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Diabetes: treatment and complications - the nurse's role

Mary Burden, RGN玛丽·伯登

  The aim of treatment for diabetes is to alleviate the symptoms, maintain quality of life and slow the progression of specific and non-specific complications.


  The nurse's role in diabetes care 护士在糖尿病护理中的作用

  The nurse's role in diabetes care may be as a specialist or as part of general care - primary or secondary. Wherever care is given, the emphasis is always on patient self-management.


  Self-care is key to the management of diabetes. Self-care should resume as soon as possible. Nevertheless, when a person with diabetes does need assistance this needs to be from knowledgeable health professionals.


  Diabetes education in the UK has, traditionally, been undertaken by diabetes specialist nurses alongside their other clinical, management and research roles. Some teaching is done on a one-to-one basis, but health professionals have come to realise that people with diabetes learn a lot from each other, so group education, to which partners and members of the family are also invited, has become the norm. It is important to invite to education sessions the person who shops for, and cooks, the family food. This may be a family member but it could be a home help or a carer in a care home.


  As the number of people in the community who have diabetes has increased, practice nurses and district nurses have taken on tasks that were previously in the domain of the diabetes nurse specialist. They will therefore be involved in planning and delivering diabetes education for patients. Today, many people with diabetes, especially those with type 2, will never have seen a diabetes nurse specialist, since these nurses tend to be hospital-based.


  Today's technology has resulted in many changes in the way people obtain advice about health. Using telephone or the internet are now common ways of accessing health information. Consequently, more and more people are coming to health professionals armed with useful (and sometimes confusing) information that they have obtained from these sources or maybe from the radio, television and friends. Interactive health advice through digital television is being piloted in Birmingham and some health promotion agencies have touch screen programmes and interactive CD-roms.


  This increased choice for patients should be welcomed. It may mean that nurses' roles will change and that they will no longer be the first information-givers, but other important roles will develop. These will include interpreting what the information means to people individually and to their friends and relatives, and creating forums for discussions about how to put the advice into action.


  Nurses caring for patients with diabetes need to be working towards the same objectives, therefore target-setting and determining priorities for managing their condition are important aspects of care. It is known from both the Diabetes Control and Complications Trial (DCCT, 1993) and the UK Prospective Diabetes Study Group (UKPDS, 1998) that it is possible to prevent diabetic complications, and that, if they do appear, their worsening progression can be slowed. The maintenance of good glycaemic control is therefore vital.


  The target for glycated haemoglobin (HbA1c) for those with type 1 diabetes is 7.5% (for type 1) and below 7% for those with type 2. Blood pressure is known to be a factor in diabetic complications and should be below 140/80mmHg for both type 1 and type 2 diabetes - the lower the better, but without feeling the symptoms of hypotension, such as dizziness. Total cholesterol should be below 5 mmol/L, with an HDL of greater than 1.0, and LDL less than 3. If there are complications, these targets may be set even more tightly to prevent their worsening. Patients need to know what the recommended levels are for these tests so they can ask for the results of the investigations and make sense of the information they are given. In this way they will be able to see for themselves if they need more treatment and whether or not they need to make changes to lifestyle and food choices.


  Screening for complications 并发症的筛检

  Routine screening for diabetic complications is often the nurse's responsibility. This will include urine testing for protein as a check on renal function, taking blood for lipid estimations, measuring blood pressure, examining the eyes and the feet.


  Screening for retinopathy: This is performed when pupils are dilated, either by fundoscopy or retinal photography. The nurse's role is to explain what will happen during the procedure and what the findings mean. The nurse may also measure visual acuity. Some patients may need to be referred for laser photocoagulation, and again, the nurse should be able to offer information and reassurance.


  Screening for neuropathy: Patients with normal circulation, gait, and vision are at low risk of neuropathy. Advice about foot hygiene and the wearing of sensible shoes should be offered to these patients. When patients cannot feel their feet and their circulation is impaired through peripheral vascular disease, the risk of neuropathy is greatly increased. These patients will need to be advised not to rely on how their feet feel but to look at them every day to check for any damage and to seek assistance urgently if a problem occurs. This may need to be done by someone else if vision is a problem. Putting a mirror on the floor can be helpful for self-examination.


  Temperature sense can be diminished in patients with neuropathy, so they must be advised not to use hot water bottles and to take care when stepping into a bath or sitting close to a source of heat.


  Neuropathy is assessed by checking the foot pulses (dorsalis pedis and post-tibial). If they are not palpable, a referral for vascular assessment and treatment may be necessary. An assessment using a hand held Doppler can be useful to detect whether there is peripheral vascular insufficiency. Patients whose foot pulses are reduced or absent should be told that this puts their feet at risk and that they should take extra precautions to protect their feet. This may mean seeking care from a podiatrist, being fitted for special shoes with appropriate insoles, inspecting their feet daily and acting on any abnormalities discovered.


  Absent or reduced vibration sense is the first sign of neuropathy. This is measured by a tuning fork. If the vibration sense is absent or reduced, there is a risk of foot damage.


  To prevent amputations in patients with peripheral disease it is important to ensure early referral to a vascular surgeon. Early referral to an orthotist for special shoes can prevent amputation in the neuropathic foot.


  Nutrition advice: As for anybody, the usual advice for healthy eating is to have at least five pieces of fruit and vegetables a day; to restrict alcohol to fewer than three units a day for women or four units a day for men, and to limit salt intake. Calorie restriction is important if the individual is overweight, and advice should be given about having less fat overall, with proportionately more monosaturated and polyunsaturated fat. If the cholesterol level is above target, a referral should be made to the GP for possible treatment with a statin.


  Patients who are having difficulty achieving their targets on nutrition should be given an opportunity to see a dietitian (preferably a diabetes specialist dietitian).


  Conclusion 结论

  When screening for complications and running diabetes clinics, nurses need to be aware that psychological and social issues will have a bearing on how patients view their diabetes and whether they are likely to make lifestyle changes.


  The role of the patient with diabetes is as an active decision-maker and the role of the nurse in this case is to provide information, direction and support. The nurse will be assessing risk, so that appropriate interventions can be made at appropriate times. In addition, the nurse should regard every annual review or screening visit as an opportunity to find out what information the patient has and to fill in any gaps, supported by educational materials. Exploring why patients may not feel able to make changes to their lifestyle and to undertake suggested treatments may help the nurse to suggest actions that such patients are likely to follow.


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