Introduction
The introduction of technology into clinical practice made it possible to determine the patterns and trends of glucose level excursions, to obtain reliable data on short-term glycemic control. Appropriate glycemic control is a critical factor influencing the course of diabetes mellitus and the risk of its complications and comorbidities. The achievement of adequate control is a significant challenge for both the clinician and the patient, whose direct contribution is the adherence to the physician’s recommendations and the effective self-management of diabetes mellitus. Thus, a preoperative glycemic management protocol should be developed for diabetic patients choosing elective surgery.
The Question and Purpose of the Project
Clinical practice guidelines (CPG) in order to effectively screen and manage the health of patients. The purpose of the setting is to manage the glycemia of diabetic patients and prepare them for elective surgery. The need for surgical care for diabetic patients is quite high, with approximately half of all patients undergoing at least one surgical procedure during their lifetime. Hence, this category of patients requires special care and monitoring by doctors and nurses (Cook et al., 2019). At the same time, they should be involved in the development of the new CPG through their considerable practical experience.
The Practice Gap
It is essential to highlight that this project focuses on the development of a unit that addresses a gap in the practice of nurses and physicians. The problem appears when a scheduled surgery date is set and the resources for the surgery are allocated, but the patient is not prepared for it. Thus, the patient needs to maintain hemoglobin A1c levels at an appropriate level to avoid the risk of cancellation of surgery (Harbaugh & Whitehead, 2020). This solves the challenge of high costs for both the institution and the patient when surgery is canceled. However, in practice, it is extremely difficult for patient to prepare for surgery on their own, which is why they need professional help (Harbaugh & Whitehead, 2020). Thus, in order to receive timely care and not waste material resources, patients are interested in controlling their body sugar. Medical workers are also interested in ensuring that the surgery is performed as planned. Otherwise, problems arise in the schedules of nurses and surgeons, causing them to work more hours. Thus, the core recipients of CPGs will be hospital staff and glycemic patients.
The Evidence Supporting Change and Their Power
Despite the availability of effective drugs to control glycemic levels and the creation of a system of prevention and treatment, the problem of diabetes is becoming increasingly urgent. According to the International Diabetes Federation, the number of diabetes patients over the past ten years has doubled, and if the situation is not changed, by 2035, there will be more than 592 million people with diabetes worldwide (Al-Sofiani et al., p. 4). At the same time, the outcomes of surgical treatment of diabetes patients in 90% of cases are successful if the diagnosis was made in time and adequate therapy was provided. The cause of elevated mortality in patients is not the disease, but inadequate preparation for surgery or ineffective glycemic control in the perioperative period. Although surgical success rates do not always depend on glycemic control, this is also influenced by patients’ comorbidities, age, and other factors. However, it is glycemic control before elective surgery that improves the chances of success by 45 percent (Al-Sofiani et al., p. 6). The absence of glycemic control may result in surgery rejection, which would have a negative impact on the patient’s health condition.
Recommendation
The planned surgical interventions are associated with a lower risk both in diabetes mellitus and in the general population. Prior to elective surgery for diabetes mellitus, an acceptable glycohemoglobin compensation (Hb1c < 8-9%) should be obtained (Care, 2018, p. ). Hence, nurses should explain to patients the importance of obtaining results that will be within acceptable norms. It is valuable to explain that optimal glycemic levels should be maintained for 3 months before surgical intervention. In the few cases where an optimal glycemic level cannot be achieved, such as chronic infection or emergencies, surgery can be performed. However, in such cases the patient should be informed about the increased risk of postsurgical complications (Care, 2018, p. 105). In this way, it will encourage the individual to comply with the recommendations they receive from the medical staff.
Nonetheless, a diet with a low glycemic index can benefit diabetics. Nurses should advise patients about foods and meals that can be consumed. It should be noted that total caloric intake and carbohydrate intake should be reduced (Malcolm et al., 2018). Nurses should also be advised to eat and drink more slowly, reduce gastric juice secretion and suppress the enzymatic conversion of polysaccharides into monosaccharides. They also need to emphasize that this method does not limit the intake of staple foods, with which the beneficial substances enter the body (Malcolm et al., 2018). It is also essential to remind patients that eating disorders lead to a disruption of metabolic processes in the body and elevates blood sugar levels. At the same time, the person constantly feels hungry and is under stress. The body begins to actively form fat deposits in the subcutaneous tissue, creating problem areas (Malcolm et al., 2018). In practice, pamphlets or reminder letters can be used for better adherence. This will enable patients to remember the significance of proper nutrition and basic rules.
The physician may propose a sample menu specifically for the patient’s needs if there is a significant deviation from the norm. For example, for breakfast, one could make porridge of oatmeal with apples or dried fruit and juice of orange or nonfat milk. Dinner can consist of cooked lentils with a small slice of lean meat. Another option is a salad of vegetables with olive oil and nonfat yogurt. Between the main meal, it is possible to drink herbal or green tea, and non-carbonated water. In total, it is desirable not to exceed the daily caloric intake of 1500 calories (Mongkolpun et al., 2019). Such an example will allow patients to understand how to balance their diet. However, nurses may call patients once a week to confirm their health status and verify that they are having difficulties. If patients have more questions, they can call the nurses for clarification.
Physical activity can decrease the sugar content of the patient’s body. The key challenge for the medical staff is to explain and offer patients a set of exercises that are appropriate for them. It is recommended that children and adolescents with elevated glycemic levels do moderate to high-intensity aerobic exercise for ≥60 minutes/day at least three days a week (Mongkolpun et al., 2019, p. 6). Physical exercise should focus on strengthening muscles and muscles or bones.
In order not to damage patients, it is crucial to indicate the duration of the training. Most adults are advised to engage in moderate- to high-intensity aerobic exercise for at least 150 minutes per week; no physical activity should exceed two consecutive days (Vogt & Bally, 2020, p. 213). All adults with diabetes mellitus, especially type 2, are recommended to reduce the time spent in the sitting position. It is advisable to interrupt 30 min of prolonged sitting for a positive effect on blood glucose levels. For the elderly, it is recommended to attend a training session 2-3 times a week to develop flexibility and balance (Vogt & Bally, 2020, p. 214). Nurses should schedule a call once a week to remind them to test their HgbA1c levels to verify their exercise and diet results. Then, patients should report results to the hospital to confirm readiness for elective surgery.
Verification of the patient’s analysis is extremely valuable in controlling HgbA1c levels. If the target HgbA1c level is not reached within six months, specific medical treatment should be prescribed. The main way to maintain HgbA1c levels within normal limits is to use insulin (Lipscombe et al., 2020). Doctors should monitor the health of the patient taking insulin, such as having a physical examined once a week. Based on the outcome, the clinician decides whether to increase the dose of insulin needed until the intended glycemic targets are reached. By titrating the insulin, the recommended glycemic time within the objective range, the target glycated hemoglobin, can be obtained (Lipscombe et al., 2020). Insulin dose titration is performed gradually according to the recommendations for a particular insulin. During the titration of human insulins, the possibility of hypoglycemia increases, because these insulins have a marked onset of action. In such a case, the therapy should be revised. Accordingly, this indicates that the doctor should periodically monitor patients’ HgbA1c levels (Lipscombe et al., 2020). In practice, it is best to establish a schedule for the patient that includes specific days and hours to visit the physician and perform tests.
The preliminary health data of patients are crucial, but the physician has to be convinced that the patients are prepared to undergo surgery. Therefore, 1 week prior to surgery, a control examination of the HgbA1c level should be conducted (Butts & Rich, 2019, p. 20). If the value is normal, the patient can be prepared for surgery. If the index does not correspond to the norm, the planned surgery should be postponed for a period that the doctor considers sufficient to stabilize the patient’s medical condition.
It is essential to mark that it is vital to monitor the patient’s health with all recommendations; this will enable all indicators to be monitored and avoid side effects or risks that may occur. For example, a person’s individual reaction to certain foods may adversely affect their absorption in the body, and the exercise of physical activity and the use of drugs, may cause the development of related diseases. It should also be emphasized that it requires updating once every 6 months, and the physician should consult with colleagues if complicated clinical cases develop (Butts & Rich, 2019, p. 21). The elaborated guideline also has to be reviewed by professionals in the field of glycemic management.
Additional Recommendations
Preoperative intervention by a physician and nurse practitioner is mandatory prior to elective surgery. The National Institute on Health and Care Excellence recommends that all diabetic patients should have their peripheral venous blood urea and electrolyte levels determined in the preoperative period (Cook et al., 2018). Surgery procedures need to be performed first to minimize the period of fasting. If the expected fasting period is limited to missing one meal, it is possible to control the glycemic level by correcting the planned diabetes mellitus therapy (Harbaugh & Whitehead, 2020). Patients should be provided with written instructions with a schedule for adjusting the dose of the medication on the day before surgery. Additionally, nurses are required to provide advice on managing hypo- or hyperglycemia in the perioperative period and are alerted to the possibility of unstable sugar levels for several days after surgery (Cook et al., 2018). Doctors need to consider the timing and duration of surgery to predict the need for intravenous insulin. This will reduce the risk of unintended consequences of surgery and promote better patient health.
The Implications for Nursing Practice
Most patients with type 2 diabetes monitor glucose levels irregularly and, most often, only in the morning on an empty stomach. A single blood sugar test cannot fully reflect all daily glucose fluctuations, let alone glucose fluctuations over 90-120 days (Harbaugh & Whitehead, 2020, p. 3). Thus, regular nurses’ intervention and testing of patients’ tests are necessary. This affects not only the patients, but also the health care workers themselves. This is because they have to make a schedule to pay attention to each patient and choose the way they contact patients. On the one hand, this is additional patient monitoring, which creates more workload for the nurse and the patients. On the other hand, though, it avoids emergency cancellations of surgeries and uses their preparation time efficiently (Harbaugh & Whitehead, 2020). Thus, CPGs have positive implications for the retrieval practice and minimize the occurrence of unpredictable situations.
Positive Consequences for Social Change, Diversity, Equity, and Inclusion
It is critical to emphasize that preoperative glycemic management not only avoids costs in the event that a planned surgery does not occur, but also has a significant social influence. For example, by controlling nurses pay significant attention to patients with inclusion. That is because they may forget to follow recommendations or may not be capable of performing them independently (Butts & Rich, 2019). Nevertheless, regardless of age, gender, race or religious affiliation, all patients receive the same care. It is mandatory because the protocol is enforced in the practice of care. Accordingly, patients are treated fairly, and hospital staff gradually change socially. This reduces the number of cases indicating unequal treatment and inadequate care (Butts & Rich, 2019). Hence, the consequences of following the protocol are extremely valuable for the hospital and the patients.
Conclusion
Therefore, a preoperative glycemic management protocol for diabetic patients choosing elective surgery avoids cancellation of surgery. That is because health care providers provide recommendations to patients to control their HgbA1c levels, namely specific diet, exercise, and medications. However, they also remind patients to check their HgbA1c levels and answer questions that patients ask. This avoids cases in which a patient learns on the day of surgery and significant funds are already predetermined. Additional recommendations on the day of surgery and after surgery enable patients to enhance their health condition. Furthermore, constant monitoring of patients allows the medical staff to plan the schedule and not work overtime due to the postponement of operations to other days. Accordingly, the guidelines are highly valuable for patients, nurses, and physicians.
References
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Butts, J. B., & Rich, K. L. (2019). Nursing ethics. Jones & Bartlett Learning.
Care, D. (2018). Medical care in diabetes 2018. Diabet Care, 41(1), 105-118. Web.
Cook, K. D., Borzok, J., Sumrein, F., & Opler, D. J. (2019). Evaluation and perioperative management of the diabetic patient. Clinics in Podiatric Medicine and Surgery, 36(1), 83-102. Web.
Harbaugh, B., & Whitehead, D. (2020). Developing a clinical practice guideline for surgical diabetic patients. Journal of Excellence in Nursing and Healthcare Practice, 2(1), 3. Web.
Lipscombe, L., Butalia, S., Dasgupta, K., Eurich, D. T., MacCallum, L., & Shah, B. R. (2020). Pharmacologic glycemic management of type 2 diabetes in adults: 2020 update. Canadian Journal of Diabetes, 44(7), 575-591. Web.
Malcolm, J., Halperin, I., Miller, D. B., Moore, S., Nerenberg, K. A., Woo, V., & Catherine, H. Y. (2018). In-hospital management of diabetes. Canadian Journal of Diabetes, 42, 115-123. Web.
Mongkolpun, W., Provenzano, B., & Preiser, J. C. (2019). Updates in glycemic management in the hospital. Current Diabetes Reports, 19(11), 1-6. Web.
Vogt, A. P., & Bally, L. (2020). Perioperative glucose management: Current status and future directions. Best Practice & Research Clinical Anaesthesiology, 34(2), 213-224. Web.
