Diabetes care business round records

During the special ward round for diabetes care in the Department of Endocrinology on May 22, 2024, three optimization and adjustment plans were finalized for immediate implementation based on the nursing pain points of 72 elderly patients with type 2 diabetes and distal symmetrical polyneuropathy. At the same time, the pros and cons of the two mainstream paths of self-management intervention for elderly diabetic patients were compared. The relevant conclusions can be directly incorporated into the department's Q3 nursing specification update items.

The ward rounds were presided over by Wang Jing, a diabetes specialist nurse in the Nursing Department, and the participants included responsible nurse Zhou Meng, three regular training nurses, and bed doctor Lin Hao. The patient was 76-year-old Aunt Zhang Guilan, an old acquaintance of our department. She had been in a hyperosmolar coma last year. This time she felt as if she was stepping on cotton, and her right foot was numb. I also had pain from needle pricks. I called my children to send me here. I was admitted to the hospital and my glycosylated hemoglobin was found to be 8.7%. My ankle reflexes were weakened. The 10g nylon thread test was positive. There were no skin ulcers for the time being. My previous routine care plan included diabetes diet education, 4 times a day subcutaneous injection of insulin into the abdomen, and cold compresses on the heels for pain relief.

When Wang Jing knelt down to check the sensation on Aunt Zhang's feet, she frowned as soon as she touched the heel and asked if she had used a cold compress. Xiao Zhou was still a little aggrieved at the time. He said that the previous training did mention that cold compress can reduce the inflammatory reaction in the acute stage of neuralgia, and the aunt also said that the pain was indeed lessened after applying it. Wang Jing pulled out the adverse event record of the department last year and showed it to everyone: Uncle Li, an 82-year-old diabetic patient, suffered from first-degree frostbite on his heel due to reduced peripheral sensory perception when applying cold compresses. She specially pulled out the 2023 version of the "Consensus on Nursing Care of Diabetic Peripheral Neuropathy" and pointed it out to everyone: Patients over 65 years old and with elevated tactile thresholds are clearly prohibited from using hot and cold compresses for analgesia. Even if the patient feels comfortable, there is a high probability of damage caused by misalignment of perception. Finally, everyone decided to replace the cold compress with soaking the feet in warm water at 37-39°C for 10 minutes, along with foot acupoint massage twice a day. Aunt Zhang was shown the massage method on the spot. She squinted and said it was more comfortable than the cold compress.

Just after talking about analgesia, Lin Hao, the bedside doctor, flipped through the insulin injection records and mentioned in passing that Aunt Zhang already had two coin-sized fat hyperplasia on her abdomen. Should the injection site be adjusted? Now another disagreement arose: The veteran nurse who has been working for 10 years feels that the previously set rule of "changing large parts every week" is easy to remember and the patient can operate it at home, so it is not easy to mess up. ； A young nurse who has just passed the specialist certificate retorted that the 2024 version of the insulin injection guidelines clearly requires that the distance between each injection point is ≥ 2cm, and repeated injections cannot be made in the same area within 1 month. Otherwise, fat hyperplasia will reduce the insulin absorption rate by more than 30%, and blood sugar will definitely be unstable. In the end, we came up with a solution suitable for elderly patients: we printed colorful site rotation cards, divided the abdomen, upper arms, thighs, and buttocks into 1cm square grids, and ticked each grid once. On the same day, we specially taught Aunt Zhang’s wife how to read the cards, so that the elderly would not have to type repeatedly at home.

Speaking of family members, the most discussed issue during this ward round was the compliance of elderly patients with diabetes. Aunt Zhang took out a small crumpled notebook on which she drew crosses for steamed buns and ticks for rice. We were all happy when we saw it - she had heard from her neighbors that diabetics couldn't eat steamed buns, so she ate two large bowls of white rice with pickles. Sometimes she forgot to take her insulin while watching TV, and only took one when she remembered. In fact, there have been two schools of thought in the industry: One school advocates strengthening in-hospital education and teaching patients daily dietary taboos and injection points. Research data from Peking Union Medical College last year said that this method can increase compliance by 22% within three months of discharge. ； The other group is currently promoting family-participated care, which allows family members living together to learn diet calculations and injection methods. Survey data from the Provincial People's Hospital last year showed that the compliance performance of this model increased by 47%. Uncle Wang, who was in bed 39 in our department last month, asked his daughter to follow him for 3 days. Three months after discharge, the glycation level dropped directly from 9.3 to 7.0. The effect is really impressive. The plan for Aunt Zhang this time is also more towards the latter: let her husband bring over the cornmeal, pickles, and oatmeal that are often eaten at home tomorrow. We will calculate the glycemic index on the spot and use the porcelain bowls she usually eats to measure the portions. For example, she drank two large bowls of white porridge before, and then replaced it with half a bowl of oatmeal porridge with a hard-boiled egg, and replaced the pickles with stir-fried green vegetables. Just follow the instructions without having to memorize complicated conversion formulas.

When the meeting ended, Xiao Zhou was still talking about it. In the past, I always thought that if you strictly follow the rules, you will not go wrong. Only when you meet specific elderly patients do you realize that you have to adjust flexibly and use all the resources around you. It is much more effective than rigid rules. Of course, there are also things that have not been discussed and the results have not been discussed: How to improve the compliance of those elderly people with diabetes who live alone without family members to accompany them? We made an appointment for a special ward round next month to deal with this hard problem.