Paediatric Nursing Essay: Medical Interventions in Pre-Operative Phase

Question

Task: You are required to submit a fully referenced academic nursing essaydemonstrating your knowledge and application of best evidence-based nursing practice in relation to the following case scenario.

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.

Answer

Introduction
The paediatric nurses assist the patients in adapting to the hospital setting as well as preparing them for medical procedures and treatment (Pierce et al., 2017). This nursing essayhas highlighted Shaun Cross: a 15-year-old male suffering from Type 1 diabetes that has been injured on his right knee while playing soccer. Shaun resides with his parents and his sister, and he has currently completed his class 10 schooling. Shaun had to undergo the surgery and the medical staff were busy preparing him for surgery. Though he has been detected with diabetes after consuming Lantus 50 units BD, his diabetes was under control. The heart rate, oxygen level, and weight of Shaun were normal but his Blood Pressure (BP) was low and his temperature was tympanic i.e. 36.2. However, when Shaun has returned to the ward after surgery, he complained of nausea and thus failed to consume any oral fluids or diet. This study will highlight the nursing and medical interventions for Shaun in the pre-operative phase. Further, it will also discuss the assessment, prevention, and management of Shaun’s post-operative hypoglycaemia, education for sick management, and exercise.

Pre-operative care
As Shaun has been suffering from Type 1 diabetes, it is the responsibility of the nurse to keep an eye on his nutrition as Shaun’s diabetes is under control and he should be provided with a balanced diet. Moreover, the nurse must also consult the registered dietician in paediatric nutrition and dieting; thereby scheduling his food preferences. On the other hand, it is also important for the nurses to check Shaun’s blood glucose level when he is kept on an empty stomach before the surgery. Children are prone to face varied types of risks and thus their blood glucose level might fall to a great extent when they are not allowed to consume any food (Elahmedi&Alqahtani, 2017). There might be varied types of concerns associated with the safety as well as the efficacy of Lantus 50 BD before the surgery. Lantus 50 can also lead to the development of renal dysfunction or sodium-glucose risk in fasting; thereby worsening the situation such as nausea as well as vomiting due to gastric emptying. Further, the prolonged and the onset of the duration of action might make it challenging to consume Lantus for the optimal level of glycaemic control within the short period (Puppalwar et al., 2017). The nurse must consult the doctor and thus under their advice must stop the medication before 24 hours of the surgery.

There should always be constant monitoring of the blood glucose level in the last 72 hours before surgery to prevent any sideeffects. The frequency of monitoring this blood glucose level should be a minimum of three times a day post 72 hours after and before consuming the food. However, if there are any such changes observed in the blood glucose level suddenly, the nurse must try to make Shaun free from stress, ask him to relax, and make him busy with varied mind games etc. If Shaun’s glucose level falls, the nurse needs to provide him oral intake of the fruit juice or hard candy; thereby consulting the doctor. The normal blood glucose level in children before food is 3.3 to 6 mmol/L and after 8.9 to 11.1 mmol/L after food (March et al. 2020). The test that has been conducted before 24 hours highlighted that his Blood Glucose Level (BGL) was 5.2 mmol which can be considered to be normal before food, but low after food and thus must be kept under continuous monitoring to prevent complications. The self-administration of insulin by Shaun must also be stopped if required and the nurses must play an active role in this aspect. Further, the symptoms and the signs of the altered blood glucose level of Shaun such as dehydration, dry mouth, excessive urination as well as fatigue must be administered by the nurses (Nishio&Chujo, 2017). If there are any such symptoms observed, the nurses must immediately refer Shaun to the doctor and seek emergency remedy so that it does not weaken Shaun’s health condition further. Under the instructions and the advice of the diabetes healthcare team, the nurses will be successful in managing his diabetes care plan.

Assessment, prevention, and management of post-operative hypoglycemia
The nurse must keep an eye on the metabolic status of Shaun after the surgery. There are higher chances of gastrointestinal instability in Shaun that might be provoked due to anesthesia leading to nausea, vomiting as well as dehydration. This is likely to compound the volume contraction that might be present due to osmotic diuresis induced by hyperglycemia thereby increasing the chances of renal failure as well as ischaemic events (Reitz et al., 2020). On the other hand, the insulin undertaken by Shaun before the surgery must be combined with potassium and dextrose infusion to prevent any complications. Further, there should be monitoring of the BGL before and after the surgery. As Shaun is a soccer player, and before and after the surgeryhe is restricted from undertaking exercise, there are increased chances of complications in this body because of which it is vital to take the appropriate level of care. Further, it has been found that as Shaun is kept on fasting before the surgery, there are increased chances of the after-effect of this fasting thereby developing the electrolyte imbalance as well as gross metabolic abnormalities in his body.

The prevention strategies of BGL in Shaun, such as the intravenous fluid therapy, that is safe for Shaun include the glycaemic target of 140-180 mg/dl. Shaun must be infused with potassium and dextrose injections with insulin after the surgery so that it does not disturb his blood glucose level. Moreover, it is also important to add albumin during the fluid therapy to prevent the non-specific absorption of insulin in the insulin apparatus. There should be adequate administration of fluids to tackle the intravascular volume. However, the deficiency of fluids is likely to lead to osmosis diuretics thereby leading to poor control of diabetes. It is the responsibility of the nurse to carry out close monitoring of Shaun to avoid any further catastrophe during this infusion regime (Nilsson et al., 2017). The administration route of this insulin is that the insulin must be administered subcutaneously by injection where the site should be clean. The size of the needle should be 4 mm and the BGL should be checked beforeinjecting insulin. The administration of the insulin is also to be carried out at a 90-degree angle and the site of the injection must be changed to prevent lipohypertrophy.

The signs and the symptoms of hypoglycemia in Shaun post-operation include palpitations, dizziness, rapid heartrate, tremor as well as sweating. The nurses must also be vital in discerning the neurogenic for the prevention of neuroglycopenic. It is also important to manage hypoglycemia by monitoring the heart rate, blood pressure, and BGL continuously after the surgery (Kallem et al., 2017). This monitoring should be done when Shaun is kept in the post-operative recovery ward to avoid further complications.

Education for sick day management
When Shaun has injured his knees, his family members must provide him complete support. The frequency of administering Shaun’s blood glucose level by his family members during his sick days includes a minimum of two times a day before and after consumption of meals (Jali, 2021). Depending on the BGL, his family members must be taught to make minute changes in the insulin level (Martyn-Nemeth et al., 2017). However, if they observe any drastic fall or increase, the family members need to consult the doctor immediately.

An example of Carbon Hydrogen Oxygen (CHO) dietary intake includes consuming the same appropriate level of carbohydrates such as 33 grams carbohydrate in breakfast, 33g carbohydrate in lunch, and 33g in dinner accordingly.

Shaun’s family members must seek appropriate medical attention when they observe some physical changes in Shaun’s reaction and body. The family members must also be provided with some videos to go through so that it becomes easier for them to understand the appropriate medical care that is required for taking care of Shaun (Kok& Lee, 2017).

Education for exercise
Before undertaking the exercise, Shaun’s BGL is to be monitored and after the exercise, there should be a gap of three-four hours for appropriate measurement. This should be continued every time while undertaking exercise. The consumption of carbohydrates must be prior to three to four hours of exercise. This is likely to increase the glycogen in the muscle and enhance endurance exercise before and after the exercise. Moreover, it is also easier to recognise hypoglycemia when the blood glucose level is found to be less than 40 mg/dl after routine monitoring (Roberts et al., 2020). The other symptoms also include loss of consciousness as well as disoriented behaviour of Shaun. For the emergency CHO supply in Shaun, IV dextrose can be the best treatment and immediate medical attention if the physician is to be undertaken. However, in some extreme cases, if Shaun gets unconscious, the airway, breathing, and pulse are to be checked. Self-management education must be provided to Shaun to prevent him from sudden deterioration.

Conclusion
Thus, it can be said that it is the responsibility of Shaun, his family members as well as the nurses to be aware of hypoglycemia, his symptoms and provide him the appropriate level of care pre-and post-surgery. The nurses must play an active role in the treatment of diabetes as well as the glycaemic control for the speedy recovery of Shaun post-operation.

References
Elahmedi, M. O., &Alqahtani, A. R. (2017).Evidence base for multidisciplinary care of pediatric/adolescent bariatric surgery patients. Current obesity reports, 6(3), 266-277.

DOI 10.1007/s13679-017-0278-3 Jali, S. (2021).Challenges and management of type-1 diabetes in COVID-19 pandemic. Indian Journal of Health Sciences and Biomedical Research (KLEU), 14(2), 169.DOI: 10.4103/kleuhsj.kleuhsj_135_21

Kallem, V. R., Pandita, A., & Gupta, G. (2017).Hypoglycemia: when to treat?. Clinical Medicine Insights: Pediatrics, 11, 1179556517748913.https://doi.org/10.1177/1179556517748913

Kok, V. C., & Lee, P. H. (2017). Management of hypoglycemia in nondiabetic palliative care patients: a prognosis-based approach. Palliative Care: researCh and treatment, 10, PCRT-S38956.doi:10.4137/PCRT.S38956.

March, C. A., Nanni, M., Kazmerski, T.

M., Siminerio, L. M., Miller, E., &Libman, I. M. (2020). Modern diabetes devices in the school setting: Perspectives from school nurses. Pediatric diabetes, 21(5), 832-840.doi: 10.1111/pedi.13015

Martyn-Nemeth, P., Quinn, L., Penckofer, S., Park, C., Hofer, V., & Burke, L. (2017). Fear of hypoglycemia: influence on glycemic variability and self-management behavior in young adults with type 1 diabetes. Nursing essayJournal of Diabetes and its Complications, 31(4), 735-741.doi: 10.1016/j.jdiacomp.2016.12.015

Nilsson, S., Hanberger, L., Olinder, A. L., &Forsner, M. (2017). The faces emotional coping scale as a self-reporting instrument for coping with needle-related procedures: an initial validation study with children treated for type 1 diabetes. Journal of Child Health Care, 21(4), 392-403.DOI: 10.1177/1367493517729041

Nishio, I., &Chujo, M. (2017).Self-stigma of Patients with Type 1 Diabetes and Their Coping Strategies Self-stigma of patients with type 1 diabetes. Yonagoactamedica, 60(3), 167-173.https://www.jstage.jst.go.jp/article/yam/60/3/60_2017.09.005/_pdf

Pierce, J. S., Aroian, K., Schifano, E., Milkes, A., Schwindt, T., Gannon, A., &Wysocki, T. (2017). Health care transition for young adults with type 1 diabetes: stakeholder engagement for defining optimal outcomes. Journal of Pediatric Psychology, 42(9), 970-982.https://doi.org/10.1093/jpepsy/jsx076 Puppalwar, G., Sawant, S., Silgiri, B., Shukla, K., &Barkate, H. (2017).Evaluation of Safety and Efficacy of Glaritus® versus Lantus® in Combination with Insulin Lispro among Adults with Type 1 Diabetes Mellitus-Phase IV Study. Open Journal of Endocrine and Metabolic Diseases, 7(04), 111.10.4236/ojemd.2017.74011

Reitz, K. M., Marroquin, O. C., Zenati, M. S., Kennedy, J., Korytkowski, M., Tzeng, E., ...& Neal, M. D. (2020). Association between preoperative metformin exposure and postoperative outcomes in adults with type 2 diabetes. JAMA surgery, 155(6), e200416-e200416.doi:10.1001/jamasurg.2020.0416

Roberts, A. J., Taplin, C. E., Isom, S., Divers, J., Saydah, S., Jensen, E. T., ...&Pihoker, C. (2020). Association between fear of hypoglycemia and physical activity in youth with type 1 diabetes: The SEARCH for diabetes in youth study. Pediatric Diabetes, 21(7), 1277-1284.doi:10.1111/pedi.13092