Diabetes: treatment and complications - the nurse's role

糖尿病：護士的作用

Mary Burden, RGN　瑪麗·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.

　　糖尿病的治療目的是緩解癥狀、維持生活質(zhì)量和減緩特異性和非特異性并發(fā)癥的發(fā)展。

　　The nurse's role in diabetes care 護士在糖尿病護理中的作用

　　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.

　　護士在糖尿病護理中既可以發(fā)揮專家的作用，也可以只承擔(dān)其中的部分護理工作。不管是何種場所的護理，都應(yīng)強調(diào)病人的自我護理。

　　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.

　　自我護理是處理糖尿病的關(guān)鍵，開始得越早越好。不過，當糖尿病患者確實需要幫助時，就必須由知識豐富的專業(yè)健康人士提供。

　　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.

　　傳統(tǒng)上，英國的糖尿病教育是由糖尿病?？谱o理師承擔(dān)的，他們還承擔(dān)著其他臨床、治療和研究工作。有些教育是以一對一方式進行，但健康專業(yè)人士已逐漸認識到，糖尿病患者互相間也能學(xué)到很多東西，因此，小組教育已經(jīng)成為一種標準，它還可以邀請同伴或家人參加。邀請家庭食品采購和烹制人員加入教育也很重要。他可能是家庭成員之一，也可能是家務(wù)女工或療養(yǎng)院護理員。 醫(yī).學(xué)教育網(wǎng)整理

　　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.

　　隨著社區(qū)內(nèi)糖尿病人數(shù)的增加，執(zhí)業(yè)護士和地區(qū)護士已經(jīng)承擔(dān)了過去由糖尿病護理專家所從事的很多工作。因此，他們也將參與糖尿病教育的計劃和實施。今天，由于糖尿病護理專家都是在醫(yī)院工作，很多糖尿病患者，特別是二型糖尿病患者，都看不到這些護理專家。

　　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.

　　當今技術(shù)的發(fā)展，使人們的健康咨詢方式發(fā)生了很大變化。電話或英特網(wǎng)已經(jīng)成為獲取健康信息的常用手段。結(jié)果，越來越多的人開始求助于擁有有用（有時也是令人迷惑）的信息的健康專業(yè)人士，他們的信息或來自上述渠道，或來自電臺、電視和朋友。伯明翰正在嘗試舉辦數(shù)字電視互動式健康咨詢節(jié)目，一些健康促進機構(gòu)已經(jīng)接觸這些屏幕節(jié)目和互動CD光盤。

　　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.

　　這為病人提供了更多的選擇，應(yīng)該受到歡迎。這可能意味著，護士的角色將發(fā)生變化，她們將不再是第一個提供信息的人，新的重要角色將出現(xiàn)，包括解釋信息對個人及其朋友和親屬的意義，創(chuàng)辦論壇，討論如何實施建議。

　　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.

　　護理糖尿病患者的護士必須有共同的工作目標，因此，制訂目標和決定病情優(yōu)先處理順序便成為護理的重要因素。研究表明，糖尿病并發(fā)癥可以預(yù)防。如果確實出現(xiàn)并發(fā)癥，其惡化進程也可以減緩。關(guān)鍵是要控制血糖。

　　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.

　　一型糖尿病患者的糖化血紅蛋白目標是7.5%，二型為低于7%.血壓是導(dǎo)致糖尿病并發(fā)癥的一個因素，兩種糖尿病的血壓都應(yīng)低于140/80mmHg，且越低越好。當然應(yīng)以不出現(xiàn)低血壓癥狀為宜，如頭暈。全膽固醇應(yīng)低于5mmol/L，HDL高于1.0，LDL低于3.如有并發(fā)癥，制定目標時應(yīng)更加仔細，以防止加劇。病人應(yīng)知道這些化驗的建議值以便索要檢查結(jié)果，弄懂信息意義。這樣，他們就能自己清楚是否需要更多的治療，是否需要改變生活方式及飲食。

　　Screening for complications 并發(fā)癥的篩檢

　　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.

　　糖尿病的常規(guī)篩檢通常是護士的責(zé)任，包括腎功能的蛋白尿檢，血脂檢查，測血壓及檢查眼睛與雙腳。

　　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.

　　視網(wǎng)膜病篩檢：眼底鏡或視網(wǎng)膜鏡檢查，擴張瞳孔。護士的作用是解釋操作時會發(fā)生的情況與檢查結(jié)果的意義。護士還可以檢查視敏度。有的病人可能需要進行激光凝固，因此，護士應(yīng)能提供信息，安慰病人。

　　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.

　　神經(jīng)病變篩檢：循環(huán)、步態(tài)和視力正常的病人神經(jīng)病變風(fēng)險小。應(yīng)向病人提出足部衛(wèi)生建議，提供合適的鞋子。當病人雙足無感覺，外周血管病引起循環(huán)障礙時，神經(jīng)病變危險就大幅增加。就要建議這些病人不要依賴足部感覺，而應(yīng)每天檢查雙腳，看有無損傷，并在發(fā)生問題時立即尋求幫助。如視力不良，則需要由他人幫助進行。在地板上放一面鏡子也有助于自我檢查。

　　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.

　　患有神經(jīng)病變的病人，溫度覺降低，因此必須勸告他們不要使用熱水瓶，告誡他們在踏進浴盆或坐在熱源邊上時要小心。

　　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.

　　神經(jīng)病變可通過檢查足動脈搏動（足背和脛骨后）進行評估。如摸不到搏動，就應(yīng)安排血管評估和治療。手提式多普勒儀器有助于發(fā)現(xiàn)是否存在外周血管供應(yīng)不足。足動脈搏動減少或無法捫及的，就告知其雙腳已有危險，應(yīng)加倍小心保護雙腳。這可能意味著要尋求足醫(yī)的護理，選用合適的填有鞋墊的鞋子，每天檢查雙腳，并對發(fā)現(xiàn)的任何異常采取措施。

　　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.

　　振動覺缺失或減弱是神經(jīng)病變的第一體征?？赏ㄟ^音叉進行檢查。如振動覺缺失或減弱，就有足部損傷危險。

　　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.

　　為防止外周病患者截肢，重要的一點是要確保盡早安排血管外科醫(yī)生。盡早安排矯形支具師制作特定的鞋子能夠預(yù)防神經(jīng)病變足的截除。

　　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.

　　營養(yǎng)建議：對任何人而言，通常的健康飲食建議是：至少每天五片水果和蔬菜；減少酒精，女士一天少于三個單位，男子少于四個單位；限鹽；如患者體胖，應(yīng)限制熱量攝入，少吃鹽，少吃脂肪，但可按適當比例增加單飽和和多不飽和脂肪。如膽固醇高于指標，應(yīng)安排全科醫(yī)生用抑制素進行治療。

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

　　達到營養(yǎng)指標有困難的病人，應(yīng)給予機會去看營養(yǎng)師（（最好是糖尿病專科營養(yǎng)師

　　Conclusion 結(jié)論

　　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.

　　當進行糖尿病篩檢及糖尿病門診時，護士要知道精神和社會因素對病人對自身糖尿病的看法和如何改變生活方式有很大影響。

　　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.

　　糖尿病人應(yīng)是一個積極的決策者，護士則是資料、指導(dǎo)和支持的提供者。護士對風(fēng)險進行評估，就可以在適當?shù)臅r候采取適當?shù)拇胧６?，護士應(yīng)將每次的年度復(fù)查或篩查視為發(fā)現(xiàn)病人掌握何種信息、彌補欠缺的好機會。探索為什么病人會覺得自己無法改變自己的生活方式，無法了解建議的治療，這有助于護士向這類病人提供他們愿意接受的行動建議。