop or damage the tank, and report any leakage to the nurse; replace the tank to maintain constant oxygen supply.

Provide emotional care to ease the resident’s fears of not being able to breathe normally.

Keep the call light within easy reach of the resident.

Observe and report any changes in the resident’s breathing pattern.

Never adjust or discontinue the oxygen.

Chronic or long-term respiratory problems such as emphysema and chronic bronchitis might lead to apnea, or respiratory arrest, which means that the resident stops breathing. The resident will require assistance to breathe artificially with the help of a mechanical ventilator. The ventilator enables oxygen and carbon dioxide to be exchanged. The ventilator tubing connects to a tracheostomy, or permanent surgical opening into the trachea, the air passage from the throat to the lungs. Ventilator-dependent residents must rely on others for their care. Conscious residents might be very frightened by the ventilator and their inability to talk; some might be comatose, or unaware of their surroundings. Special considerations in caring for the ventilator resident are as follows:

Remember that you are caring for a human being, not a machine.

To protect the resident’s airway, work with another caregiver to move the resident.

Measure, record, and report vital signs, noting any change in respiratory effort.

Provide personal care and ADLs that protect the resident’s airway.

Provide frequent oral care.

Keep the ventilator connected to the electrical outlet, and tubes connected and free of kinks.

Provide for frequent position changes and rest periods to conserve the resident’s energy.

Keep the call light within easy reach of the resident and answer it promptly to help allay resident fears.

Speak to the unconscious, comatose resident on a ventilator as though the resident can hear you.

Offer emotional support.

Immediately report any signs of respiratory difficulty or ventilator alarms to the nurse.

Never adjust the ventilator settings or remove a resident from a ventilator.

Cardiovascular Problems

Cardiovascular problems involve the heart and blood vessels.

Heart Disease

Heart disease kills more elders worldwide than any other disease. Diseased blood vessels can prevent adequate blood circulation, which can result in pain, disability, and death. The arteries supplying the heart muscle (coronary arteries) can become narrowed (arteriosclerotic) over time or blocked by a buildup of plaque (a patch inside the artery’s lining caused by accumulated fats or calcium, also called atherosclerosis). The narrow or blocked artery cannot deliver oxygen to the heart muscle, causing chest pain (angina), which can worsen with any type of strenuous activity. Arteriosclerosis is also responsible for a temporary condition in which the resident experiences dizziness, light-headedness, or confusion due to an inadequate supply of oxygen to the brain, known as a transient ischemic attack (TIA). The resident is at high risk for falling during a TIA. Should this occur when assisting the resident to walk, stop the walk, ease the resident to the floor, stay with him or her, and call for help. Any condition that causes the blood flow into and outside the heart can also threaten the resident’s life. This is one reason why an accurate and thorough description, recording, and reporting of any abnormal pulse rate or rhythm is so important.

Following a heart attack, the heart is often weakened and loses its ability to pump adequately, which can lead to congestive heart failure (CHF). CHF causes a buildup of fluid in the lungs, resulting in dyspnea and a wet cough or swelling of the extremities (edema). A sudden, severe episode of dyspnea, edema, and urine retention can result in death.

Circulatory Conditions

Arteries or veins in the circulation of the lower extremities can also be blocked by a clot (thrombus), which can cause swelling, pain, and disability. Signs of thrombosis (a blood clot in the vein) include a reddened, warm area in the lower leg, swelling, and pain, which increases with movement.

If a thrombus becomes dislodged from a vein in the lower extremity, it becomes a traveling clot, meaning it moves to the heart, lungs, or brain, causing a heart attack, respiratory distress, or a stroke. Report all resident complaints of sudden pain or dyspnea immediately because these are considered emergencies.

Clots in the arteries of the lower extremity can slow or stop circulation. The resident will complain of pain, coolness, and a pale color in the affected leg, which is a condition requiring immediate surgery to restore adequate circulation.

Hypertension

Hypertension, or high blood pressure, is defined as unusually high blood pressure for an individual, usually exceeding 140/90 after two consecutive readings in the same arm. Hypertensive individuals are more prone to develop heart disease or other medical conditions. Although the cause of hypertension is unknown, diet, obesity, the effects of diabetes, and other lifestyle factors affect blood pressure. Hypertension can affect all body systems, damage organs, and become lethal because it can lead to a stroke. Specialized care of residents with cardiovascular problems or hypertension is similar and includes the following:

Follow the plan of care very carefully to promote healing and prevent further complications.

Provide foods and fluids, and monitor I & O as prescribed to provide energy and prevent edema.

Assist in monitoring the resident’s prescribed dietary restrictions regarding salt, fat, sugar, and fluid.

Modify ADLs and care activities to save energy and promote rest.

Provide exercise as tolerated to maintain function and activity level.

Monitor vital signs and report any changes immediately to the nurse.

Provide comfort measures and emotional support.

Closely observe and promptly report any changes in the resident’s condition.

Paralysis

Residents might be unable to move a body part, which is called paralysis. Paralysis is classified according to how much of the body is affected. For example, paraplegia affects the lower half of the body; quadriplegia involves both arms and legs; hemiplegia means that half of the body, either the right or the left side, is paralyzed. A stroke or other neurological disease results in decreased blood flow and oxygen to the brain cells, causing them to die, which leads to paralysis. Signs and symptoms of a stroke depend on the location of the brain injury and the amount of the damage. A stroke on one side of the brain affects the opposite side of the body. Effects of a stroke include aphasia (being unable to speak), a partial paralysis or weakness of the face (causing drooping of the mouth, eyelid, and so on), or complete paralysis of the arm or leg on the affected side (leaving the arm or leg limp, or flaccid). An injury to the spinal cord can cause paralysis of the body below the injury site, leading to paraplegia or quadriplegia. Paralysis in any part of the body can pose problems with mobility and ADLs. Special care is required to keep the affected muscles and tendons functioning as much as possible. Mobility-impaired residents run the risk of contractures, or a shortening of the muscles due to lack of exercise or movement, pressure ulcers, and other hazards of immobility; respiratory difficulties, especially pneumonia; and muscle spasms, incontinence (bowel and bladder), and swallowing difficulties (dysphagia). Provide special care to residents affected with an injury that caused paralysis to protect them from further complications, and maintain or restore normal functioning by including the following:

Follow each resident’s care plan to help residents regain independence.

Maintain a calm, reassuring environment.

Arrange ADLs to promote rest and sleep.

Encourage independence and self-care to promote autonomy.

Show patience and empathy.

Use touch to help orient the resident and show genuine care and concern.

Allow the resident with dysphagia plenty of time to chew and swallow.

Be sure that the dysphagic resident swallows food each time it is offered and before continuing with the feeding.

Use thickener with fluids as ordered when feeding the dysphagic resident.

Perform passive range of motion to all affected extremities.

Assist the resident in bowel and bladder retraining.

Dress and undress the resident’s affected side first.

Report any change in the resident’s condition.

In all situations requiring your assistance to move a resident, use proper body mechanics: Keep the spine straight, bend your knees, lift with your legs (not your back), and seek assistance as necessary to protect you and the resident.

Use a mechanical lift, as ordered, to assist in lifting residents.

Digestive and Elimination Problems

Diseases or conditions involving the digestive and urinary system can cause malnutrition (inadequate intake and use of foods), elimination difficulties, and complications due to infections, cancer, or organ failure.

Infections

Severe infections of the digestive organs include gall bladder disease (cholecystitis), pancreatitis (inflammation or infection of the pancreas), hepatitis (liver infection), or nephritis, (kidney disease). Common symptoms include severe pain, nausea, vomiting, fever, diarrhea or constipation, dysuria, or a yellowish color to the skin (jaundice), and life-threatening chemical imbalances. Residents may also become confused, which can be mistaken for a psychological event when, in fact, they may be exhibiting the first sign of a urinary tract infection (UTI). Residents recovering from infections might be kept NPO, meaning they can have no foods or fluids by mouth. The resident will receive fluids, nutrients, antibiotics, and other medications through an IV (within the vein), or intravenous access device. IV therapy provides direct access to the bloodstream through an IV catheter and tubing attached to a sterile bag of fluids; the solution is connected to a pump that controls the amount of fluid delivered. A sterile dressing covers the IV catheter insertion site and must be maintained according to facility procedure. The tasks of starting, adjusting, and discontinuing IV therapy are reserved for the licensed nurse. You can support the resident receiving IV therapy by being careful to not pull on the IV catheter, kink the IV tubing, or interrupt the IV flow.

Change the resident’s gown or clothing carefully to maintain the IV connection. Immediately report to the nurse any signs of infection, swelling at the IV site, or activation of IV pump alarms.

Cancers in the Digestive and Urinary Tract

Cancerous growths, or tumors, can interfere with normal food intake, nutrient use, and elimination of digestive wastes, putting pressure on or within the digestive organs that interferes with normal digestion and circulation. As cancer cells grow, they rob normal cells of nutrients and interfere with normal cell activity. Cancer cells can travel through the body from an original invasion site to a distant organ (metastasis), resulting in further damage and, eventually, death. Common sites for metastasis are the brain, bone, and liver.

Residents recovering from surgery to remove a cancerous tumor in the GI tract, bladder, or kidney who cannot swallow or take foods or fluids by mouth (PO) might require tube feedings or total parenteral nutrition (TPN). A small tube inserted into the stomach through the nose (nasogastric tube or feeding tube) provides short-term nutrition during the healing process. If needed for an extended period, a gastrostomy tube (G tube) is inserted directly into the stomach through a stoma (a surgical opening in the abdomen). A pump attached to the feeding tube delivers the prescribed amount of food and fluid over time. For safety considerations, an alarm will sound to signal a pump problem. Residents receiving their total diet through a feeding tube are often NPO, or can have no food or fluids by mouth. Be careful to observe this order. It is also important to protect the skin and mucous membranes around the nose or the stoma because they can become irritated. Provide oral care at least every two hours or more, raise the head of the bed at least 35 degrees, and keep the call light in easy reach. Remember to keep the skin around the G tube clean and report any sign of skin breakdown or abdominal discomfort.

Residents recovering from surgery to remove cancer from the bladder, small intestine, or colon (large intestine that holds solid wastes) might also have a temporary or permanent ostomy, or surgical diversion to aid in elimination. Diversion means that, in the case of bladder cancer, an artificial appliance is attached to a stoma in the abdomen to provide an alternative path to expel urine. If a portion of the large intestine is removed, an appliance is attached to an abdominal stoma to collect feces/stool (colostomy). The resident will need ostomy care training and emotional support to adjust to dramatic changes in urine and bowel elimination that affect body image, especially if the ostomy is permanent.

Chronic Diseases

Chronic liver disease such as cirrhosis (scarring of the liver) causes a buildup of toxic wastes in the body due to failure of the liver to handle the chemicals released by metabolism. The liver might eventually fail, which causes lethal consequences in other body systems, including hemorrhage from ruptured veins in the esophagus. Treatment for digestive disorders might include dietary restrictions, medications, chemotherapy, or surgery.

Chronic kidney disease, often linked to type I diabetes, affects all body systems and can result in kidney failure. The resident with kidney failure is at increased risk of life-threatening complications, such as congestive heart failure and severe generalized infection, because the kidneys are not able to filter toxins from the body or control fluid and electrolyte absorption. Specialized care of residents with chronic diseases or those recovering from surgery includes the following:

Observing, recording, and reporting vital signs, and pain tolerance

Observing, recording, and reporting any changes in the surgical site

Strictly adhering to the diet order, including fluid restrictions

Keeping feeding tubes free of kinks

Prompt reporting of vomiting, diarrhea, constipation, or skin color changes

Observing, recording, and reporting of emesis (vomit) or abnormal stools or urine, especially color, consistency, or odor

Using standard precautions when handling bodily fluids

Prompt emptying and care of stoma appliances

Observing, recording, and reporting I & O

Observing and reporting any behavior changes

Providing frequent oral care

Providing comfort measures to help relieve pain and promote rest (position changes, diversion activities, quiet environment, and so on)

Removing noxious odors

Providing emotional support

Diabetes

Diabetes mellitus, a disease of the endocrine system, is listed separately because it affects metabolism, impacts every system of the body, and is becoming an epidemic among Americans. Diabetes mellitus is a disease of the pancreas in which the body cannot use carbohydrates (sugars and starches) efficiently. The pancreas cannot produce enough insulin or does not use insulin properly to change carbohydrates to energy. When this occurs, the body burns fats for energy instead, leading to a dangerous imbalance in ketones, the product of fat breakdown.

The exact cause of diabetes is unknown, but several factors such as age, obesity, and family history can contribute to developing diabetes. Residents with type 1 diabetes must take insulin to live; those with type 2 diabetes can control their disease with diet and medication. Both types of diabetes require a careful diet that contains the right amount of proteins, fats, and carbohydrates to maintain adequate nutrition and systems functioning. Signs and symptoms of diabetes include excessive thirst, excessive hunger, excessive urination (polyuria), weight loss, night sweats, and irritability.

Despite treatment, diabetes can cause blindness, cardiovascular disease, kidney failure, leg ulcers, and nerve damage. Poor circulation due to diabetes can lead to amputation of the leg. Death can result from a diabetic coma, caused by extreme blood sugar (glucose) levels such as hyperglycemia (abnormally high amounts of glucose in the blood) or by dangerously low blood sugar, called hypoglycemia.

Strict adherence to the diabetic diet is essential to meet caloric needs and control blood glucose levels.

Diabetic residents might have trouble following a restricted diet, eating foods not prescribed, or overeating. Family members or others might supply snacks or forbidden foods, making compliance a challenge for the nursing staff. You must praise and support the efforts of the diabetic resident as well as educating and supporting family members to follow the care plan to promote health and prevent complications. Careful monitoring of food consumption is important to keep the resident safe. Tell the nurse if the resident does not finish the food served during a meal or refuses snacks.

Special care of the diabetic resident includes

Inspecting the resident’s skin daily, paying attention to the feet for decreased sensation or pain (indicates neuropathy, or nerve damage), redness, or a skin break (sign of tissue damage due to poor circulation).

Inspecting the resident’s shoes for items that may be in them before putting them on the resident’s feet.

Keeping the skin and feet clean, dry, and moist; do not apply moisturizing lotion between the toes.

Avoiding pressure on the feet or toes by tight shoes, socks, or bed linens.

Serving meals and snacks on time.

Encouraging the resident to follow the care plan.

Observing and reporting any changes in condition immediately.

Protecting the resident from thermal injury due to extreme water temperature. (Diabetic clients often have reduced sensation to temperature caused by nerve damage in the extremities, known as diabetic neuropathy.)

Including the resident in all aspects of care to promote independence, self-esteem, and compliance with the care plan.

If allowed by state law for your level of practice, monitoring blood sugars as ordered; promptly reporting excessively high or low blood sugar levels to the nurse.

Assisting the resident to manage stressful situations because increased stress causes a rise in blood sugar levels.

HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome)

Residents with HIV have been attacked by a virus that robs them of the ability to fight infections. This viral invasion makes them targets for serious illnesses or cancer. Once infected, the HIV is always present. HIV can be transmitted by infected persons who share IV drug needles or have sexual contact. Although transmission of the virus is not spread by casual contact (for example, touching, caressing, sneezing or coughing, and so on), caregivers need to use standard precautions to protect themselves when handling the blood or body fluids of the HIV-infected resident, most particularly, to avoid a needle stick or sharps injury. HIV is transmitted by means other than IV drug needles and sexual contact; contact with blood or other body fluids from an infected person, unclean surgical instruments, and transmission from mother to baby in utero and/or breast milk are other modes of transmission. Residents with HIV might develop AIDS, a progressive weakening in the HIV resident, which can occur many years after contracting the virus.

AIDS exposes the resident to opportunistic diseases, illnesses that take advantage of the resident’s weakened immune system. Although there is no cure for HIV/AIDS, residents receive treatment to combat infections, relieve respiratory distress, weakness, and fatigue, decrease pain and discomfort, and promote nutrition. Although medications and treatments are prolonging the life of AIDS residents, the drugs given to treat AIDS have serious side effects, such as nausea, vomiting, and diarrhea.

Residents with AIDS must be protected from infections and exposure to others who might be ill. They should be provided long periods of rest and planned ADLs to preserve energy.

Staff must also follow agency protocol for handling blood and/or body fluids of residents with AIDS. Staff must be very careful with handling sharps to avoid exposure to the resident’s blood. If handling sharps, be careful to never recap or place used sharps in the trash container. Always place used sharps in the sharps container.

The ravaging effects of drug treatment can discourage residents; they need emotional support to help them comply with the medical care plan. Counseling services can help these residents deal with the lack of information about the disease, accept the realities of AIDS, and restore hope. Listening to the resident and being empathetic, caring, and nonjudgmental are essential approaches you must take when caring for these residents. Support of family members, friends, or support groups can also help improve the quality of life for the AIDS resident.

Psychological Problems

Psychological problems, meaning those conditions affecting thought, mood, and behavior, can be as threatening to the health and well-being of residents as physical illnesses. This section reviews those conditions placing the resident at highest risk for psychological distress and, sometimes, physical danger.

Confusion

Residents might become confused for physical or psychological reasons. Any disease or condition that causes hypoxia can lead to confusion. Drug interactions and side effects, hearing difficulty, and reasoning problems might also contribute to confusion. Other causes can include stress and grief, changing routines or living arrangements, hospitalization, and language or cultural factors. Confused residents often tell the same story repeatedly; they live in the past because it is a more familiar time for them and continually repeat the same task such as buttoning their clothes and pacing. They might become frightened and resist care and involvement in activities.

Confused residents might become suspicious of facility staff, accusing them of stealing from them or trying to hurt them or to keep them from leaving the facility. Residents might also experience Sundowner’s Syndrome, which means increased confusion or disorientation in the afternoon or evening hours. Confused residents who are ambulatory might wander from the facility and injure themselves or become lost. If confined to the bed or wheelchair, they might try to get up and risk falling or injuring themselves.

It is important to remind the confused resident of who they are, where they are, and the current date and time. This is part of reality orientation. Keeping calendars, clocks, and bulletin boards current can support reality for the resident. Sharing current events with the resident can also help. Being acutely aware of environmental hazards that might harm the confused resident and taking every precaution to protect the resident is a priority.

Aggressive Residents

Confused residents who become defensive, aggressive, or combative need your calm demeanor and understanding so that you can find out what is causing the resident’s behavior. It is important that you alert the nurse immediately because reporting the incident might help avoid further escalation by the resident and avoid potential harm.

To diffuse the aggressive behavior, leave the situation if you can and return later. Do not argue with the resident or return his or her aggression. Sit down or, if you must stand, turn your body slightly away from the resident with your arms at your side and your hands open; maintain eye contact with the resident. This open stance also enables you to quickly move out of reach of the resident. Keep your voice calm, supportive, and nonthreatening. Using clear, simple language, attempt to “talk them down.” Listen carefully, letting the resident know that you are paying attention to what he or she is telling you, and acknowledge the resident's feelings.

Allow the resident to make as many choices as possible to resolve issues, to “save face,” and provide the resident with an opportunity to regain self-control. Watch for signs of increased aggression, such as jaw or fist clenching, pacing, crying, or yelling. If the resident becomes violent toward you or others, protect the resident as well as yourself from harm. Special training is often needed to safely restrain the combative resident. Review the facility procedure for restraints as well as the procedure review in Chapter 6. Never hit, push, pull, or otherwise retaliate against a resident, despite the provocation; this is considered assault.

Dementias

Dementia is an irreversible, progressive loss of mental function as evidenced by the loss of memory, ability to make judgments, ability to comprehend/understand and learn, ability to carry out tasks or to use language. Residents with dementia lose their ability to socialize, maintain an occupation, or think abstractly or rationally. They become disoriented, meaning they are confused as to who they are, or cannot recall the current date or time. In later stages of the disorder, residents with dementia become agitated, depressed, and suspicious of others (paranoid). They are frightened and frustrated because they try to adjust to their changing world. Dementia is not a part of aging but, when it occurs, it can be devastating to the resident and family, especially when the resident appears healthy but cannot function normally. In the advanced stage, residents become totally incapacitated and can die from complications of immobility.

Dementia can take many forms, but the most common is that associated with Alzheimer’s disease, an increasing occurrence with the population served by long-term care. Alzheimer’s disease is the most common type of irreversible dementia in persons over age 65, affecting men and women alike. Alzheimer’s disease progresses in stages, eventually destroying all mental and physical abilities. In the Alzheimer’s resident, confusion results from the resident’s decreased cognitive ability, contributing to a lowered ability to manage stress; the resident becomes easily agitated or frustrated and might experience depression when the resident realizes his or her condition is getting worse.

Persons with Alzheimer's disease experience learning difficulties, cannot complete complex tasks, and have trouble concentrating. They get very upset, cry, or become combative with any change in their normal routine or overstimulating events. As the disease progresses, symptoms worsen and losses become more severe, making ADLs, speaking, and activity more difficult. Residents might see or hear things that are not present (hallucinations), think irrationally (delusions), or become suspicious (paranoid). They might wander and lose interest in eating. Anorexia, or loss of appetite, can lead to nutritional deficiencies. Wandering and getting lost can put them in grave physical danger because they are not afraid of road traffic or other environmental hazards. During the late stages of the disease, Alzheimer’s residents no longer recognize others and cannot communicate.

Eventually, Alzheimer’s residents lose their swallowing reflex, become incontinent, lapse into a coma, and die.

Special care of residents with dementia includes

Protecting the resident from accidents and injuries

Providing a reassuring environment (controlling noise, loud television, radios, and conversation)

Keeping the environment clean and uncluttered

Using side rails and other assistive devices per facility protocol to protect resident from wandering

Maintaining routines to avoid confusion and overstimulation

Allowing the resident time to complete tasks and make simple decisions

Avoiding disagreements with the resident

Gently touching and reassuring the resident who is suspicious; offering simple explanations

Reorienting and using distraction for agitated or wandering residents

Arranging evening activities to prevent Sundowner’s Syndrome

Providing emotional support to family and friends

Referring family and friends to the nurse for more information on the resident’s progress

Recent advances in pharmaceutical research have made medical treatment of Alzheimer’s disease more promising.

The Depressed Resident

Depression is listed here as a mood disorder that interferes with normal activity of the resident and is either short-term or chronic in nature. Symptoms of depression include insomnia or excessive sleeping, extreme sadness, crying, fatigue, poor hygiene and grooming, changes in appetite and weight, withdrawing from social activities, and feelings of worthlessness and hopelessness. Losing loved ones, a spouse, friends, and pets, and dealing with chronic or terminal illness can be very stressful for residents, leaving them to mourn, or grieve for the loss of loved ones, declining health, or a past lifestyle. These feelings and reactions are part of the grief process, which occurs in stages necessary for adjusting to a loss. They might enter a stage of denial, and then become angry and depressed. They experience other grief stages that include a physical bargaining stage, in which a resident might make a promise to self or to God that, if the situation could change, they would do or feel something different to change their life. In the acceptance stage, the grieving resident finds peace in accepting the loss and can move on. Not all residents resolve their grief and might go back and forth between the five grief stages. Those who can find acceptance can regain hope and find joy in their lives.

Residents might also regret their loss of independence, their reliance on others, and changes in their primary role as spouse, homemaker, or wage earner. Their new role of widow or widower might be very difficult to assume as well. Chronic health problems and infirmity can further increase their loss of self-esteem as well as worries about their declining health and the prospect of dying. Further, residents might resent being placed in a long-term care facility, acting out their frustration on others, especially family members responsible for the placement decision. Severe depression can lead to serious illness, disability, and suicide. Watch for statements such as, “I might as well be dead,” “I’m not good for anything,” or “Everybody would be better off without me.”

Special care of the depressed resident includes

Encouraging the resident to express feelings

Being empathetic

Encouraging self-care, decision making, and independence

Assisting the resident to meet personal care needs (including grooming, eating, and toileting)

Encouraging activity to help improve mood

Observing warning signs of potential suicide (talking about killing self, describing method and timeline, and giving away belongings)

Observing and removing potential hazards in the environment to protect the resident from harming self (including razors, other sharps, cords, and so on)

Being realistic with reassurances; avoiding making statements like “Everything’s going to be all right.”

Avoiding judgmental statements like, “You shouldn’t be depressed.”

Encouraging physical activity and socialization to help improve mood

The Terminally Ill Resident

Coming to grips with one’s own mortality is a term describing the need to realize that everyone’s life is finite, or has a timeline. A normal developmental task of elders is to leave a legacy they can be proud of and to be prepared to face death with as much dignity as possible. For that purpose, the resident might have an advance directive such as a living will, power of attorney for health care, or a health-care surrogate, which act as legally binding documents outlining allowances and restrictions for treatment and care should they become terminally ill (near death) and unable to make decisions for their own care. In such cases, the resident authorizes another person to carry out his or her expressed wishes. The resident’s right to make end-of-life decisions is protected by law in the Patient Self-Determination Act, which gives patients the right to refuse medical or surgical treatment and the right to prepare legally binding advance directives for such purpose.

End-of-life issues can become controversial, especially if family members or loved ones disagree with the resident’s wishes. If the resident does not want to be resuscitated in case of respiratory or cardiac arrest, the doctor will write an order for do not resuscitate, or DNR. It is important to carry out the order. Current research and development to prolong life are legal/ethical issues debated in the legislature as well as the court system. A controversial practice, euthanasia (mercy killing) is legal in Oregon as a means to end suffering and promote dignity of terminally ill persons.

Terminally ill residents might receive hospice care, specialized treatment by a team of doctors, nurses, therapists, chaplains, and volunteers who provide pain relief, comfort measures (also called palliative care), emotional and psychological support, and grief counseling for families as well as respite (relief) care for caregivers. Terminally ill residents have a right to the same level of care and comfort as other residents. They deserve to be informed of their condition and to be included in all aspects of their care as much as possible. Often, nursing staff and family ignore the dying resident, “talking over him or her” as though the resident were not present or excluding him or her from conversation. Terminally ill residents must be treated holistically (as a complete human being), meaning they deserve to receive optimal physical, psychological, and spiritual support. Physical needs include personal care, comfort measures, pain relief, food, fluids, and ADLs as tolerated. Keeping the resident comfortable is of utmost importance. Many residents might appear depressed and consider suicide when, in fact, they are experiencing intense pain. Do not ignore their reports of pain, and observe closely for other signs of discomfort, especially for residents whose culture does not allow them to complain.

Providing comfort measures, listening to the dying resident, and spending time with him or her are essential in helping to allay fears, which arise more often from not being able to manage pain rather than fear of dying. Perform personal care to promote rest and prevent discomfort or fatigue. Tailor your care to the needs of the dying resident, offering food or fluids, skin and oral care, and assisting with toileting as much as his or her condition will permit. The dying resident receiving strong pain killers (analgesics), especially narcotics, might experience constipation; report bowel changes or abdominal discomfort immediately to prevent further complications. Analgesics can also cause confusion, putting the resident at risk for falls. Monitor the resident carefully for any change in alertness that might indicate confusion.

Because talking about death is uncomfortable, caregivers or family members and friends might avoid talking about it and, due to their own fears, might avoid spending time with the dying resident. It is equally important for you to confront your own thoughts and attitudes about dying in order to be effective when caring for the terminally ill resident. If the resident wants to talk about death, listen carefully and respond openly, honestly, and with compassion.

Often, the resident is not looking for answers but needs someone to listen. Along with fear of pain is the resident’s common fear of dying alone. Although it might be easier to avoid the resident, staying with him or her to provide emotional support is a form of “being in the moment” and “giving of yourself,” the most meaningful care you can provide.

Signs of impending death for terminally ill residents include rapid, irregular and shallow respirations, followed by decreased respirations and periods of apnea (Cheyne-Stokes respirations). Other signs of impending death include decreased blood pressure; increased, weak pulse; cyanotic lips, nail beds, hands, and feet; ashen, cold skin; loss of gag reflex; and decreased body functions and awareness, which progresses to unconsciousness or coma. Death occurs when the vital signs are absent. You must report these changes immediately to the nurse, staying with the deceased resident until the nurse arrives. When family members or friends visit the resident, respect their need for privacy but offer your condolences and assistance. Other residents might need support to adjust to the loss. Roommates are especially affected. Be honest and open with them but be careful to maintain confidentiality regarding details of the resident’s death.

Assisting the nurse, you will provide postmortem care, or care provided for the deceased resident, as soon as possible after the family views the body. The procedure, “Assisting with Post-Mortem Care,” is described in Chapter 6.

Exam Prep Questions

  1. How can the nursing assistant best ensure the safety of a resident who is legally blind?

A. Keep the call light within easy reach.

B. Keep an overhead light in front of the resident.

C. Speak loudly when addressing the resident.

D. When assisting residents to walk, stand in front of them and hold their hand to guide them.

  2. Which of the following is the best way to communicate with a resident who is completely deaf?

A. Speak loudly and clearly.

B. Smile and turn on the television.

C. Write out all communication.

D. Sit next to the resident and speak into his or her ear.

  3. Which of the following is not preventative care for a resident receiving oxygen therapy?

A. Provide oral care more frequently.

B. Provide the resident supervision while smoking.

C. Encourage fluids.

D. Provide careful skin care around nares.

  4. A resident complains of sudden chest pain and shortness of breath. What is the nursing assistant’s first action?

A. Help the resident to sitting position.

B. Call for another nursing assistant’s help.

C. Offer the resident a medication for pain relief.

D. Call the nurse immediately.

  5. A resident with diabetes wakes up in the middle of the night asking for a snack. What is the best action of the nursing assistant?

A. Check the resident’s diet before bringing the snack.

B. Inform the resident that snacks are not served on the night shift.

C. Let the resident know the kitchen staff is not available.

D. Serve the resident his or her breakfast early.

  6. Which of the following is the appropriate response of the nursing assistant when a resident complains of dysuria?

A. Encourage the resident to drink more water.

B. Tell the nurse during the end of shift report.

C. Offer the resident cranberry juice with a meal.

D. Report the complaint to the nurse as soon as possible.

  7. A resident who is on continuous gastrostomy tube feedings needs to have the linens changed. Which of the following is a necessary action of the nursing assistant to prevent aspiration of the tube feeding liquid?

A. Keep the tube feeding infusing and place the resident in supine position.

B. Ask the nurse to stop the tube feeding and wait 15 minutes before changing the resident to supine position.

C. Keep the tube feeding infusing and place the resident in prone position.

D. Ask the nurse to stop the tube feeding and wait 5 minutes before changing the resident to prone position.

  8. What protective equipment should be worn when disposing of emesis?

A. Gown

B. Mask

C. Gloves

D. Goggles

  9. Which of the following is not a sign of hypoglycemia?

A. Shallow respirations

B. Cool skin

C. Irritability

D. Slurred speech

10. Which of the following is a form of paralysis?

A. Hemiplegia

B. Hypertension

C. Aphasia

D. Flaccid

  11. What is the best action for the CNA who is taking care of a confused resident whose agitation is increasing?

A. Touch the resident frequently while talking to her.

B. Ask other CNAs to help you in case the resident becomes aggressive.

C. Threaten to put restraints on the resident if his behavior does not change.

D. Report the change to the nurse to prevent potential harm to the resident.

12. The scope of practice for a CNA in an emergency includes all of the following except

A. Apply oxygen.

B. Place the resident in the best position for difficulty breathing.

C. Call for help.

D. Stay in the room and provide assistance as directed by the nurse.

Answer Rationales

  1. A. A call light is to be easy to locate and reach when needed by the resident to call for help. Keeping an overhead light in front of the resident (B) is incorrect because the light source should be behind the resident to prevent a glare effect. Speaking loudly when addressing the resident (C) is incorrect because other senses such as hearing are heightened. When assisting residents to walk, stand in front of them and hold their hand to guide them (D) is incorrect. The nursing assistant should stand beside or slightly behind the resident and gently guide by the elbow.

  2. C. When a resident is 100% deaf, the only form of communication is written communication. Speaking loudly and clearly (A) and sitting next to the resident and speaking into his or her ear (D) is effective for someone who is partially deaf or hard of hearing. Smiling and turning on the television (C) is an incorrect form of communication for the hearing and the deaf.

  3. B. A resident on oxygen should not smoke. Providing oral care more frequently (A), encouraging fluids (C), and providing careful skin care around nares (D) are all part of nursing care for a resident on oxygen.

  4. D. Chest pain can be caused by the resident having a heart attack. The nurse needs to be notified immediately to increase the resident’s chance of recovery and survival. Helping the resident to a sitting position (A) is incorrect because the resident should be placed in a position of comfort and one that enables for ease of breathing. Calling for the assistance of another nursing assistant (B) is incorrect because the nurse needs to be notified immediately. Offering the resident a medication for pain relief (C) is incorrect because it is not part of the nursing assistant’s role or responsibility.

  5. A. Checking the resident’s diet to verify what the resident may receive for a snack is part of the procedure when feeding a resident. The nursing assistant washes her hands, checks the identification of the resident, and verifies that the proper diet is delivered. Informing the resident that snacks are not served on the night shift (B), letting the resident know the kitchen staff is not available (C), and serving the resident his or her breakfast early (D) involve not allowing resident choices, freedom, or involvement in care.

  6. D. Dysuria is the term used to describe painful urination. Dysuria can be caused by infection or obstruction. Telling the nurse during the end of shift report (B) is incorrect because pain should always be reported as soon as possible. Encouraging the resident to drink more water (A) and offering the resident cranberry juice with a meal (C) are related to the care of a urinary tract infection, but that determination is made by the physician.

  7. B. The head of the bed is to be at 30–45° while feeding is infusing. When changing position, the nursing assistant is to ask the nurse to turn the tube feeding off and wait 15 minutes before moving the resident. Keeping the tube feeding infusing and placing the resident in supine position (A) and keeping the tube feeding infusing, and placing resident in prone position (C) are incorrect because the tube feeding is still infusing when the position is changed and could lead to aspiration of tube feeding liquid. Asking the nurse to stop the tube feeding and wait 5 minutes before changing the resident to prone position (D) is the incorrect position to change bed linen, and it does not state the correct time of 15 minutes.

  8. C. Gloves are the only protective equipment needed when emptying an emesis basin. A gown (A), a mask (B), and goggles (D) are not necessary.

  9. D. Slurred speech is a sign of hyperglycemia. Shallow respirations (A), cool skin (B), and irritability (C) are signs of hypoglycemia.

  10. A. When a resident suffers a stroke, it could lead to paralysis. The paralysis can involve hemiplegia or quadriplegia. Hypertension (B) is high blood pressure and could lead to a stroke. Aphasia (C) and flaccidity (D) can result from a stroke.

  11. D. It is important that you alert the nurse immediately because reporting the incident might help avoid further escalation by the resident and avoid potential harm. Actions (A) and (C) may increase agitation. Action (B) is consider false imprisonment, threatening to do harm, and having the ability to carry it out.

  12. A. The CNA’s scope of practice does not include the application of oxygen; it is considered a drug and must be administered by licensed persons only. Answers B, C, and D are within the CNA’s scope of practice.