A nurse is preparing a 62-year-old client with type 2 diabetes mellitus for a scheduled total hip arthroplasty. The client has been NPO since midnight and received their prescribed evening dose of long-acting insulin. During the preoperative assessment, the blood glucose reading is 180 mg/dL. The client appears highly anxious and asks, "Will my surgery be canceled because my sugar is high?" What is the most appropriate nursing intervention?

Preoperative blood glucose management is critical for diabetic clients undergoing surgery. A glucose level of 180 mg/dL requires intervention before surgery to optimize outcomes and reduce complications.

Perioperative blood glucose management in diabetic patients is an important nursing responsibility that directly affects surgical outcomes and patient safety. When a diabetic patient presents with a preoperative blood glucose of 180 mg/dL, immediate intervention is needed to optimize metabolic control before surgery.

Several factors are involved in the pathophysiological background of preoperative blood glucose elevation. Surgical stress triggers the secretion of counter-regulatory hormones such as cortisol, epinephrine, and growth hormone, which promote gluconeogenesis and glycogenolysis and cause hyperglycemia. Additionally, the patient's anxiety about surgery can further raise blood glucose levels through sympathetic nervous system activation. The fasting state since midnight may have disrupted the patient's normal blood glucose regulation patterns.

Hyperglycemia in the perioperative period significantly increases the risk of surgical complications. Elevated blood glucose impairs immune function, particularly by impairing neutrophil chemotaxis and phagocytosis, and increases the risk of infection. Wound healing becomes poor due to decreased collagen synthesis and impaired angiogenesis. The likelihood of cardiovascular complications increases due to increased blood viscosity and endothelial dysfunction. Electrolyte imbalances and dehydration can occur due to osmotic diuresis.

The most appropriate nursing intervention is to administer rapid-acting insulin according to a sliding scale protocol and notify the anesthesiologist. This approach addresses the immediate hyperglycemia while ensuring the surgical team is aware of the patient's metabolic status. The anesthesiologist needs this information to make informed decisions about anesthesia management and intraoperative blood glucose monitoring. Rapid-acting insulin effectively lowers blood glucose levels within 1-2 hours, allowing surgery to proceed safely.

Current evidence-based practice recommends maintaining preoperative blood glucose levels between 80-180 mg/dL for diabetic patients, though many institutions aim for tighter control when possible. The key is to achieve stable blood glucose levels rather than perfect normalization, as rapid blood glucose fluctuations can be more dangerous than mild hyperglycemia.

Understanding the Clinical Scenario

A 62-year-old client with type 2 diabetes mellitus is scheduled for total hip arthroplasty. The client has been NPO since midnight but received their long-acting insulin the evening before. The preoperative blood glucose is 180 mg/dL. The client is anxious about surgery cancellation. This situation requires the nurse to interpret a moderately elevated glucose value in the context of surgical stress and NPO status, and to select an intervention that maintains glycemic control without causing undue delay or risk.

Why a Glucose of 180 mg/dL is a Concern, Not a Crisis

In the perioperative setting, the goal is to avoid both severe hyperglycemia and hypoglycemia. The American Diabetes Association (ADA) Standards of Care recommend maintaining a glucose range between 140 mg/dL and 180 mg/dL for most hospitalized patients, including those in the perioperative period ^[1][2][3]. A reading of 180 mg/dL sits at the upper threshold of this target. It is not an indication to cancel a necessary surgical procedure, but it does warrant action to prevent further elevation. The stress response from surgery itself, including the release of cortisol and catecholamines, promotes insulin resistance and hepatic glucose production, which can drive glucose levels dangerously high intraoperatively if not addressed proactively ^[4].

Analysis of the Correct Intervention (Option 1)

Administering rapid-acting insulin per a sliding scale protocol and notifying the anesthesiologist is the most appropriate nursing action. This approach directly treats the current hyperglycemia and establishes a plan for intraoperative control. The rationale is twofold:

1. Pharmacological Correction: A sliding scale insulin protocol uses the current blood glucose value to determine a corrective dose of rapid-acting insulin. This is the standard of care for managing hyperglycemia in the hospital setting, as it provides a safe, standardized method to return glucose to the target range ^[1][2]. The client’s long-acting insulin provided basal coverage overnight, but it is insufficient to counteract the dawn phenomenon and preoperative anxiety, both of which contribute to the elevated morning glucose.

2. Interprofessional Communication: Notifying the anesthesiologist is a critical component of this intervention. The anesthesiologist will manage the client’s glucose during the procedure, often with an intravenous insulin infusion if significant fluctuations are anticipated. A preoperative glucose of 180 mg/dL is a key piece of information that will influence their intraoperative management plan, ensuring a seamless transition of care ^[4].

Why the Other Options are Incorrect

- Option 2 (Cancel the surgery): This is an overreaction. A single glucose reading of 180 mg/dL in a client with known diabetes is not a criterion for cancelling surgery. Guidelines focus on avoiding extreme hyperglycemia (e.g., >250-300 mg/dL) and, more critically, on the long-term marker of glycemic control, HbA1c, to assess risk of complications like periprosthetic joint infection (PJI) ^[4]. Cancelling the procedure would cause unnecessary psychological distress and logistical burden without clinical justification.

- Option 3 (Proceed without intervention): This is a passive and unsafe approach. While 180 mg/dL is at the upper limit of the acceptable range, proceeding without any corrective action ignores the predictable hyperglycemic effect of surgical stress. The glucose level is highly likely to rise further during the procedure, increasing the risk of osmotic diuresis, electrolyte imbalances, and poor wound healing. A proactive intervention is required to maintain control ^[1][2][4].

- Option 4 (Give orange juice): This is contraindicated and dangerous. The client is already hyperglycemic at 180 mg/dL and is NPO in preparation for surgery. Administering orange juice, a source of simple sugar, would cause a rapid and significant spike in blood glucose, worsening the hyperglycemia. Furthermore, it violates the NPO order, increasing the risk of pulmonary aspiration during anesthesia.

Connecting Glycemic Control to Surgical Outcomes

The imperative for tight perioperative glucose management is directly linked to the risk of adverse events. Research on patients with diabetes undergoing total joint arthroplasty demonstrates that hyperglycemia more than doubles the risk of periprosthetic joint infection (PJI), wound dehiscence, and thromboembolic events ^[4]. The underlying mechanism involves impaired immune function, including decreased neutrophil chemotaxis and phagocytosis, which are critical in the immediate postoperative period to prevent bacterial colonization of the new prosthesis. By administering a corrective dose of insulin now, the nurse is actively participating in a strategy to optimize the client’s immune defenses, reduce the risk of a devastating surgical site infection, and promote long-term implant survival ^[4]. The current glucose level of 180 mg/dL provides a crucial window of opportunity to intervene before the surgical stress response drives it to a level that definitively impairs these protective mechanisms.