Diabetes care rounds

There is no universal diabetes care template. The personalized plan needs to be built around the three cores of "dynamic blood glucose threshold adjustment, early screening of complications, and out-of-hospital compliance design." The blood glucose control goals of elderly patients with multiple underlying diseases can be appropriately relaxed, and there is no need to forcefully adhere to the standard values ​​of general guidelines.

The subject of this ward round is Aunt Zhang Guilan, who lives in bed 3 of our department. She has type 2 diabetes for 12 years and has a history of hypertension for 7 years. She burned her left ankle last month when she soaked her feet at home without testing the water temperature.

As soon as she found her blood sugar monitoring record yesterday, Xiao Zhou spoke first: "Yesterday's blood sugar test before going to bed was 5.8. I gave her half a soda cracker as per the previous rules, but Dr. Li who was on duty yesterday said no, saying that the value was not low for the elderly, and eating it would increase her fasting blood sugar. I'm not sure who to listen to."

Everyone present laughed when these words came out - this is indeed a point that has been debated in the diabetes care circle for a long time: traditional guidelines require adult patients with type 2 diabetes to control fasting blood sugar at 4.4-7.0mmol/L, and non-fasting blood sugar should not exceed 10.0. However, the "Senior Glucose" updated last year The "Consensus on Diabetes Diagnosis, Treatment and Nursing" also mentions that patients over 70 years old, with cardiovascular and cerebrovascular diseases, and a history of hypoglycemia can completely relax the fasting threshold to 7.0-9.0. After all, cerebral infarction and myocardial infarction caused by a severe hypoglycemia are much more harmful than higher blood sugar levels. We checked Aunt Zhang’s past history. Last winter, she forgot to eat because she took insulin at home. She fainted and was sent to the emergency room due to hypoglycemia. She was a clear high-risk group for hypoglycemia. We adjusted her blood sugar control target on the spot to 7.0-8.5 on an empty stomach and no less than 6.0 before going to bed, so that the elderly would not be hungry all the time and sneak snacks instead.

As we spoke, we squatted down and lifted up her trouser leg to look at the ulcer on her left foot. We found that she was recovering well, the scabs had almost fallen off, and her skin temperature was no different from that of her right foot. Xiao Zhou specially found cotton socks without elastic at the top for her. She wears them every day now. Before, she always thought these socks were loose and unsightly, so she insisted on wearing the elastic stockings she bought. Speaking of which, the head nurse interjected. There used to be a 70-year-old man with diabetic foot who wore leather shoes to go to the park. When they were worn out, he came back for half a month. So now we don’t say "wear loose shoes" when doing missionary work. We directly ask family members to bring the shoes that patients usually wear. We put our hands in and feel if there are raised seams or hard toes. If they are not suitable, let the family members change them on the spot. It is more effective than just saying ten precautions.

Later, when we talked about self-care after discharge, Xiao Zhou asked another question: Aunt Zhang's hands were shaking a little. She was taught to rotate the site of insulin injections, the abdomen, upper arms, and thighs, but she couldn't remember. Is there any problem if she injects insulin in the same place every time?

This is another question with no standard answer. According to the operating standards, each injection should be spaced at least 2cm apart. The same site cannot be injected repeatedly within a month to avoid fat induration that affects absorption. However, Sister Wang, an old nurse who has worked in our department for 15 years, has a different opinion: She has cared for several elderly people living alone before, and her hands and feet are not easy to use. She cannot inject the upper arms and thighs by herself. Let them rotate the parts, and they will either hit the wrong place or pierce the muscles. Instead, let them hit the abdomen in a fixed way. Every time they change positions, they can use their fingers to measure the distance of one finger width. The operation is easy and the absorption rate is stable. In the past two years, we have used this method for patients with poor ability to operate at home. The feedback is better than strictly following the regulations. Aunt Zhang's son and daughter-in-law can only do the injection for her after they get off work. Our final plan was to rotate the sites when there are people at home. If we were doing it at home, we would only do the abdominal injection. We specially drew a few small circles on her belly and marked the positions from Monday to Sunday, so that she would not have to remember.

In fact, I have been doing diabetes care for almost 8 years. The biggest headache is not the blood sugar control during hospitalization, but the patient's compliance after discharge. Too many people have stable blood sugar control when they are discharged from the hospital, but it returns after a month after returning home. To put it bluntly, it is not that the plan is not good, but that it does not suit the patient's living habits. For example, Aunt Zhang goes for a walk in the park every morning, drinks soy milk and eats fried dough sticks with her old friend. Previously, we taught her not to eat fried dough sticks but to eat multigrain steamed buns instead. She promised well, but turned around and told the nurse that breakfast without fried dough sticks would not taste good. We didn’t force her to change this time. We calculated the calories of half a fried dough stick for her, and told her to take half of the anti-diabetic medicine for breakfast and just drink soy milk without adding sugar. Her eyes lit up after hearing this, and she even said that she would definitely be able to do this plan.

We chatted for almost 40 minutes during this ward round. When we finally left, we left our department’s diabetes follow-up WeChat account with Aunt Zhang. Someone will follow up on her blood sugar level every week. If you have any questions, you can ask her at any time. To be honest, there has never been a perfect answer to diabetes care. Guidelines are dead and people are living. They allow patients to understand them, do them, and stick to them for a long time. They are more effective than any perfect care plan.