A nurse is caring for a diabetic client who is scheduled for major abdominal surgery in the morning. The client's preoperative blood glucose is 180 mg/dL, and the surgeon has ordered to proceed with surgery. What is the most appropriate nursing intervention at this time?

Preoperative management of diabetic clients requires careful coordination between nursing and medical teams to prevent both hyperglycemia and hypoglycemia during surgery.

Perioperative management of diabetic patients requires specialized protocols to maintain glucose homeostasis and prevent complications. A blood glucose of 180 mg/dL is an elevated level that requires intervention, but coordination with the surgical and anesthesia teams is essential.

The most appropriate nursing intervention is to contact the physician to clarify insulin management and blood glucose monitoring protocols. Surgery induces significant physiological stress that affects glucose metabolism through increases in cortisol, epinephrine, and other stress hormones. This stress response typically elevates blood glucose levels, complicating perioperative glucose management.

Proper perioperative diabetes management involves several considerations: timing of insulin administration, type of insulin to use, frequency of blood glucose monitoring, and coordination with anesthesia protocols. Many healthcare facilities have specific perioperative diabetes protocols that include insulin infusions, modified insulin regimens, or specific monitoring schedules.

While elevated preoperative blood glucose indicates the need for intervention, this must be done safely and in coordination with the medical team. The physician should provide specific orders for insulin administration, blood glucose monitoring frequency, and target blood glucose ranges during the perioperative period.

Effective communication between the nursing team and the medical team is essential for safe perioperative management of diabetic patients. The nurse's role is to advocate for appropriate medical management while ensuring patient safety through proper monitoring and intervention protocols.

Understanding the Clinical Situation
The client has a known history of diabetes and presents with a preoperative blood glucose of 180 mg/dL. While this value is elevated, the surgeon has decided to proceed with the major abdominal surgery. The nurse's primary responsibility is not to independently manage this hyperglycemia, but to ensure a clear, safe, and evidence-based plan for perioperative glycemic control is in place, as perioperative hyperglycemia is strongly linked to increased risks of postoperative complications, including infections and prolonged hospital stay ^[1].

Analysis of Options
The most appropriate intervention is to contact the physician to clarify insulin management and glucose monitoring protocols. The surgeon's order to "proceed with surgery" is a directive about the surgical schedule, but it does not constitute a complete medical order for managing the client's diabetes during the perioperative period. Given the elevated glucose level, a clear, multi-disciplinary plan is essential to mitigate risks. The nurse must advocate for the client by obtaining specific orders that address the intraoperative and immediate postoperative phases.

Why Other Options Are Incorrect
- Administering the client's usual morning insulin dose as prescribed is a high-risk action without a current, verified order that is specific to the preoperative setting. The client will be NPO (nothing by mouth) for surgery, and their usual subcutaneous insulin regimen, designed for a normal dietary intake and activity level, could precipitate dangerous hypoglycemia under the stress and fasting conditions of surgery. The nurse cannot assume a home medication schedule is safe to administer in the hospital without explicit provider direction.
- Holding all insulin until after the surgical procedure is completed is equally dangerous. Uncontrolled hyperglycemia during surgery increases the risk of poor outcomes. The American Diabetes Association's standards for hospital care emphasize the importance of managing glucose levels, and simply withholding insulin allows hyperglycemia to persist or worsen, directly contradicting the goal of reducing perioperative risk ^[2].
- Giving the client a light snack to prevent hypoglycemia during surgery is contraindicated. The client is NPO for major abdominal surgery to prevent aspiration. Administering any food would violate a critical safety protocol and put the client at severe risk of pulmonary aspiration during anesthesia induction.

The Pathophysiology and Clinical Rationale
The stress of surgery triggers a counter-regulatory hormone response (e.g., cortisol, catecholamines), which promotes hepatic glucose production and insulin resistance, often leading to intraoperative hyperglycemia . This metabolic state impairs immune function and wound healing, directly increasing the risk of surgical site infections and periprosthetic joint infections, a risk that is more than doubled in patients with diabetes . A proactive, clarified plan for insulin management—whether through a variable-rate intravenous insulin infusion or a modified subcutaneous insulin regimen with frequent glucose monitoring—is the cornerstone of safe care. This plan must be explicitly ordered by the provider to balance the risks of hyperglycemia against the catastrophic risk of intraoperative hypoglycemia, which can be masked under anesthesia [1,2]. The nurse's role is to recognize the incomplete nature of the initial order and seek the necessary clarification to ensure a safe transition through the perioperative continuum.