Diabetes care difficult case discussion record sample

[Core conclusions first] This discussion focused on a difficult case of a 68-year-old with type 2 diabetes combined with Wagner grade 1 diabetic foot, brittle blood sugar, and early Alzheimer's disease. It was finally determined that the optimal nursing plan is "a hierarchical nursing plan with four-party linkage of endocrinology + nutrition + rehabilitation + family caregivers". At the same time, it also addresses the previously controversial "strict sugar control vs. moderate relaxation of sugar control goals" " question, a compromise consensus of "fasting blood glucose 7.5-9.0mmol/L, and 2-hour postprandial blood glucose ≤ 12.0mmol/L" is moderately relaxed compared to the conventional "China Type 2 Diabetes Prevention and Treatment Guidelines (2024 Edition)" corresponding population standards. Verified by the department's past data, it can reduce the risk of hypoglycemia in this type of patients by 37%, while not delaying the healing of foot disease.

Discussion time: May 22, 2024 16:00-17:30

Discussion location: Endocrinology classroom

Participants: 2 diabetes specialist nurses, 1 responsible nurse, 1 nutritionist, 1 rehabilitation physician, 1 patient’s family member

Basic information of the case: Patient Zhang Guilan, female, 68 years old, has a history of type 2 diabetes for 21 years. She was diagnosed with early-stage Alzheimer's disease (MMSE score 24 points) 3 months ago. She lives alone every day, and only her son comes to the door twice a week. The cause of admission was that the outer side of the first toe of the right foot was cut while trimming the toenails by oneself. The wound did not heal for 12 days. The fasting blood sugar was 13.2mmol/L during the visit, and the glycated hemoglobin in the past 3 months was 8.9%. There were two episodes of hypoglycemia and syncope in the past, both of which were caused by repeated injections of insulin.

Xiao Zhou, who had just finished reading the case and got his specialist nurse certificate, spoke first: "I checked the latest guidelines. For patients over 65 years old with complications, fasting should be controlled at 4.4-7.0mmol/L. She has just developed foot disease, her blood sugar is not suppressed, and the wound will be rotten to the bone, so she will have to have her limb amputated. I think she still needs to follow the guidelines and strictly control her." ”

As soon as these words were said, Nurse Li, who had been in charge of the geriatric diabetes ward for 12 years, waved her hand: "The guidelines state that the dead are alive. The 72-year-old Uncle Wang we admitted last year had the same situation as her. He also had a bad memory and lived alone. We strictly followed the guidelines to control sugar and suffered hypoglycemia three times a week. The third time he fell and fractured his femoral neck. He lay in bed for three months. In the end, his foot disease did not heal and he contracted hypostatic pneumonia. It was not worth the loss." ”She took out the rolled-up follow-up book in her hand and said, "Look what I've written down. Last year, there were 17 brittle blood sugar patients with cognitive impairment in our department who moderately relaxed their sugar control goals. The incidence of adverse events was 42% lower than those who strictly followed the guidelines. This data is not deceptive. ”

The two of them argued about this for almost 10 minutes. Dr. Chen from the nutrition department who was sitting next to him interrupted: "Oh, by the way, I asked my aunt about her eating habits. She drinks two large bowls of millet porridge every meal. This raises blood sugar faster than white rice. Don't fight about the goal. Think about how to get her to change this habit first. I don’t recommend banning her directly. The old lady has been drinking porridge her whole life, and if you suddenly stop her, she will get angry with you and not eat, which will make her prone to hypoglycemia. My opinion is to add two more spoonfuls of oats every time you make porridge, make it thinner, and drink only half a bowl with half a piece of corn. This can reduce the rate of raising blood sugar by 40%, and she can accept it. ”

This immediately opened everyone's minds. Dr. Liu from the Rehabilitation Department followed up: "I went to see my aunt last week. Her feet hurt now and she dare not walk. She lies on the sofa and uses TikTok every day. Her muscles have atrophied a little. The longer she lies down, the higher her blood sugar level. In fact, there is no need to let her walk more. She can hold the table and walk for 10 minutes every day, divided into two walks. Wear old cloth shoes with a wide front to avoid squeezing the wound. This is much more effective than simply controlling sugar. ”

The patient's son also chatted nearby, saying that he had bought an ordinary insulin pen for his mother before, but she often forgot about it after taking it, and took it again half an hour later. This was the reason for the two previous syncopes. Nurse Li immediately said that our department has an insulin pen with a memory function. After injecting it, the button will light up green, and if pressed again within 24 hours, the red light will turn on. It is just right for her. I will walk you through the application process later, and you don’t have to run every day. We will create a WeChat check-in applet for you. Every morning and evening, you can take a 2-minute video and watch her type, and confirm that the green light turns on, so that she will not have to remember.

Regarding the care of podiatry, everyone has also come up with practical methods: do not rub the wound with iodophor every day, which will stimulate the new granulation tissue. Soak your feet in warm water of 37 degrees for 5 minutes every day - this water temperature must be measured with a thermometer and cannot be touched with hands. Diabetic patients have damaged peripheral nerves and are not sensitive to temperature, so they are easily burned. After soaking, use an old pure cotton towel to gently dry it, and wipe it between the toes. When wearing socks, wear socks without sutures to avoid rubbing your feet.

Finally, going back to the initial controversy about the sugar control target, we made a compromise and settled on a fasting standard of 7.5-9.0, which is neither so high as to worsen wounds nor so low as to easily cause hypoglycemia. Xiao Zhou also accepted it and said that it turns out that you really can’t stick to the guidelines, it depends on the patient’s actual condition. Head nurse Li smiled and patted her shoulder: "You have just come into contact with clinical practice. You will know when you encounter more cases in the future. Nursing is not a math problem. There is no single standard answer. The best one is the one that suits the patient. ”

When the discussion was about to end, Xiao Wang, the nurse in charge, suddenly remembered something and added: "Last time we cared for the grandma who was in a similar situation to my aunt. We put a dietary sticker on her refrigerator with pictures of what she could eat and what she couldn't eat. The pictures were like little people, which was much more effective than writing a bunch of words. The nurse who visited her home every week brought her two pieces of sugar-free peach cakes. She was happy and cooperated with the treatment. We can also use this. ”

The follow-up follow-up plan has also been decided: in the first two weeks, the nurse will visit the patient every three days to measure blood sugar and check the wound healing. Later, it will be changed to once a week. After one month, the glycosylated hemoglobin and the healing of the foot disease will be reviewed. If the effect is good, this plan will be compiled into a reference template for similar cases, which can be used directly when encountering similar patients in the future.