3.1. INTRODUCTION TO MAINTAIN A SAFE HEALTH CARE ENVIRONMENT

Nursing assistants must provide safe, clean, comfortable environments and safely use equipment and supplies. This chapter will review common emergency situations and provide guidelines on how a nursing aide should respond. A typical nursing home environment will be described, and strategies for helping residents transition from living independently to residing in a facility will also be discussed. Proper equipment and body mechanics for lifting residents will also be described to help keep you and those you care for safe.

3.2. EMERGENCY SITUATIONS

Nursing assistants must be prepared to respond to emergency situations when providing patient care. Common situations requiring immediate emergency response include heart attacks (myocardial infarctions), strokes (cerebrovascular accidents), seizures, falls, fires, and choking.

Heart Attack or Myocardial Infarction (MI)

Myocardial infarction (MI) is the medical term for what is commonly referred to as a “heart attack.” It is caused by a lack of blood flow and oxygen to a region of the heart, resulting in the death of cardiac muscle cells. An MI is typically caused by a blocked coronary artery that occurs when the buildup of plaque creates a clot or when a piece of the plaque breaks off and travels to a smaller vessel, creating a blockage.

When the cardiac muscle cells are starved of oxygen and begin to die during an MI, there is typically a sudden onset of severe pain called angina beneath the sternum. This pain often radiates down the left arm or into the jaw. However, some patients (especially female patients) may not experience severe pain but instead experience symptoms that feel like indigestion. Patients may also have associated symptoms like difficulty catching their breath referred to as shortness of breath (SOB), sweating, anxiety, irregular heartbeats, nausea, vomiting, or fainting. Symptoms should be immediately reported to the nurse for emergency assessment and treatment to preserve as much of the heart as possible.[1] See Figure 3.1[2] for an illustration of a male experiencing a myocardial infarction.

Figure 3.1

Myocardial Infarction

View the following supplementary TED-Ed video[3] with additional information on heart attacks: What Happens During a Heart Attack? – Krishna Sudhir.

Stroke or Cerebrovascular Attack (CVA)

A cerebrovascular attack (CVA), often referred to as a “stroke” or “brain attack,” is caused by a lack of blood flow and oxygen to the brain, resulting in the death of brain cells within a few minutes. Similar to the cause of a heart attack, the lack of blood flow is often caused by a blockage in an artery, but in the case of a stroke, the artery is located in the brain. Strokes can also be caused by a blood vessel in the brain rupturing and bleeding, called a hemorrhagic stroke. Risk factors for strokes include smoking, high blood pressure, and cardiac arrhythmias (i.e., irregularities in heart rate and/or rhythm).

Lack of blood flow to the brain for more than a few minutes causes irreversible brain damage. The longer a person goes without treatment for a stroke, the more damage that occurs to their brain cells. Damaged brain cells can result in paralysis, cognitive impairment, difficulty speaking and understanding words, and mood swings. For this reason, it is important to recognize early signs of a stroke and obtain rapid emergency treatment.

The treatment for a stroke depends on the cause. Eighty percent of strokes occur due to a blockage of an artery in the brain. Strokes caused by a blockage are treated with thrombolytic medication (such as tPA) to dissolve the clot. See Figure 3.2[4] for an image of a stroke caused by a blockage. Hemorrhagic strokes occur due to a ruptured vessel in the brain. These types of strokes often require surgery to stop the bleeding. Stroke treatments work best if the symptoms of a stroke are recognized early and emergency treatment occurs within three hours of the onset of symptoms.[5]

Figure 3.2

Stroke

Strokes typically affect one side of the brain based on where the blood flow was disrupted. Because of the brain’s anatomy, the symptoms of a stroke occur on the opposite side of the body as the affected side of the brain. For example, if a stroke occurs in the left side of the brain, the right side of the body will be affected, resulting in signs and symptoms occurring only on the right side of the body. This unilaterality (i.e., one-sidedness) of symptoms is important to recognize and report to the nurse.

The FAST acronym is used to remember early signs of a stroke:

• F: Facial drooping
• A: Arm weakness (unilateral)
• S: Slurred speech
• T: Time, meaning the quicker the response, the better the outcome

Given the central role and vital importance the brain is to life, it is critical that its blood supply remains uninterrupted. If blood flow is interrupted, even for just a few seconds, a transient ischemic attack (TIA), also called ministroke, may occur. A TIA is a temporary period of symptoms similar to those of a stroke, but they usually last only a few minutes, and they don’t cause permanent brain damage. However, TIAs can be a warning sign for a future stroke and should be reported to the nurse.

View a YouTube video[6] from the Centers for Disease Control and Prevention (CDC): Recognizing the Signs and Symptoms of Stroke

Fire

In Chapter 2 you learned about agencies that govern health care, such as the Occupational Safety and Health Administration (OSHA). OSHA provides fire regulations and guidelines for every place of employment. This knowledge is essential for keeping residents safe in health care settings due to their limited mobility. Compliance to these regulations when responding to fires is commonly reviewed during the survey process.

The response to a fire can be remembered by the RACE and PASS acronyms. See Figure 3.3[14] for using the PASS method with a fire extinguisher.

Figure 3.3

RACE for Fire Safety

• R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life.
• A: Activate the alarm by pulling the nearest fire alarm or calling 911.
• C: Contain the fire by closing all doors and windows.
• E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. If the fire cannot be extinguished, then evacuate patients and oneself from the area. The PASS method includes the following actions:
  • P: Pull the pin on the fire extinguisher.
  • A: Aim the extinguisher nozzle at the base of the fire.
  • S: Squeeze or press the handle.
  • S: Sweep from side to side at the base of the flame until the fire appears to be out.

View the UC San Diego Health’s YouTube video[15] on using RACE + PASS: RACE + PASS Training.

Choking and Airway Clearance

Choking is a common cause of unintentional injury and death. Over half of the people who die from choking are over the age of 70.[16] Food is often responsible for choking incidents in the elderly, especially those who have difficulty swallowing or have dentures. Many people who have dementia or who have had a previous stroke have difficulty swallowing. If you see any signs of choking, immediately notify the nurse and take action to clear the person’s airway.

If you are in a setting without a nurse present, it is important for you to know what to do and how to rescue someone who is choking. If a person is continuing to cough forcefully, encourage continued coughing to clear the object. However, a person who can’t cough, speak, or breathe needs immediate help. Ask the person if they are choking and let them know you will use abdominal thrusts, known as the Heimlich maneuver, to help them clear their airway and breathe. (Keep in mind the Heimlich maneuver is not recommended for children younger than 1.) See Figure 3.4[17] for an image of the Heimlich maneuver.

Figure 3.4

Heimlich Maneuver

To perform the Heimlich maneuver, perform the following steps[18]:

• Stand behind the victim with one leg forward between the victim’s legs. If the person is sitting in a wheelchair or not able to stand, lean them forward in the chair and stand behind them.
• For a child, move down to their level and keep your head to one side.
• Reach around the abdomen and locate the navel.
• Place the thumb side of your fist against the abdomen just above the navel.
• Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks.
• For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms.
• Continue thrusts until the victim expels the object or becomes unresponsive.
• If the person becomes unconscious, perform standard cardiopulmonary resuscitation (CPR) with chest compressions and rescue breaths.
• After choking stops, seek medical attention for the client.

View the “Skills Checklist: Choking Maneuver” with an associated video of performing the Heimlich maneuver.

3.3. RESIDENT ENVIRONMENT

When an individual moves into a nursing home, it can be a complicated, stressful, and sometimes confusing time for them and their loved ones. Because nurse aides spend more time with residents than any other staff member, your actions are critical to help ease their worries associated with a change in their environment.

Reflective Activity

Reflect about a time when you moved, changed schools, started a new job, or went to a new place on your own. What things made you feel more comfortable during those transitions? Applying how you felt during those experiences can help you empathize with and provide peace of mind for anyone experiencing a transition.

In addition to experiencing a new environment, newly admitted residents have also typically had a recent major change in cognitive or physical functioning. They are adjusting to not only a new environment but also to how they feel, think, and move. Actions that were previously taken for granted, such as walking, eating, and performing self-care, now require assistance from others. Review the activity in the Chapter 1 subsection “Managing Clients’ and Family Members’ Stress” to increase your awareness of factors that may affect a resident’s outlook and the ways you can improve their quality of life.

As a nurse aide, you can be a major factor in promoting better outcomes for residents by making observations related to their nutritional intake, physical activity, and psychosocial well-being and communicating these observations to the nurse. The Fulmer SPICES tool is a good framework for promoting health in the older adult population. SPICES is an acronym that stands for observing the following aspects that can affect well-being for older adults: Sleep, Problems eating, Incontinence, Confusion, Evidence of falls, and Skin Breakdown[1]:

• Sleep: Older adults need 7-9 hours of sleep per day. To promote good sleep, control environmental factors such as noise, lighting, and temperature. Report sleep disturbances such as excessive snoring or gasping for air or if the resident states they don’t feel rested on awakening.[2]
• Problems Eating: Report issues with chewing and swallowing during meals, as well as residents’ food preferences. Insufficient nutritional intake can lead to skin breakdown issues, infection, and an overall decline in function. More information about eating problems can be found in Chapter 5.
• Incontinence: Incontinence is a lack of voluntary control over urination or defecation. Offer toileting to your residents at least every two hours and on their request. Check incontinence products at least every two hours, especially for those residents with communication problems. More information about incontinence can be found in Chapter 5.
• Confusion: Report any new onset of confusion because it can be a sign of infection. An example of a resident with new confusion would be not knowing the day of the week or where they are when normally they are aware and oriented.
• Evidence of Falls: Report any new weakness or difficulty in transferring from bed to wheelchair or a change in the ability to walk. Read more about fall prevention in the “Emergency Situations” section of this chapter and in Chapter 9.
• Skin Breakdown: Damage to the skin is called skin breakdown. Common preventable causes of skin breakdown are immobility and incontinence. For residents who are unable to independently move, reposition them at least every two hours. For residents with incontinence, provide proper hygiene to keep their skin clean and dry. More information about skin breakdown can be found in Chapter 5.

Transitioning to a New Environment

Transitioning to a nursing home environment involves an abrupt change to an individual’s living environment in terms of privacy, size, and personal belongings. See an image of a typical shared room in a nursing home in Figure 3.5.[3] In addition to this change in environment, residents often cannot follow their typical schedule they had at home, although accommodations should be made to meet their preferences as much as possible.

Figure 3.5

Typical Resident Environment in a Nursing Home

Nurse aids help residents transition to a new environment. When a new admission is expected, a staff member should be at the entry area to greet the individual and their loved ones. The room should be prepared before arrival, which includes sanitization procedures and making the bed. Read more about how to make a hospital bed in the “Skills Checklist” section of this chapter.

Actions to help residents transition to their new environment include the following:

• Introduce the resident to the staff and identify who is responsible for which resident care needs, such as CNAs, dietary aides, activities personnel, nurses, etc.
• Provide a tour of the facility.
• Show the resident where they can find the daily schedule of events and activities.
• Assist the resident in organizing their belongings and arranging their room to fit their needs and preferences.
• Introduce their roommate if they are sharing a room.
• If possible, arrange to have a resident mentor. A resident mentor is another resident who can answer questions and encourage interaction.

Every facility has their own admission procedures, but a common requirement is the completion of a written inventory of the resident’s belongings. This inventory is typically done by the nurse aide depending upon the care setting. See an example of a Resident Personal Belongings Inventory used in an adult family home in Figure 3.6.[4]

Figure 3.6

Sample Resident Belonging Inventory

3.4. BODY MECHANICS AND SAFE EQUIPMENT USE

In addition to promoting safety for patients and their families, it is important for health care workers to be aware of safety risks in the environment and to take measures to protect themselves. Common safety risks to health care workers include sharps injuries, exposure to blood-borne pathogens, lack of personal protective equipment, and lifting injuries. A sharps injury is a penetrating wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne pathogens. Blood-borne pathogens are pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B (HBV) and human immunodeficiency virus (HIV). Personal protective equipment (PPE) is used to prevent transmission of blood-borne pathogens and infection and includes gloves, masks, goggles, gowns, and other types of protective equipment. This section will focus on lifting injuries related to moving clients, and the other safety risks will be discussed in Chapter 4.

The health and well-being of nurse aides is directly related to the quality of care residents receive. When a health care worker is injured, they may be unable to provide care to the extent required by residents. With this in mind, it is vital for nursing assistants to know how to prevent injury in the workplace. An article published in the 2018 International Journal of Environmental Research and Public Health noted that 88% of nurse aides reported at least one of their body parts having a work-related musculoskeletal symptoms (WRMS).[1] The lower back was the most commonly affected WRMS area, followed by the arms and shoulders. According to this study, nursing assistants ranked first for occupational-related back sprains and strains, above construction workers, garbage collectors, and other health care workers. WRMS reported by nurse aides account for over 50% of all musculoskeletal injuries reported in the United States. These injuries are attributed to manual handling of clients, lifting heavy physical loads, assuming frequent awkward positions, and performing repetitive movements.[2]

Using gait belts and mechanical lifts for transferring residents from one location to another, such as from the bed to a wheelchair or a wheelchair to the toilet, has greatly reduced the risk of lifting injuries to both residents and aides. These transferring techniques will be discussed in Chapter 8.

Lifting injuries can also occur when repositioning residents while they are in bed. Repositioning is frequently performed for residents to provide hygiene, alleviate pain, or prevent skin breakdown. The ABC mnemonic for using proper body mechanics when transferring or repositioning residents stands for Alignment, Base of support, and Center of gravity[3]:

• Alignment: Correct body alignment is also referred to as good posture. When standing up straight, an imaginary line should be able to be drawn straight down through the center of the body so that both sides of the body are mirror images of each other. Body parts should be lined up naturally, with arms at one’s side, palms directed forward, and feet pointed forward and slightly apart. Follow these guidelines to use proper alignment to prevent lifting injuries:
  • Maintain correct body alignment when lifting or carrying an object.
  • Keep the object close to your body, unless close proximity could transmit pathogens.
  • Point your feet and body in the direction you are moving.
  • Do not twist at the waist.
• Base of support: Creating a good base of support improves your balance, whereas imbalance creates awkward positioning that can lead to injury. To create a strong base of support, place your feet about shoulder width apart or just slightly wider than your hips.
• Center of gravity: A person’s center of gravity is where most of one’s weight is concentrated. When standing, the pelvis is the center of gravity. Maintaining a low center of gravity provides a stable base of support and improves balance.

For example, when lifting objects or people, keep your center of gravity low with a good base of support by bending at the knees with the feet shoulder width apart. Keep in mind that your center of gravity also includes the resident or the object, so keep them as close to your body as possible. To maintain good alignment, face the person or object you are moving and use both sides of your body equally. Figure 3.7[4] illustrates safer body mechanics in Option “C” by maintaining good alignment, establishing a base of support, and keeping the load close and near to one’s center of gravity while bending the knees.

Figure 3.7

Center of Gravity

Facilities have specialized equipment used to assist in lifting and transferring clients that significantly reduces the risk of lifting injuries. Manufacturers provide specific instructions for the safe use and maintenance of their equipment. Be certain that you receive extensive training on safely using this equipment during your orientation to the facility. Orientation to lifting equipment should include becoming familiar with all parts of the device, the requirements for the mobility status of residents who will use that device, and potential risks to residents and caregivers while using the device. See Figure 3.8[5] for an image of lifting equipment.

Figure 3.8

Lifting Equipment

For additional information on OSHA regulations for using lifting equipment and preventing lifting injuries, refer to this document: Guidelines for Nursing Homes PDF.

3.5. SKILLS CHECKLIST: MAKING AN UNOCCUPIED BED CHECKLIST

Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or whenever they become soiled.

Follow these infection control guidelines when making beds:

• Never allow linens to touch your uniform.
• Do not transfer linens from one room to another.
• Do not place soiled linens on the floor.
• If linens touch the floor, they should be placed in the soiled laundry for cleaning and not used.
• Do not shake linens because it can spread airborne pathogens.
• Store clean linens in a closed closet or a covered cart.

Making an Unoccupied Bed Checklist

1.

Gather Supplies: Linens

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Place a clean barrier on a flat surface. Flip the linens over and place them on the barrier so the fitted sheet is on top.
• Don gloves.
• Look for any personal belongings that may have been left in the bed and return them to their proper place.
• Untuck the corners and roll all linens together to the middle of the bed.
• Place soiled linens in a linen bag or other appropriate container according to facility policy.
• Remove gloves.
• Perform hand hygiene.
• If the bed is soiled, sanitize it or notify environmental services to sanitize it.
• After the bed has dried from sanitization, place the fitted sheet on the bed. Seams should be against the mattress and away from the resident. Smooth the sheet to prevent wrinkles that can cause injury to fragile skin. (Note: If a flat sheet is used as the bottom sheet, refer to sub-bullets below for details on making mitered corners.)
• Place the lift sheet where it is estimated the resident’s shoulders to hips will be when they are in bed.
• Place a soaker pad or other waterproof barrier on top of the lift sheet.
• Place the flat sheet on top and smooth it out. Make mitered corners at the foot of the bed by doing the following:
  • Tuck the entire end of the sheet under the foot of the bed.
  • While facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet.
  • Place the angled edge of the sheet on top of the bed and tuck in anything hanging below the bed frame.
  • Lower the angled sheet back over the edge of the bed.
• Place a bedspread or blanket on top of the sheet per the resident’s preference. Make a mitered corner in the bedspread or blanket by performing the steps above.
• Lay a pillow on the bed and slide the pillowcase over the pillow.
• Put the pillow at the head of the bed with the open end of the pillowcase faced away from the door. Repeat for multiple pillows.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check on resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Report abnormal findings to the nurse.

3.6. SKILLS CHECKLIST: MAKING AN OCCUPIED BED

Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or whenever they become soiled.

Follow these infection control guidelines when making beds:

• Never allow linens to touch your uniform.
• Do not transfer linens from one room to another.
• Do not place soiled linens on the floor.
• If clean linens touch the floor, they should be placed in the soiled laundry for cleaning and not used.
• Do not shake linens because it can spread airborne pathogens.
• Store clean linens in a closed closet or a covered cart.

Making an Occupied Bed Checklist

1.

Gather Supplies: Linens

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Place a clean barrier on a flat surface, flip linens over, and place them on the barrier so the fitted sheet is on top.
• Don gloves.
• Look for any personal belongings that may have been left in the bed and return them to their proper place.
• Put the side rail up.
• Move to the opposite side of the bed.
• Using the lift sheet, roll the resident towards the side rail.
• Begin rolling soiled linens to the middle of the bed and under the resident.
• Remove gloves.
• Perform hand hygiene.
• Place a fitted sheet on the half of the bed you are working on.
• Place the lift sheet and soaker pad in the same manner, fan folding them under the resident.
• Raise the side rail.
• Move to the opposite side of the bed.
• Put on gloves.
• Lower side rail on working side of the bed.
• Roll the resident to the opposite side.
• Remove the soiled linens and place them in a linen bag.
• Remove gloves.
• Perform hand hygiene.
• Pull through the fitted sheet, lift sheet, and soaker pad, ensuring there are no wrinkles.
• Assist the resident to a supine position.
• Keeping the resident covered, place a new flat sheet on top of them.
• Make mitered corners at the foot of the bed by doing the following:
  • Tuck the entire end of the sheet under the foot of the bed.
  • Facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet.
  • Place the angled sheet on top of the bed and tuck in anything hanging below the bed frame.
  • Lower the angled sheet over the edge of the bed.
• Put a clean pillowcase on a new pillow and exchange it for the soiled pillow. Put the pillow at the head of the bed with the open end of the pillowcase faced away from the door. Repeat for multiple pillows.
• Repeat steps for any blankets or bedspreads.
• Make a toe pleat (i.e., a pleat in the sheet which allows an individual to move feet) to prevent pressure.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check on resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Report abnormal findings to the nurse.

3.7. LEARNING ACTIVITIES

III. GLOSSARY

Ambulating

Walking.

Angina

Sudden chest pain beneath the sternum (breastbone) associated with a heart attack (myocardial infarction), often radiating down the left arm in male patients.

Assistive devices

Devices such as gait belts and walkers that are used when moving a patient.

Blood-borne pathogens

Pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B (HBV) and human immunodeficiency virus (HIV).

Cardiac arrhythmias

Irregularities in a person’s heart rate and/or rhythm.

Cerebrovascular attack (CVA)

The medical term for what is commonly referred to as a “stroke,” caused by a lack of blood flow and oxygen to the brain.

FAST

An acronym used to remember the early signs of a stroke: Facial drooping, Arm weakness, Slurred speech, and Time (meaning the quicker the response, the better the outcome).

Heimlich maneuver

A procedure used for someone who is choking that uses abdominal thrusts to clear the airway so they can breathe.

Incontinence

A lack of voluntary control over urination or defecation.

Myocardial infarction (MI)

The medical term for what is commonly referred to as a “heart attack,” caused by a lack of blood flow and oxygen to the heart.

Nonskid footwear

Shoes or socks with rubberized soles used to prevent falls.

PASS

An acronym for using a fire extinguisher that stands for the following: P: Pull the pin on the fire extinguisher. A: Aim the extinguisher nozzle at the base of the fire. S: Squeeze or press the handle. S: Sweep from side to side at the base of the flame until the fire appears to be out.

Personal protective equipment (PPE)

Equipment used to prevent transmission of blood-borne pathogens and infection, including gloves, masks, goggles, gowns, and other types of protective equipment.

RACE

An acronym for responding to a fire that stands for the following: R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life. A: Activate the alarm by pulling the nearest fire alarm or calling 911. C: Contain the fire by closing all doors and windows. E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. Evacuate patients and oneself if the fire cannot be extinguished.

Resident mentor

A resident who can answer questions and encourage interaction for a new resident recently admitted to a long-term care facility.

Seizure

A transient occurrence of signs and/or symptoms due to abnormal neuronal activity in the brain.

Sharps injury

A penetrating wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne pathogens.

Shortness of breath (SOB)

Difficulty breathing or a feeling of not being able to catch one’s breath.

Skin breakdown

Damage to the skin due to common preventable causes like immobility and incontinence.

SPICES

An acronym that stands for observing the following aspects of well-being for older adults: Sleep, Problems eating, Incontinence, Confusion, Evidence of falls, and Skin breakdown.

Thrombolytic medication

Medication (such as tPA) used to dissolve clots in arteries.

Transient ischemic attack (TIA)

A medical term for what is commonly referred to as a ministroke. A TIA is a temporary period of symptoms similar to those of a stroke that usually last only a few minutes and don’t cause permanent brain damage.

Work-related musculoskeletal symptoms (WRMS)

Symptoms from musculoskeletal injuries experienced at work, such as lower back pain, that are attributed to manual handling of clients, heavy physical loads, frequent awkward positions, and repetitive movements.