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Diabetes mellitus is a common metabolic disorder of elevated blood glucose levels that causes symptoms due to either a lack of insulin (type 1 diabetes) or the body's resistance to insulin (type 2 diabetes). The disorder, which affects more than 34 million Americans, alters the way the body utilizes food for energy. Nursing assistants must be observant of their diabetic patients due to the myriad of complications and dangers caused by diabetes.

There are two types of diabetes. Type 2 diabetes is the most common kind of diabetes in the United States, affecting almost nine out of ten diabetics. In type 2 diabetes, the body does not use insulin effectively due to insulin resistance. The body's cells have difficulty converting glucose into energy; therefore, blood sugar levels rise. As a result, the body's cells are starved for energy. The following are signs and symptoms of very high blood sugar levels that the nursing assistant must report to the charge nurse immediately (CNA Training Advisor, 2011):

• Extreme thirst/hunger 
• Rapid weight loss 
• Frequent urination 
• Decreased vision 
• Dry skin and mouth 
• Fatigue, drowsiness 
• Nausea 
• Fruity-smelling breath 
• Very deep, gasping breath 
• Unconsciousness

Nursing assistants must know about diabetes since they will encounter numerous diabetic patients in all types of healthcare settings throughout their careers. The alert nursing assistant should be able to recognize dangerous situations such as low blood sugar, also known as hypoglycemia, or high blood sugar, also referred to as hyperglycemia. 

If symptoms such as pale moist skin, shallow rapid breathing, irritability, or nervousness are observed, it is important to contact the nurse immediately because these are symptoms of low blood sugar. If the patient’s blood glucose is too low for too long, brain damage can occur. You don’t need the nurse’s permission to give juice to the resident if the blood sugar is low.

The nursing assistant also passes meal trays and helps diabetic clients adhere to dietary restrictions. When assisting with activities of daily living (ADLs), nursing assistants check the patient’s oral hygiene, overall cleanliness, and ensure they bathe regularly to prevent skin infections. Additionally, the state-testable skill of foot care is related to diabetes because it allows nursing assistants to observe for cuts and discoloration on the feet. 

Routine diabetic foot care also prevents infections by keeping the feet clean and reducing the number of disease-causing germs, thereby lowering amputation risk. Diabetics are more prone to infections of all types than patients that do not have diabetes. Therefore, the nursing assistant must help diabetics with personal hygiene to reduce the germ counts on their bodies. Good personal hygiene lowers the risk of infection.

Neuropathy, sometimes referred to as peripheral neuropathy, is a disease in which damage has occurred to the peripheral nerves that results in symptoms such as numbness, pain, weakness and tingling. Since an estimated 30 million Americans have it, this disease is exceedingly common (The Foundation for Peripheral Neuropathy, 2019). Neuropathy can have a terribly negative impact on patients' quality of life by causing chronic pain and distress. 

Diabetes is the leading cause of neuropathy in the United States. When a physician has determined that the condition was caused by diabetes, it is referred to as diabetic neuropathy. In fact, diabetic neuropathy is a complication of long-term diabetes that usually happens when the diabetic patient's blood glucose levels remain elevated over many years. Continually elevated blood sugar levels damage the body's peripheral nerves, causing them to work incorrectly.

Tingling, nerve pain or numbness are usually described by patients as occurring in the legs and feet. Due to numbness, many patients with neuropathy cannot accurately detect how hot or cold things are. Therefore, the nursing assistant must always ask patients to check the water temperature with a finger in all skills that involve the use of water! In addition, the state-testable procedural skill of foot care is directly related to neuropathy since many clients who receive foot care have this condition.

First of all, the chest region of the body is also known as the pectoral area. Angina pectoris is pain occurring in the chest, or pectoral area. In other words, it is chest pain. The pain occurs because the heart muscle is not receiving a sufficient amount of oxygen and nutrients to the heart muscle, so it reacts by sending pain signals. The patient with angina pectoris feels pain on the left side of the chest over the heart. 

Risk factors include older age, male gender, a family history of coronary heart disease, cigarette smoking, high blood pressure and diabetes. Signs and symptoms may include pain radiating from the jaw and down into the neck or back, diaphoresis (excessive sweating), faintness and difficulty breathing (dyspnea). Nausea, vomiting and indigestion are also signs and symptoms of angina pectoris.

If a patient is having an episode of chest pain, the nursing assistant can take multiple actions to help him through the ordeal. The pain usually stops when the patient’s heart has a decreased need for oxygen, so the nursing assistant must encourage patients with angina pectoris to rest. Rest reduces the heart’s demand for oxygen, whereas exercise and constant movement increases the heart's need for oxygen. Also, assist with daily living activities so the client doesn’t over-exert himself.

It is the nursing assistant's duty to notify the nurse immediately if a resident is having chest pain. Also, the nursing assistant might be asked to check vital signs such as pulse, respiration rate and blood pressure as needed. These are all state-testable procedural skills that nursing assistants must know how to perform accurately. 

Furthermore, the nursing assistant should provide friendly reminders to their patients with angina pectoris to avoid overeating. The rationale for not overeating is because the body shunts blood to the digestive system after a large meal to promote digestion and absorption. However, when a patient is having an episode of chest pain, oxygen-rich blood needs to be shunted to the heart muscle. Thus, a patient with angina pectoris should not overeat when chest pain is present.  

Heart failure, also known as congestive heart failure, is a type of heart disease that occurs when the heart is too weak to pump blood to the rest of the body efficiently. Swelling and fluid retention are the hallmark symptoms of heart failure that nursing assistants must address. Heart failure often leaves patients exhausted and negatively impacts their quality of life.

Two types of heart failure exist: left-sided heart failure and right-sided heart failure. In left-sided heart failure, the left side of the heart does not pump properly, so blood backs up into the lungs, leading to frothy sputum and wheezing due to fluid retention. In right-sided heart failure, blood backs up into the general circulation, causing the feet, legs, abdomen and other body parts to swell due to fluid retention.

Nursing assistants help patients with heart failure in a number of ways. Two state-testable skills, urine output and applying an elastic stocking, are related to heart failure symptom management. When the nursing assistant applies elastic stockings to the legs, it encourages fluid to return to the circulation rather than collect and swell. Since physicians often order fluid restrictions and intake/output measurements on patients with heart failure, the nursing assistant checks urine outputs and assists with adherence to fluid restrictions.  

Nursing assistants typically weigh long-term patients just once monthly, but those with heart failure might be prescribed daily weights. The charge nurse might also request nursing assistants to perform pulse oximetry, also called oxygen saturation, which is measurement of blood oxygen levels through placement of a small device on the finger or ear. Measurement of vital signs such as pulse, respiration rates and blood pressure may be done routinely by the nursing assistant.

Since patients afflicted with heart failure tend to have poor circulation, nursing assistants might need to turn and reposition them more frequently. Due to reduced circulation and poorly hydrated skin from heart failure, these patients are more prone to skin breakdown. As a result, the nursing assistant will need to turn patients with heart failure at least  every two hours to prevent consequences of skin breakdown such as pressure ulcers.

The nursing assistant will need to ensure that patients with heart failure are regularly urinating. This is because heart failure patients are more likely to retain fluid on their bodies than persons who do not have heart failure. The nursing assistant might need to take patients to the toilet more often due to prescribed diuretics (water pills) that lead to increased urination. 

Urinary incontinence is a disorder in which the patient has an inability to voluntarily control urine in the bladder; therefore, wetting accidents occur. The patient wets bedding, clothing and chairs with urine. A loss of bladder control is distressing and, though "it does not lead to death, it causes substantial morbidity, social seclusion, and psychological stress resulting in impaired quality of life" (Biswas et al., 2017). 

Urinary incontinence is often caused by certain neurological disorders such as Parkinson's disease, multiple sclerosis, and end-stage Alzheimer's dementia. It can also be caused by generalized weakening of the pelvic muscles. However, urinary incontinence is never a normal part of aging because, under normal circumstances, most patients are able to reach advanced age without becoming incontinent of bladder. 

Some patients with urinary incontinence wear incontinent devices such as adult briefs, pads and diapers. These patients might need the assistance of the nursing assistant to apply these devices. Incontinent patients also need assistance with incontinence care to prevent skin breakdown. The nursing assistant must perform good, meticulous incontinence care because urine is acidic and causes skin problems. Old urine also has an unpleasant odor.

Incontinence care involves the use of personal cleansing wipes, also known as baby wipes, to clean excess urine away from the skin after a wetting episode. Devices such as briefs, pads or diapers are also changed during the incontinence care. Some patients with urinary incontinence receive topical barrier cream to the buttocks and groin to protect these areas from the acidity of urine against their skin. Urinary incontinence can lead to urinary tract infections.

The state-testable skill of perineal care, also called 'peri-care' for short, involves cleansing the patient's private areas with soap and water. More specifically, the genitalia, buttocks and rectal area are cleaned during perineal care to remove all traces of urine and stool. Perineal care is frequently performed by nursing assistants on patients with urinary incontinence to prevent infections, promote skin integrity, eliminate unpleasant odors, and ensure cleanliness.   

When performing perineal care, the nursing assistant must always ask the patient to check the temperature of the water prior to starting the procedure. This step is required for the safety and comfort of the patient. The skin in the perineal area is extremely sensitive to extreme temperatures, so the nursing assistant needs to ensure that the water is not too hot or cold before starting care.

A urinary tract infection, or 'UTI' for short, is an infection that occurs when disease-causing germs end up in any part of the urinary tract, including the bladder. Women are more prone to get UTIs than men due to shorter urethras. Also, elderly patients are more likely to have UTIs due to the reduced immunity that comes with advanced age. In addition, patients with indwelling urinary catheters are more likely to develop UTIs, as are hospitalized individuals.

The most common symptoms of a UTI include pelvic pain, foul-smelling urine, and a burning sensation while urinating. Sometimes the urine of a patient with a UTI appears cloudy due to large amounts of bacteria. Under normal circumstances, urine has no bacteria and appears clear. However, the presence of bacteria and other microbes in the urinary tract may cause the urine to take on a cloudy appearance.   

Nursing assistants must utilize proper guidelines when caring for patients with UTIs. Two state-testable skills, perineal care and catheter care, are directly related to UTI prevention in females. Proper perineal care (cleansing of the genitalia and buttocks) greatly reduces the pathogenic germ count around the urinary tract, thereby reducing risk of UTI development. Proper catheter care reduces the pathogenic germ count on the catheter, thereby lowering chances of a UTI developing. 

Nursing assistants who routinely empty the urinary drainage bag of their clients with catheters reduce the risk of UTIs. As a general guideline, never hold the urinary drainage bag above the level of the bladder. The old urine will flow back inside the patient's body of the urinary drainage bag is held too high. Also, the nursing assistant should remain aware that the urinary drainage bag should be emptied at least once a shift, or several times per day.

A pressure ulcer, commonly referred to as a bedsore, is an injury to the skin caused by constant pressure over a bony area which reduces the blood supply to the area. Blood contains oxygen and nutrients that nourish the skin and surrounding tissues. When a certain part of the body is under continual pressure, not enough blood is being supplied to that area. Whenever the blood supply (circulation) to bony areas such as the elbows, tailbone or heels is inadequate due to sustained pressure, the skin and underlying tissues become damaged.

Hospitalized patients and long-term nursing facility residents who cannot easily reposition themselves are more susceptible to this condition than persons with good mobility.  Pressure ulcers can be dangerous and painful for patients because broken skin can allow infectious microbes into the body. If untreated, pressure ulcers can deepen and even expose the bone. Nursing assistants must know about pressure ulcers because they are in the perfect position to help prevent them from occurring by taking a number of proactive steps. 

A state-testable skill, positioning a client on the side, is directly related to prevention of pressure ulcers. Patients at heightened risk of developing pressure ulcers must be turned and repositioned at least every two hours. Draw sheets are special half-sheets that help nursing staff members turn and reposition patients without causing shearing injuries. Another state-testable skill, perineal care, helps prevent pressure ulcers because urine and stool accelerates skin breakdown. On the other hand, perineal care keeps the skin clean and removes urine and stool from the genitalia, buttocks and rectal area.

Nursing assistants should offer water to their patients frequently because it promotes well-hydrated skin. Be mindful that well-hydrated skin does not break down easily. Nursing assistants must also check the patient’s skin each time they provide care for any changes in condition. It is important to note and report redness, especially over a bony area, that does not disappear. Newly opened areas on the skin must be reported to the charge nurse as soon as possible so healing treatments can be initiated.

If the patient’s care plan requires a dressing, nursing assistants should make sure it is still there and intact. The nursing assistant should notify the nurse if a dressing is missing or falls off during a shower. Additionally, take note of the patient's eating habits and ensure they have nutritious meals. If a patient is not eating much, notify the charge nurse. Poor nutritional status leaves patients more prone to skin breakdown and pressure ulcers.

Hepatitis A is a viral infection that causes inflammation of the liver. Nursing assistants need to know that many different types of hepatitis exist. While hepatitis B and hepatitis C are bloodborne pathogens that are transmitted from person to person via the bloodborne route, hepatitis A is also contracted through the fecal-oral route. 

This means that the hepatitis A virus enters the body through the mouth, also called the oral cavity. It gets inside the body typically when an individual eats food or drinks liquids that have been contaminated with stool that contains the hepatitis A virus. The only requirements for fecal-oral transmission of the hepatitis A virus to occur are the following:

1. An individual is a carrier of the hepatitis A virus.
2. That individual does not practice good hand washing and his/her hands get contaminated with stool that contains the hepatitis A virus.  
3. That individual touches food or utensils with his/her contaminated hands.
4. A susceptible person consumes the contaminated food and/or uses the contaminated utensils and contracts the hepatitis A virus.

Signs/symptoms of a hepatitis A infection appear two to six weeks after the initial exposure and can last for months. Signs and symptoms of an infection with the hepatitis A virus include abdominal pain, diarrhea, extreme fatigue, elevated body temperature, jaundice (yellowing of the skin and/or whites of the eyes), loss of appetite and nausea.

Nursing assistants must adhere to proper hand hygiene when caring for patients with hepatitis A. Proper hand-washing is the single most effective way to prevent the spread of infections, including hepatitis A. Furthermore, hepatitis A can be prevented by good personal hygiene and strict adherence to hand hygiene, especially after personal use of the restroom. 

Nursing assistants need to know that a vaccine exists to protect against the hepatitis A virus. In addition, there is a hepatitis B vaccination series that healthcare employers are required to provide to their employees at no charge. Regrettably, no vaccines are available to protect against the hepatitis C virus or human immunodeficiency virus (HIV).

Biswas, B., Bhattacharyya, A., Dasgupta, A., Karmakar, A., Mallick, N.I., & Sembiah, S. (2017). Urinary Incontinence, Its Risk Factors, and Quality of Life: A Study among Women Aged 50 Years and above in a Rural Health Facility of West Bengal. Journal of Mid-Life Health, 8(3), 130 - 136.

CNA Training Advisor. (2011). Caring for residents with diabetes. HCPro, 9(1), 1-5. 

The Foundation for Peripheral Neuropathy. (2019). Peripheral Neuropathy Risk Factors + Facts. Retrieved April 28, 2020 from https://www.foundationforpn.org/what-is-peripheral-neuropathy/types-risk-factors/