Diabetes
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Diabetes
Table of content
- Abstract
- Introduction
- Methods
- Results
- Synopsis of literature
- Discussion
- References
Abstract
The incidence of diabetes is rising rapidly over time. Patients with diabetes are at higher risk of developing post-operative complications such as hyperglycemia or hypoglycemia which in turn contribute to increased morbidity and mortality and length of hospital stay in patient with diabetes undergoing surgery. Therefore, it is extremely important for nurses to take vigilant care of patients with diabetes undergoing surgery. This paper will describe the guidelines of peri-operative management of patient with diabetes and why it is important for nurses to follow these guidelines. Moreover, observations at clinical placements as compared to the findings in peer reviewed research articles will also be discussed in this paper.
Introduction
Diabetes is a metabolic disorder in which blood glucose levels remain high above normal. Patients with diabetes undergoing surgery may have specific needs, particularly in relation to blood glucose control and healthcare professionals such as nurses need to be able to assess and manage these individuals to ensure optimum surgical outcomes. Moreover, the metabolic impact of surgery, pre-op fasting and disruption in insulin therapy contribute to poor glycemic control which in turn leads to increased mortality and morbidity. To deal with this issue, it is always necessary for nurses to follow guidelines for perioperative management of diabetes for the diabetic patients. However, the problem is that most nurses and other professionals are likely to overlook these guidelines, thus placing the patient at a health risk.
Methods
This study involved the use of national database CINAHL Complete, which is available publically and through Australian Catholic University library. This study was conducted by gathering the results from medical research particularly from peer-reviewed journal articles.
Results
The results indicate that the level of awareness among nurses and other professionals such as anesthetists with regard to perioperative guidelines has increased over the last three decades.
Synopsis of literature
According to Marchant et al (2009), patients with uncontrolled diabetes are at greater risk of developing post-operative complications when compared with patients with controlled diabetes. Merchant et al (2009) suggested that healthcare professionals should monitor blood glucose levels pre-operatively as it is independent predictor of morbidity and mortality in patient with diabetes undergoing surgery. However, they also recommend healthcare professionals to monitor HbA1c levels to assess the risk of post-operative complications. Moreover, HbA1c level less than 7% is associated with lower risk of post-operative complications (Kerry, Scott & Rayman, 2013).
On the other hand, Holt (2012) reviewed the available data on pre and post-operative needs of patient with diabetes. He stated that it is very crucial for nurses to conduct appropriate pre-operative assessment of patient with diabetes at the earliest opportunity. However, not only blood glucose levels or Hb1Ac levels should be assessed, but also a complete patient history and examination should be carried out as further backed up by Dhinsa, Khan & Puri (2010). This allows time to assess adequacy of patient’s control of their diabetes and instigate action if needed. This minimizes the risk of post-operative complications such as hyperglycemia. In addition, Holt (2012) also explored that patients with poorly controlled diabetes experience more post-operative pain as compared to patients with well controlled diabetes.
Dhinsa, Khan & Puri (2010) explored the clinical guidelines for peri-operative management of patient with diabetes in their article. They mainly discuss the post-operative complications of patient with diabetes and nursing interventions. According to Dhinsa, Khan & Puri (2010), it should be nurse’s first priority to keep patient pain-free as to minimize the effect of body’s stress response to pain on blood glucose levels. This is further supported by Holt (2012) who argued that body’s stress response inhibit insulin secretion as well as increase insulin resistance. Nevertheless, stress due to surgical interventions not only raise the blood glucose levels in patient diagnosed with diabetes but also in patients without pre-operative diagnosis of diabetes as stated by Dhinsa, Khan & Puri (2010).
Dhatariya (2012) explains some clinical guidelines for patients with diabetes. He suggests it is preferable to place patients with diabetes early on theatre list to reduce the patient’s fasting time. This is because pre-operative fasting and discontinuation of oral hypoglycemic agents can cause hypoglycemia. It is also recommended that elective surgery should be postponed if pre-operative glycemic control is poor (Dhatariya, 2012). Dhatariya (2012) also argues that it is necessary for the nurses to work with the patient and the patient’s family to help them with adhering to the part of the preoperative guidelines that are beyond the nurse’s domain. These include the pre-surgery fasting (Learning Zone, 2012).
Discussion
During my clinical placements, I noticed that not all patients are tested for diabetes before surgery. This is a major issue as not all patients are aware of whether they have diabetes or not. In addition to this, I have observed that despite the fact that patients whose diabetic status is already known, the nurses are likely to overlook the symptoms of hyperglycemia such as itching skin, fruity breath, and confusion. It is difficult to identify usual warning signs of poor glycemic control while patient is unconscious which is potentially life-threatening and the nurses therefore need to do this before the patient is in sedated. Furthermore, when measuring blood glucose levels, the patient’s type of diabetes and type of antidiabetic medication they are on were overlooked, thus placing the patient at a much higher risk. I have seen that blood glucose checks are not performed while patient is in operation theatre, however, which goes against he guidelines as discussed by Campbell (2011). Discharge education for patient with diabetes plays an important role in their well-being post-operatively such as teaching patient about signs and symptoms of hyperglycemia, wound infection and wound non-healing. However, I have seen very few nurses in post anesthesia care unit giving discharge education to patients with diabetes which is also argued by Rutan and Sommers (2012). The other issue that is observable at the clinical placements is the fact that the different healthcare personnel are fully aware of the recommended guidelines. Other staff such as the anesthetists who also play an important role in the surgery process are also likely to be ignorant of the most up-to-date guidelines for preoperative care for patients with diabetes. All these factors work together to bring in a problem that can affect the post surgery results.
In this regard, even if the surgical team is able to fully adhere to the peri-operative care from the time that the patient is at the hospital, they are not able to do the same for the patient when he or she is not at the hospital. This includes the pre admission time where pre surgery fating is part of the peri-operative care. To implement the peri-operative care in a comprehensive manner, some aspects of the hospital’s operations will need some changes. First, there is a need for a better support system to help the patient and the patient’s family with regard to the part of the preoperative care that they are responsible for, such as pre surgery fasting. Secondly, the nurses need to update their knowledge of the full process of preoperative care. Thirdly, the hospitals should develop policies which will make it easier for healthcare personnel to identify surgery patients with diabetes and who do not already know they have diabetes.
References
Campbell, A. (2011). Pre-Operative Fasting Guideunes For Children Having Day Surgery. Nursing Ohildren And Young People, 23, 4 , pp. 14-21.
Dhinsa, B., Khan, W., & Puri, A. (2010). Management of the patient with diabetes in the perioperative period. Journal Of Perioperative Practice, 20(10), 364-367.
Rutan, L., & Sommers, K. (2012). Hyperglycemia as a risk factor in the perioperative patient. AORN Journal, 95(3), 352-363. doi:10.1016/j.aorn.2011.06.010
Dhatariya, K. (2012). Perioperative management of adults with diabetes: why do we need guidance?. British Journal Of Hospital Medicine (17508460), 73(7), 366-367.
Holt, P. (2012). Pre and post-operative needs of patients with diabetes. Nursing Standard, 26(50), 50-56.
Kerry, C. S., Scott, A., & Rayman, G. (2013). Daily temporal patterns of hypoglycaemia in hospitalized people may reveal potentially correctable factors. Diabetic Medicine, 30, 12 , 27-38.
Learning Zone. (2012). Pre and post-operative needs of patients with diabetes. Nursing Standard. 26, 50 , pp. 50-56.
Marchant, H. et al. (2009). The Impact of Glycémie Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty. The Journal Of Bone And Joint Surgery, Incorporated, 97, 1 , pp. 1621-1629.
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