Nursing Essay: Peri& Post-Operative Care of a Patient

Question

Task: Case Study Scenario:
It is 0800 hours, and you are working in a Paediatric Unit in a large metropolitan hospital. You are caring for Shaun Cross, a 15 -year-old male, who has Type I Diabetes. Shaun has been admitted for an exploratory arthroscope on his right knee, from an injury incurred whilst playing soccer. Shaun has fasted from 0600 hours and continues to fast (Nil by Mouth) in preparation for the surgery which is booked for 1000hours. Shaun last administered insulin to himself at 2000 hours the previous evening.

Medical history: Nil known allergies. Shaun was diagnosed with Type I Diabetes six (6) months ago. Shaun’s diabetes has been well controlled with Lantus 50 units BD (mane and nocte). His last HbA1c three (3) weeks ago was 6.4% / 48mmmol.

Social History: Shaun lives with his family of four, Mother Leanne, Father Paul, and Sister Kelsey. Shaun is currently completing year 10 at secondary school and enjoys playing Basketball and Soccer.
The following data was assessed when Shaun was admitted to the ward:

Subjective data:
• Verbal pain rating 0/10
• Alert and talkative
• Objective data:
• Blood pressure: 115/60 mm Hg
• Heart rate: 62 beats per minute
• Respiratory rate: 16/minute
• Temperature 36.2 tympanic
• SaO2: 100% Room air
• Random BGL 5.2mmol
• Weight: 61Kg

Shaun returns to the ward following his procedure at 1130 hours. He complains of severe nausea and is unable to tolerate any diet or oral fluids. You are required to submit a fully referenced academic nursing essay demonstrating your knowledge and application of best evidence-based nursing practice in relation to the above case scenario. Your academic paper should directly relate to the scenario of Shaun Cross and cover all aspects outlined in the marking criteria.

Answer

Introduction:
The nursing essayfocuses on a 15 -year-old patient, Shaun Cross who has been admitted to the pediatric unit in one of the large metropolitan hospitals due to exploratory arthroscopy of his right knee which got injured during a soccer game. Shaun Cross is Type I Diabetic which was diagnosed 6 months ago and till now has controlled his diabetic condition by administrating himself with Lantus 50 unites BD morning and night.Shaun Cross’sHbA1c was 6.4 percent or48mmol/molwhich is below the normal range for diabetes. He has been administered insulin the previous evening at 2000 hours before his surgery and was fasting from 0600 till his surgery was carried out. After surgery, he complains about nausea and intolerance to any diet or oral fluids. The assessment thus will focus on assessing the perioperative interventions as well as post-operative clear relation to his state of Type I Diabetes.

Pre-operative care:
Focusing on the condition of type I diabetes in the case ofShaun Cross, maintaining perioperative acre is necessary to ensure stable healthcondition and minimized risk of complication.Glycaemic monitoring is one of the necessary interventions that need to be maintained in the case of the perioperative phase as it helps in fighting any possible neuroglycopenic issues due to underlying hypoglycaemic conditions. As Shaun Cross sustains the risk of altered blood glucose level, it is necessary tothe administration of insulin and carbohydrates (CHO) or equivalent Intravenous therapy to ensure a stable blood glucose level before, and during surgery. It is necessary to ensure intravenous infusion of carbohydrates to the patient 2 hours before surgery in order to make sure that the patient's body does not develop insulin resistance post-surgery. It is necessary that the blood glucose is monitored regularly on the surgery day as well as during the phase of a perioperative acre in order to ensure effective and better management of perioperative glucose. The glucose level of the patient in the perioperative care as well as post-operative care must be measured and monitored within a duration of every 30 minutes and 2.5 hours prior to surgery. From the case study, it was found that the random Blood Glucose LevelofShaun Cross was 5.2mmol after fasting from 0600 till completion of operation and administration of insulin the previous evening. When compared to the normal blood glucose range (1.4 mmol/L and 6.2 mmol/L) and the range after fasting for 72 hours (3.5-5.5 mmol/L) in case of infants, children, and adults, it was found that the Shaun Cross had low blood glucose level even after not taking insulin the same day of surgery. In case of surgery of patients who are onlong-actinginsulin such as Lantus 50 units, should be discontinued insulin one to two days before surgery in order to maintain glycaemic stability, but, in the case of Lantus, it can be administered the night before surgery. It is necessary for nursing facilities to regularly monitor blood glucose levels as sudden fall or rise in blood glucose level in the patient may lead to alteration in body vitals such as a sudden rise or all of the blood pressure, decreased or increased respiratory and heart rate. In the case ofShaun Cross, thesigns and symptoms of altered blood glucose levels were indicated in the vital such as a fall in blood pressure (115/60 mm Hg)from the normal range of blood pressure (120/80) as well as low respiratory and heart rate.

Assessment, prevention, and management of post-operative hypoglycemia
Assessment of post-operative hypoglycemia includes assessing the level of consciousness of the patient, the respiratory rate, intravenous access, glucose level, insulin dose and time as well as intake of food (Kang, Huo&Zhai,2018). It helps in evaluating the developing or occurring condition of hypoglycemia in post-operative patients similar to Shaun Cross. It is evident that often patient sustains post-operative hypoglycaemic which developfurthercomplications and liner stay in health acres setting. Thus, it is necessary to manage and maintain prevention and management interventions in the case ofShaun Cross. One of the main aims of post-operative care is managing the condition of hypoglycaemia andtreating the condition of nausea and vomiting in suffering individuals. Intravenous fluid helps in restoring hydration in the patient post-surgeryis often nausea and vomiting and post operates stressleads to dehydration of the body (Bilhimer, Treu&Acquisto, 2018). Anothersignificantprocess to manage vomit and nausea includes Cyclizine which is known to be effective in managing nausea and vomitingand is effectively used in the Australian health care system post-surgery to manage similar issues (Rathod, Rathod&Tiwari, 2019). In order to reintroduce diet and fluid in the body in the case of Shaun Cross, it will be necessary to include a liquid diet to help him restore his body energy. Fasting and an inappropriate diet can make the condition of hypoglycemia worse and developfurthercomplications and in order to make the medication effective and balance the blood glucose level, it is necessary to include a liquid diet. Another effective measure to manage and prevent the condition of hypoglycemia is regularly monitoringthe blood glucose level in case of sufferingindividual post-operation. The duration of monitoring is explained to be hourly in order to ensure abyabnormality or alteration in the Blood Glucose level is assessed at an early stage. According to American Diabetes Association’s 2012, it is recommended that post-operative hypoglycemia can be managed by regularly monitoring the blind glucose level as well as administering 15 to 29 gm of carbohydrate if the blood sugar level is below 70mg/dl (Arslanian et al., 2018). The procedure needs to be repeated three times until the blood glucose level is close to the normal range. In case the body sustains a sudden rise in glucose level, it is recommended to administer insulin and it is also necessary to ensure that administration of glucose and insulin must be carried out using intravenous methods and ensure nothing by mouth procedure.

Education for sick day management:
In order to assist Shaun and his family with his diabetes management during sick days after discharge, it is necessary to guide and educate him and the family about the core aspect of managing diabetes. It is necessary that Shaun and his family are educated about the blood glucose maintenance procedure during the sick day. It is recommended that during sick and unhealthy days, Shaun and his family need to monitor blood glucose levels every two to four hours a day to avoid any issue or complication (MacCallum& Senior, 2019). It is also necessary to add 10 to 15 percent addition to the total daily dose of insulin during sick days to manage the condition of altered blood glucose level.

It is calculated with the help of the below-mentioned formula in order to evaluate the significant percentage of the total daily dose:

Calculate 10% (0.1 x TDD) =__________
15% (0.15 x TDD) =__________
20% (0.20 x TDD) =__________

The total daily dose (TDD) is calculated by adding up the total amount of insulin taken each day. Though insulin is taken, it is necessary that carbohydrate is also taken during a sick day within a period of every 1 to 2 hours. It is recommended that a total of 150 gm of carbohydrate must be taken throughout the sick day which has to be distributed through the daily meals and snacks. In case the blood glucose level is difficult to control and is insistently above 18mmol/L for two consecutivereadings with symptoms such as nausea, vomiting, abdominal pain, and breathlessness, it is necessary to seek immediatemedicalassistance toavoid any major complications or health deterioration (Burns et al., 2018).

Education for exercise:
Shaun and his familyneed to be guided about the measures they need to keep in mind before and after exercise to avoid sudden rise or fall of the blood glucose level. It is generally recommended that children with type I diabetes must be involved in 60 minutes of moderate to heavyexercise every day. In case the patient is on insulin similar to Shaun, it is significant to make sure that the blood glucose level is monitored 15 to 3 minutes before exercise. It is also a major step to monitor blood glucose after every 30 minutes of exercise (Cockcroft, Narendran& Andrews, 2020). If the glucose level falls below 3.9 mmol/L and the patient feels weal and uncomfortable it is recommended to stop exercising and immediately intake fast-acting 15gms of carbohydrate. Post-exercise, it is again recommended to monitor the blood glucose level and takes carbohydrate if the sugar level falls below the designated limit (Ilkowitz et al., 2020).

Conclusion
In order to conclude, it can be stated that the case study assessment of Shaun Cross provided a brief understanding of the peri and post-operative care and treatment for a patient suffering from type I diabetics and associated risk of hypoglycemia. It explains the routine and method of managing, and preventing the condition of hypoglycemia in case of a patient on insulin and sustain the risk of sudden blood glucose fall.

References:
Arslanian, S., Bacha, F., Grey, M., Marcus, M. D., White, N. H., &Zeitler, P. (2018). Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Diabetes care, 41(12), 2648-2668.https://doi.org/10.2337/dci18-0052

Bilhimer, M. H., Treu, C. N., &Acquisto, N. M. (2017).Current practice of hypoglycemia management in the ED. The American journal of emergency medicine, 35(1), 87-91.https://doi.org/10.1016/j.ajem.2016.10.009

Burns, K., Farrell, K., Myszka, R., Park, K., & Holmes?Walker, D. J. (2018). Access to a youth?specific service for young adults with type 1 diabetes mellitus is associated with decreased hospital length of stay for diabetic ketoacidosis.Nursing essay Internal medicine journal, 48(4), 396-402.https://doi.org/10.1111/imj.13649

Cockcroft, E. J., Narendran, P., & Andrews, R. C. (2020).Exercise?induced hypoglycaemia in type 1 diabetes. Experimental physiology, 105(4), 590-599.https://doi.org/10.1113/EP088219

Ilkowitz, J. R., Wu, F., Chen, Y., & Gallagher, M. P. (2020).Perspectives on the role of exercise in the treatment of pediatric type 1 diabetes. Pediatric diabetes, 21(3), 466-472.https://doi.org/10.1111/pedi.12965

Kang, Z. Q., Huo, J. L., &Zhai, X. J. (2018).Effects of perioperative tight glycemic control on postoperative outcomes: a meta-analysis.

Endocrine connections, 7(12), R316-R327.https://doi.org/10.1530/EC-18-0231

MacCallum, L., & Senior, P. A. (2019). Safe use of metformin in adults with type 2 diabetes and chronic kidney disease: lower dosages and sick-day education are essential. Canadian journal of diabetes, 43(1), 76-80.https://doi.org/10.1016/j.jcjd.2018.04.004

Rathod, A., Rathod, A., &Tiwari, K. (2019). Emetics and Antiemetics: A Review. Research Journal of Pharmaceutical Dosage Forms and Technology, 11(1), 15-18.10.5958/0975-4377.2019.00003.X