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Lesson 6: Specialized Care

While all patients require the care skills you can find under the personal care skills, restorative skills, and psychosocial care skills sections of this website, there are other patients who have different issues that require other specialized skills. These issues can be physiological or psychological and might be beyond what is considered standard resident care. In this section, we will address some of these specialized care skills.


Vision Impairment

With aging, it is common for residents to have vision impairment problems. This can also increase their risk for accidents or affect their mental health. Inability to use their vision properly is likely to create issues of self-confidence and lack of well-being. The following vision impairment problems commonly occur in aging patients:

Cataract: Cataract is a clouding of the eye’s lens, which results in a blurred vision. It is a common condition in older adults.

Glaucoma: Glaucoma is a condition that damages the optic nerve and impairs the patient’s vision. There is build-up of extra fluid in the front part of the eye which increases the pressure in the eye and causes blindness, if not treated.

Macular Degeneration: In this condition, the central portion of the retina, the macula, deteriorates thereby resulting in loss of vision.

Diabetic Retinopathy: Diabetic retinopathy occurs due to diabetes mellitus. In this condition, high blood sugar levels damage the blood vessels in the retina resulting in blindness.

The CNA should be aware of the difficulties and problems that such patients face and accordingly plan care. CNAs should ensure that the patient’s room is well lit, organized and clean. This will make it easy for the patient to locate the things he needs, and also prevent accidents.

The CNA should also take the following actions when providing care for a patient with impaired vision:

  • Maintain the right lighting in the room according to the vision needs of the patient.
  • Knock the door when entering the patient’s room, so the patient is aware of who is entering the room, and is not afraid of any unknown noises.
  • Before providing care, explain to the patient what will be done, so that the patient co-operates in the care process.
  • Ensure that the bed is in a comfortable, low position for the patient to get out of the bed.
  • Encourage the patient to be independent in performing activities of daily living, but provide assistance when required.
  • Familiarize the patient with the room surroundings and ensure that he knows where the light switch is located.
  • When assisting with walking, stand close to the patient to prevent any possible falls or accidents.
  • Encourage the patients to use their eyeglasses and other devices that will assist in activities such as reading.

Hearing Impairment

Hearing impairment is a common problem in patients due to aging. The patient may find it difficult to understand instructions or communicate effectively if he is unable to hear appropriately or there are multiple noises in the background. This can also result in a loss of self-confidence and mental well being of the patient. The patient may feel that he is not able to articulate his needs clearly, and may stop socializing.

The CNA should use the following guidelines when communicating with patients with hearing loss or impairment:

  • The patient may not be able to hear you enter the room, or approach him. So, approach the patient from the front, and touch them gently on the arm so they are not startled.
  • Face the patient and speak slowly and clearly so the patient understands each word.
  • Ask for confirmation from the patient after each instruction to ensure that the patient has understood the message. This can be done by asking the patient to repeat what you say.
  • Do not cover your mouth when talking. This will help residents to lip read when you are communicating.
  • Keep the conversation simple to avoid confusion.
  • Ensure there are no background noises when you are talking.
  • Use visual aids, sign language and writing material such as notepad and pencil along with the verbal communication with the patient.
  • Encourage the patient to use other senses such as touching and smelling things which will help the patient to articulate his needs or assist them in getting the message across.
  • If the CNA is unable to understand what the resident is saying, the CNA should ask the resident to speak slowly and also repeat after him to clear the confusion.
  • Place the hearing aids, call buttons, water and other necessary things that the resident needs, close to the bed, so that they can access it when required.
  • Let the patient know when you are leaving, and that you are done with your work in the patient’s room.

Speech Impairment

Patients with a speech impairment may not be able to articulate their needs clearly. They may communicate using noises or grunts which the CNA may find difficult to interpret. However, consistent contact with the patient will familiarize the CNA with the patient and help them understand better.

The CNA should use the following guidelines when interacting with patients with speech impairment:

  • Before entering the patient’s room, knock on the door. Approach the patient slowly and in a non-threatening manner.
  • Be respectful, and call out the patient by name, or in a way that they like to be addressed.
  • Keep the conversation simple and to the point to prevent confusion. Smile when talking to the resident, and keep a relaxed attitude to ease the communication. Do not leave the conversation incomplete or leave the patient in the middle of the conversation. If you have to leave, assure the patient that you will soon be back.
  • Use short, simple and direct questions when interacting with the patient. This will help the patient articulate their needs better, by using simple yes, no answers or by nodding their heads.
  • Repeat the message back to the patient, to show that you understood their needs. If you do not understand what they need, try and communicate again. Do not pretend to understand the patient.
  • Provide enough time for the patient to respond, if he is unable to answer quickly. It may be possible that the patient understands the question, but is unable to respond at once.
  • Use written material, sign language, or other communication aids such as flashcards and picture boards to enhance communication.
  • If the patient appears to be frustrated, assure them that you understand them and that their needs will be met, and then ask for help from another colleague.
  • When the conversation ends, let the patient know you are leaving. Before leaving make sure that the patient is safe, and the call button and other personal items are within the patient’s reach.

Respiratory Problems

The respiratory system is composed of lungs and the airway and is involved in two main functions – supplying oxygen to all parts of the body and expelling carbon dioxide from the body. Any complication or diseases of the respiratory system can be life-threatening as it may disrupt the normal breathing in a patient. Acute diseases of the respiratory system such as respiratory arrest can result in a lack of oxygen in the body and damage the vital organs, resulting in further complications.

The CNA should be able to identify any respiratory complications in a patient. Usually, a patient with breathing difficulty will show symptoms such as gasping, bluish skin, a rise in heart rate and an increase in blood pressure. If the patient appears confused, it indicates a shock and the patient may require prompt medical assistance.

The CNA should also be alert to accidents such as choking, which can cause respiratory distress in a patient. The patient may be found clutching his throat and is unable to speak. In such cases, the use of the Heimlich maneuver can help in expelling the food or another object that is blocking the patient’s airway. If the CNA is unable to dislodge the choking object, and the patient stops breathing, the CNA should immediately call for assistance or provide mouth resuscitation.

Use the following guidelines to assist the choking patient:

  • Check the patient’s mouth. If the object is seen, use a finger sweep to remove the object from the airway.
  • If the object is not visible, and the patient is not breathing, give 12 continuous breaths per minute.
  • Check again if the object is seen.
  • Continue these steps till the patient starts breathing or until help arrives.

In patients with chronic respiratory conditions, the doctor will usually prescribe oxygen therapy. Such conditions include bronchitis or congestive obstructive pulmonary disorder. In such cases, the CNA should ensure that there are adequate signs in the patient’s room to warn others of the patient’s condition. The CNA should also take the following precautions when assisting such patients:

  • Ensure that the amount of oxygen prescribed is followed strictly.
  • Ensure that nobody smokes near the patient’s room.
  • Ensure that the patient is properly positioned and is not distressed. Change the patient’s positions at regular intervals to prevent pressure ulcers.
  • Provide mouth care and nose care to keep the patient clean. Use safety measures while suctioning sputum. Explain what you will be doing before performing any procedure.
  • Encourage the patient to eat and drink as prescribed by the doctor.
  • Ensure that the patient’s oxygen mask is in place and there are no leakages in the oxygen tank. If the oxygen tank is not functioning properly, report immediately to the supervisor.
  • In case the patient appears aggressive due to abnormal breathing, assure the patient and respond calmly. Encourage the patient to use the call button, and keep it near the patient’s bed.
  • Note any change in the patient’s conditions or breathing patterns and report them immediately to the supervisor.

In case the patient is connected to a mechanical ventilator, he is dependent on the healthcare providers for day to daycare. The patient will have a surgical opening of the trachea and oxygen tubes from the ventilator will be connected to the patient’s lungs to facilitate breathing. In such cases, ensure all safety standards are followed while providing care. Treat the patient with dignity and respect even in they are not conscious, or comatose.

The CNA schools displayed in this section offer tuition-based programs.

Cardiovacular Problems

The cardiovascular system is made up of the heart and the blood vessels. Its main function is to transport blood and nutrients to different parts of the body. The common diseases of the cardiovascular system are arteriosclerosis, thrombosis, hypertension, and heart valve problems.

By being aware of these diseases and their accompanying symptoms, the CNA will be able to provide proper care for such patients. Identifying any symptoms of cardiovascular disease and reporting them immediately will help save the patient’s life.

Arteriosclerosis: Arteriosclerosis is a common condition in the elderly patients. It occurs when plaque builds up along the walls of the coronary arteries. The arteries become too narrow, making it difficult for the blood to pass through the arteries. This may also cause blood clots which stops blood flow to the heart. This can result in a heart attack or stroke. A patient with arteriosclerosis will display signs of confusion, dizziness, and light-headedness. This increases the patient’s risk of falls and accidents.

The CNA should take the following actions when symptoms of arteriosclerosis are seen in a patient:

  • Hold the patient safely and stop him from moving.
  • Place the patient on a bed or the floor.
  • Do not leave the patient. Stay with him/her and call for help.
  • Make note of the patient’s condition and be alert for any signs of deterioration of health
  • If the patient is experiencing a heart attack, he/she requires emergency intervention.

Thrombosis: Thrombosis is a condition of the circulatory system in which a blood clot causes blockage of an artery or vein. If prompt treatment is not given, this condition can result in disability or death. The area where the clots occur becomes red and swollen. If it occurs in the heart, it causes a heart attack. Such a patient will display shortness of breath (dyspnea).

The CNA should immediately report any such conditions to the supervisor, as it may indicate thrombosis.

Hypertension: Hypertension or high blood pressure is a condition when the patient’s blood pressure exceeds 140/90. It can gradually cause heart disease and damage other organs of the body. Obesity and diabetes are some of the factors for hypertension.

The CNA should take the following actions for a patient with hypertension:

  • Ensure that the patient eats a healthy diet. Foods that cause edema and fatty and sugary foods should be discarded.
  • Observe the patient closely. Monitor intake and output of the patient.
  • Monitor vital signs. Report any changes in the vital signs immediately.

Heart Valve Problems: Stenosis is a heart valve problem in which the heart valves don’t open enough to allow the blood to flow through. The other condition is regurgitation in which the heart valves don’t close properly, resulting in blood leak. In such cases, the patient will display signs such as shortness of breath, chest pain, rapid heartbeats, lightheadedness, swollen ankles and feet, and loss of consciousness.

The CNA should be alert to such changes in the patient’s health and report them immediately to the nurse as it needs emergency intervention.

Paralysis

A patient with paralysis cannot move a part or the whole of his/her body. When the lower half of the body is paralyzed, the condition is called paraplegia. When the left or right half of the body is paralyzed, the condition is known as hemiplegia. When the patient’s arms and legs both are paralyzed, the condition is called quadriplegia.

Paralysis usually occurs when a patient has had a stroke, spinal cord injury or head injury. When a stroke occurs, the different cells of the body start dying and as a result, different parts of the body stop functioning.

Inability to function effectively can affect the patient’s mental health, and also damage their self-confidence.

The CNA should encourage the patient to exercise the paralyzed muscles, as prescribed by the physician. Movement of the paralyzed muscles will enable blood circulation, prevent muscle contractures and help the patient to maintain normal body functions. This will avoid bedsores, incontinence and further complications in the patient.

The CNA should take the following actions when assisting the patient with paralysis:

  • Maintain a calm and stress-free environment.
  • Take the patient out for some fresh air, unless contraindicated by the doctor.
  • Promote rest. However, ensure that the patient does not lie in the same position for more than 2 to 3 hours. Change the patient’s position to either side every few hours. This will prevent pressure ulcers.
  • Encourage the patient to perform activities of daily living. Provide assistive devices so that the patient can perform chores like eating or bathing.
  • Be respectful and caring. Talk slowly and listen carefully to the patient, as he/she may not be able to express pain and other needs due to slurred speech.
  • Perform range of motion exercises as prescribed. This will strengthen the muscles.
  • Provide assistance when exercising weak paralyzed areas. Provide a walker or cane when the patient is trying to walk.
  • Ensure there are grab bars in the patient’s bathroom, to prevent falls.
  • Be supportive and encourage the patient towards recovery. A relaxed conversation will go a long way in promoting the patient’s emotional health.

Infections and IFT

A patient with a compromised immune system or with a weak digestive and urinary system is prone to infections and illnesses. Infections can affect the physical and mental health of a patient, and also result in life-threatening situations.

The CNA should be aware of the signs and symptoms of different infections in a patient so that he/she could promptly report them for emergency intervention. This will prevent the patient’s health from worsening and also avert a life-threatening incident. The infections of the digestive system include:

  • Gastroenteritis (infectious diarrhea)
  • Cholecystitis (gall bladder disease)
  • Hepatitis (liver infection)
  • Nephritis (kidney infection)

The patient with such infections will display the following symptoms:

  • Malnourishment
  • Abdominal cramping and bloating
  • Diarrhea
  • Organ failure
  • Lack of energy
  • Dehydration
  • Fever

In severe cases, the patient may need intravenous fluid therapy (IFT) to recover from the infection. IFT provides the essential fluids and nutrients that are lost due to diarrhea and dehydration. IFT are transported in the patient’s body with IV tubing and IV catheter which is placed in the peripheral vein. The IV catheter is held in place with a sterile dressing.

The CNA will usually be involved in the insertion of the catheter, observing for any signs of infiltration (fluid is not flowing through the vein), infection and reporting any inconsistencies in the fluid flow. The CNA should not discontinue the IV line or make adjustments to the fluid flow, but report any issues such as a change in the infusion rate, redness, swelling, to the nurse, who will then make the necessary adjustments.

The CNA should also ensure that the IV line is not pulled when helping the patient change his clothes or perform other activities. The CNA should perform proper hand hygiene when coming in contact with the patient, to avoid infections. Also, he/she should ensure that the catheter site is dry and clean. The CNA should also ask the patient if the IV site feels itchy, as it may indicate some problem, and report the findings to the nurse.

Digestive and Urinary Tract Cancer

Cancers of the digestive and urinary tract are progressive diseases and may become more complicated with time. The cancer cells multiply in the body and take the nutrients from the normal cells, thereby depriving the normal cells to function effectively.

Cancerous tumors in the digestive and urinary tract can damage the urinary bladders and kidneys and may need surgery. Often the patients cannot take in food and fluids and may have nasogastric or gastrostomy tube feedings. While nasogastric tubes are inserted through the nose into the stomach, gastrostomy tubes are placed directly on the stomach through a surgical opening.

A safety alarm is heard from the pump machine, thereby alerting the healthcare team in case of any feeding problems.

The CNA should take the following actions for patients with tube feedings:

  • Ensure that the patient does not have any food or drink by mouth.
  • Provide proper oral care to prevent infection. Ensure that the head of the bed is placed in a high position.
  • Observe for any signs of infection at the tube site.
  • Report any changes in the patient’s health immediately.

Chronic Illness

Chronic diseases are diseases that last for a long time and affect different organs of the body. Such diseases become more common with age. Chronic diseases such as arthritis, epilepsy, oral health problems, liver cirrhosis and kidney disease are commonly found in older adults.

The CNA needs to provide special care for such patients as lack of activity and poor eating habits can further deteriorate the condition of the patients.

Arthritis: Arthritis is a musculoskeletal condition that affects the joints, tissue, ligaments, and tendons. This chronic condition impacts the daily life of the patients as they are unable to cope with the pain and stiffness of the joints. In addition to aging, obesity, joint injuries and heavy occupations such as farming, and heavy industry work are the risk factors for arthritis.

The patient is usually prescribed heat and cold applications for pain relief. The CNA should also encourage the patient to exercise regularly as prescribed by the doctor. The CNA should also ensure that the patient eats a proper diet and takes adequate rest.

Epilepsy and Seizures: Epilepsy is a brain disorder in which the patient experiences recurrent seizures. Seizures can be tremors and jerks, convulsions, loss of consciousness, sensory disturbances, or a blank stare. This can increase the risk of falls, accidents, and injuries in a patient. The CNA should ensure that the patient is safe during a seizure. Keep them from falling or gently guide the patient to the floor. The CNA should stay with the patient and call for medical help immediately. If the patient is already lying down, position the patient to one side so that fluids can leak out of the mouth. Stay calm and do not hold down or apply pressure to the patient, as it may cause injury. After the seizure, observe the patient for any injuries and place a patient in a safe area. Do not give the patient anything to eat or drink until he/she is fully alert.

Liver Cirrhosis: This is a chronic condition in which there is scarring of the liver. When the liver is not able to function efficiently, there is a buildup of toxic waste and it could further result in liver failure. The CNA should take the following actions when providing care for such a patient:

  • Monitor fluid intake and output to check for dehydration.
  • Encourage the patient to exercise and eat meals as prescribed.
  • Promote rest.
  • Report immediately if there is nausea, vomiting, diarrhea or constipation.
  • Reassure the patient and limit their activities, if there are signs of bleeding. Report to the nurse immediately.
  • Emphasize on giving up alcohol.

Kidney Disease: Kidney disease can cause a failure of kidneys, which may further result in heart congestion and generalized infection. The CNA should provide special care for such patients by observing and reporting any health changes, using safety measures and ensuring there is no damage to the patient’s IV fluid sites and feeding tubes. After surgery, such patients should be closely monitored for complaints of pain, change in color, vomiting, color, and consistency of stool and urine, or other complications. The CNA should ensure that the patient takes the prescribed diet and medications.

Diabetes

Diabetes is a big concern for many people as it is a direct result of leading an unhealthy lifestyle. It can result due to age, family history and obesity as well and the exact cause of this disease is not known.

Diabetes mellitus is a disease in which the pancreas is not able to produce enough insulin. Insulin is a hormone that enables glucose/sugar to pass from the blood into the blood cells. An imbalance in insulin will result in too little or too much sugar in the bloodstream. This will cause diabetic complications such as poor blood circulation, disabilities, coma or even death. Also, low insulin levels are not enough to convert carbohydrates into energy. When this happens, the body starts burning fats to produce energy. In this process, the fats burn and create a by-product called ketones, which is harmful to the body.

There are two types of diabetes:

Type I diabetes (Insulin-dependent diabetes): In this type, the immune system of the body destroys the cells that create insulin. As a result, the patient needs to take insulin regularly to maintain blood sugar levels.

Type II diabetes (Non-insulin dependent diabetes): In this type, the body has low insulin levels. The patient needs medication and a change in lifestyle to manage this diabetes.

Patients with Type I and II diabetes need a healthy diet to manage their condition and ensure the proper functioning of the body. It includes taking the right amount of proteins, carbohydrates, and fats.

Diabetes can result in serious conditions such as kidney failure or blindness. Therefore, the CNA should be aware of the following symptoms of diabetes in the patient.

  • Excessive urination
  • Excessive thirst
  • Night sweats
  • Irritability
  • Fruity breath

Diabetes can be managed with a healthy diet and exercise. The healthcare provider prescribes a diabetic diet that provides the required calories and also prevents an imbalance in the blood sugar levels.

Diabetic patients need to consume snacks in between their meals to maintain their glucose levels. The CNA should ensure that diabetic patients follow the diet plan strictly, as patients have a difficult time prescribing to the diet. Any imbalance in their diet will directly affect their health and make their condition worse. It is a good practice to involve the patient’s family members in the diet plan so that they do not bring unhealthy food items for the patient.

The CNA should take the following actions when providing care for a diabetic patient:

  • Praise the patient for following the diet. This will encourage the patient to stick to the prescribed diet.
  • Observe any changes in the patient’s dietary habits such as a decrease in appetite. Report it immediately to the nurse.
  • Assess the patient’s lower extremities regularly for signs of redness, pain, and swelling.
  • Maintain daily hygiene and ensure that the patient is clean and dry. There should be no leftover moisturizer between the toes.
  • Monitor the blood sugar levels and report any abnormal findings immediately to the nurse.

Poor blood circulation in diabetic patients reduces wound healing. Ensure tasks such as nail cutting are performed carefully to avoid any injuries.

HIV and AIDS

Human Immunodeficiency Virus (HIV) is a virus that attacks the patient’s immune system. As a result, the patient is unable to fight infections or other diseases.

HIV is transmitted when a person shares IV needles of an infected person, comes in contact with blood and fluids of the infected person or has sexual contact with an HIV infected patient.

The CNA should be careful and follow all safety measures when handling body fluids and blood of an infected patient. It is possible to get HIV due to needlestick injuries and also when handling other equipment that can cause cuts or injuries. However, it is important to note that HIV does not spread by touching or coughing an infected person.

HIV eventually progresses to AIDS or Acquired Immune Deficiency Syndrome that further weakens the patient’s immune system and makes him prone to several diseases.

HIV/AIDS has no cure and the patient with this condition needs early treatment for infection, pain, and weakness. As the patient’s immune system is not working properly, there can be other health problems such as drug dependency, nausea, and vomiting. Even though HIV is a chronic disease and has no cure, the condition is manageable if the patient starts treatment on time.

The caregiver should encourage the patient to take the prescribed medications. It is important to inform the patient about his health condition so that he does not have any misconceptions related to the disease. It is also important to provide a great amount of emotional support and care to such patients. A CNA should be non-judgmental when providing care and also build a good rapport with the patient. This will encourage the patient to be co-operative in the plan of care and also accept their health condition.

As with other conditions, the family members and support groups should be involved in the patient’s plan of care. This will provide hope and confidence to the patient and further improve his life.

Confused Residents

A change in the mental health of the resident can cause confusion, lack of orientation and other memory-related issues. It is important for the CNAs to provide proper care to such patients as the patient is unable to decide for themselves, and also cannot think normally.

Confusion can occur because of psychological problems, stressful events, oxygen deprivation, or it could also be a side-effect of medications.

Confusion can make the residents repeat the tasks and speak the same statements, or speak about past events all the time. They may not co-operate in the activities and be afraid or suspicious of others. If they become disoriented to time and place, they may even roam about the place and become lost or injured.

When providing care for such patients, it is important to use tools that can orient them to their surroundings and make them feel comfortable and safe. Telling them where they are and answering their questions can encourage them to be co-operative. Keeping clocks, calendars in their rooms will keep the patient-oriented to present. Reading to them from the newspapers and using bulletin boards to give them information about the present is another good strategy to decrease confusion.

Aggressive Residents

Sometimes a CNA may come across patients who are confused and angry, as a result of which they respond aggressively to others. The CNA should respond to such patients calmly and try to understand the reason for such behavior. If the CNA argues with the patient, it is likely to make him or her more aggressive.

The CNA should allow the patient to express their anger but at the same time ensure one’s safety by keeping a safe distance. In this way, the patient does not feel threatened and he feels that the CNA is willing to acknowledge his feelings.

The CNA should use these guidelines when interacting with an aggressive patient:

  • Sit down at a safe distance and keep arms at side, so that the patient does not feel threatened.
  • Maintain eye contact as it shows the patient that you are paying attention and are willing to listen.
  • Listen to the patient attentively and reply calmly.
  • Do not counteract any decision that the patient makes to solve his or her problems unless it’s harmful to them or embarrasses them in any way.
  • Be alert if there are any aggressive reactions such as shouting or yelling or the situation worsens and the patient becomes violent toward others or you. In such cases do not react violently towards the patient, as it is considered as an assault and can have legal consequences.

Special training is used to restrain and stabilize a violent patient.

Dementia

Dementia is a mental/cognitive malfunction in which the patient is unable to recall past events. Sometimes the patient is unable to perform everyday activities, and he may also be unable to express himself properly.

Other conditions that accompany dementia are the inability to speak, disorientation to time and place, memory loss and confusion.

With time, dementia progresses and the patient may become immobile, depressed and paranoid. They may not remember who they are and become frightened and upset. They may find it difficult to adapt to the changing environment and may not be able to co-operate in their plan of care. Immobility can cause other diseases and complications and eventually lead to the patient’s death.

Dementia is also found in patients with Alzheimer’s disease. Alzheimer’s disease is a cognitive malfunction in which the patient has irreversible dementia. It is most commonly seen in patients over 65. The patient can even react violently because he is unable to perform normal functions. The patient can also experience auditory or visual hallucinations which make them frightened.

The CNA should use the following guidelines when providing care for such patients:

  • Be caring and provide emotional support as the patient often experiences frustration and depression.
  • Be supportive as it can improve the patient’s self-esteem and outlook towards life.
  • Ensure that the patient consumes meals at the right time, as a loss of appetite can result in malnutrition.
  • The patient becomes disoriented and wanders around and may even hurt himself. Keep the patient’s surroundings neat and clean to prevent accidents and injuries.
  • Reassure the patient and maintain a routine so it keeps the patient-oriented to the place and surroundings.
  • The care plan should also include measures that help the patients maintain daily functions. As the patient is forgetful, regularly inform the patient to follow the routine.
  • Respond calmly when the patient reacts aggressively.

Involve the family members in the plan of care so that they provide emotional support to the patient.

Depression

Depression is a mood disorder in which the patient becomes so sad that it affects his daily normal functioning. Depression can affect a patient mentally, emotionally as well as physically. Usually, sad events such as loss of a loved family member, aging, and dependence on others, chronic or terminal illness are some sources of depression.

Symptoms of depression include excessive sleep, frustration, sadness and crying, loss of appetite, loss of self-esteem, and feelings of hopelessness.

A person experiences different stages of grieving when coping with depression:

  1. Denial: Denying the sad event such as the death of a family member
  2. Anger: Expressing anger towards all, or the dying person, for leaving him/her alone
  3. Bargaining: Bargaining with god or a higher power to return the loved person or change the situation
  4. Depression: Extreme sadness and feeling unable to cope with the loss
  5. Acceptance: Ability to accept the loss and find peace, the patient finally begins to cope with the loss

If the patient is unable to cope with the sad events, he may get more and more depressed and gradually attempt suicide, or have suicidal thoughts. It is important to keep a close watch on such patients. The CNA should immediately report any signs of depression in a patient before the situation worsens.

A patient with suicidal thoughts will talk about being dead. The CNA should ensure there are no objects in the patients’ surroundings that can be used to harm themselves. For safety purposes, it is important to keep sharp objects, pipes, and wires out of the patient’s room.

The CNA should also encourage the patient to be open and communicative and socialize with others, as it can improve their state of mind.

Terminal Illness

A patient with a terminal illness experiences a variety of feelings. The CNA should respect their needs and desires and focus more on comforting the patients rather than curing them. This includes providing emotional and spiritual support, providing family time and caring for the dying person.

The CNA should be aware of the rights of the dying patient and also understand what the patient is feeling in the final stages of his/her life. A terminally ill patient:

  • Can decide how he/she will spend the final days of his life
  • Can refuse food and treatment
  • Has the right to relief from pain and suffering

The patient may also decide to stop life-sustaining treatment altogether.

The patient often feels anger and depression and it is difficult for them to accept the inevitable. The CNA should listen and support the patient during this time. It is important to accept the person and his choices without passing judgments. Depending on the patient’s ethnic background, the patient may want to meet a priest, recite prayers or do other things according to his/her religious beliefs and cultural values. If the CNA is not comfortable about supporting the patient’s beliefs, he should notify the supervisor at once. The nurse will accordingly transfer the patient’s responsibilities to another CNA.

The CNA should check regularly to see that the terminally ill patient is comfortable at all times. It can relieve the pain and discomfort that the terminal illness causes. The CNA can do the following to improve the patient’s comfort level:

  • Ensure that the pillows are positioned comfortably.
  • Position the patient comfortably.
  • Provide regular oral care and skin care.
    Look for signs of skin breakdown that may occur due to long periods of immobility.
  • Notify the supervisor immediately in case there are sudden changes in the patient’s health:
    • Nausea
    • Constipation
    • Anxiety and depression
    • Breathing difficulty
  • Provide hard candy or ice chips if the patient’s throat and mouth are excessively dry.
  • Provide emotional support and care when the patient expresses anger or frustration.
  • Comply with the patient’s request, and show that you care.

The patient may also show a decrease in appetite, because of his/her health condition. In such cases, the CNA should not force meals on the patient, as it can increase pain and suffering. Remember, the patient has a right to refuse food or treatment.

The best strategy is to provide the food that the patient asks for but not force him/her to consume it. In fact, providing food and water when necessary, creates the necessary chemical processes in the body that relieves pain and discomfort.

Continue to Lesson 7: CNA Skills Test Practice