A nurse is preparing a 65-year-old client with type 2 diabet… | 마이메르시 MyMerci
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문제

A nurse is preparing a 65-year-old client with type 2 diabetes mellitus for a total knee arthroplasty at 8:00 AM. During the 6:00 AM preoperative assessment, the client's blood glucose level is 190 mg/dL. Which priority action should the nurse implement?

해설
Priority action for diabetic surgical clients with elevated preoperative glucose levels.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the perioperative management of a patient with diabetes mellitus (DM). The core principle is that Key Point! uncontrolled hyperglycemia in the perioperative period is a significant risk factor for poor surgical outcomes, including increased risk of surgical site infection (SSI), poor wound healing, and metabolic complications like diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The goal is to maintain blood glucose within a target range, typically 140-180 mg/dL (7.8-10.0 mmol/L) for most hospitalized patients, as recommended by evidence-based guidelines.

Answer Rationale: The correct answer is ① Administer prescribed sliding scale insulin as ordered. The client's blood glucose of 190 mg/dL is above the target range for surgery. A sliding scale insulin regimen is a common preoperative order for diabetic patients to correct hyperglycemia before a procedure. Administering the insulin is a direct, timely, and independent nursing action (within the scope of a physician's order) to address the identified problem and optimize the client's condition for surgery. This action aligns with the principle of preventing complications.

Distractor Analysis:
• Watch out for confusion! ② Notify the surgeon immediately about the elevated glucose level: While communication is important, a glucose level of 190 mg/dL is moderately elevated and typically managed per established protocols (like sliding scale insulin). An "immediate" notification is not the priority when there is a clear, standing order to address it. Notification might be warranted for critically high levels (e.g., >250-300 mg/dL) or if the patient is symptomatic.
• ③ Encourage the client to drink additional fluids: This is contraindicated as the client is NPO (Nothing by mouth) preoperatively. Encouraging oral intake could increase the risk of aspiration during anesthesia.
• ④ Document the findings and continue with preoperative preparation: Documentation is essential but is not the priority action. Simply documenting an abnormal finding without intervening is negligent nursing practice. The elevated glucose requires an intervention to correct it.

Related Concepts: Perioperative glycemic control is part of the Surgical Care Improvement Project (SCIP) measures to reduce infections. Understanding the stress response to surgery (release of cortisol, catecholamines) which increases blood glucose is key. Also, know the differences in management for Type 1 DM (always require basal insulin to prevent DKA) vs. Type 2 DM (may be managed with oral agents or insulin). Concept Summary • Goal: Maintain perioperative blood glucose between 140-180 mg/dL.
• Risk: Hyperglycemia → ↑ Infection risk, poor wound healing, fluid/electrolyte imbalances.
• Action: Follow prescribed insulin regimens (sliding scale, basal-bolus).
• Contraindication: Maintain NPO status; do not give oral fluids/medications unless specifically ordered. Side-by-Side Comparison!
SituationPriority Nursing ActionRationale
Pre-op Diabetic Patient: BG 190 mg/dL with sliding scale orderAdminister sliding scale insulinCorrects hyperglycemia per protocol to optimize surgical outcomes.
Pre-op Diabetic Patient: BG 55 mg/dL (Symptomatic)Administer fast-acting carbohydrate (e.g., IV D50W per protocol)Hypoglycemia is an immediate threat to neurological function and safety.
Pre-op Diabetic Patient: BG 450 mg/dL with ketones in urineNotify provider immediately, prepare for IV fluids/insulin dripIndicates potential DKA/HHS, a medical emergency requiring rapid intervention.
Anatomy, Physiology & Pharmacology Points • Physiology: Surgical stress → ↑ Stress hormones (cortisol, epinephrine, glucagon) → ↑ Hepatic glucose production & ↓ Insulin sensitivity → Hyperglycemia.
• Pharmacology: Sliding scale insulin is typically rapid-acting (e.g., lispro, aspart) or short-acting (regular) insulin given subcutaneously based on current blood glucose level. It corrects hyperglycemia but does not provide basal coverage. Memory Tips • Acronym: For perioperative DM management, think "Sugar Control Is Priority" (SCIP also reminds you of infection prevention guidelines).
• Rule of Thumb: "If there's an order to fix it, do it. If it's NPO, don't give PO. If it's an emergency (severe hypo/hyper), call." High-Frequency NCLEX Topics This integrates several high-yield NCLEX areas: Diabetes Management, Perioperative Nursing, Priority Setting, and Medication Administration. The NCLEX loves to test if you know when to follow a protocol vs. when to escalate to the provider. Watch Out for Question Variations! • Instead of blood glucose, the question could give a lab value like HbA1c of 9.5% and ask for the nurse's concern (long-term control, risk for complications).
• The scenario could shift to a postoperative setting where the patient is nauseated and can't eat, asking about the priority action to prevent hypoglycemia when insulin is due.
• It could test knowledge of different insulin types (e.g., which insulin should be held if the patient is NPO? Usually, hold short/rapid-acting; may give a reduced dose of long-acting insulin).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the day-shift nurse on an orthopedic unit. Mr. Johnson, 65, with a history of Type 2 DM managed with metformin and occasional sliding scale insulin, is scheduled for a left total knee replacement at 8:00 AM. At 6:00 AM, you perform your preoperative assessment. His vital signs are stable, but his fingerstick blood glucose reads 190 mg/dL. He has been NPO since midnight. His preoperative orders include: "Fingerstick BG AC&HS and Q6H, Sliding Scale Insulin (Regular) subcut per protocol."

Nursing Intervention Strategy:
1. Assessment: Confirm the glucose reading. Assess the client for any signs of hyperglycemia (e.g., polyuria, polydipsia, blurred vision) or other distress. Verify the NPO status and the last dose of his home diabetes medications (metformin is typically held the day of surgery).
2. Planning & Implementation:
• Consult the sliding scale insulin protocol (often posted in the chart or MAR). For a BG of 181-220 mg/dL, the order might read "Administer 4 units of Regular insulin subcut."
• Perform the "rights" of medication administration, specifically checking the insulin type (Regular vs. NPH), dose, and route.
• Administer the insulin subcutaneously, typically in the abdomen for more consistent absorption.
• Re-check the blood glucose in 1-2 hours as per unit protocol to evaluate the insulin's effect before surgery.
3. Documentation & Communication: Document the BG result, the insulin dose given, site of injection, and the patient's tolerance. Inform the OR transport team and the preoperative nurse of the recent BG value and insulin administration during handoff.

Patient Safety and Precautions:
• Key Point! Never administer oral hypoglycemics (like metformin) or have the patient eat or drink when NPO.
• Be vigilant for signs of hypoglycemia after insulin administration, especially if surgery is delayed. Have a source of rapid-acting glucose (like IV D50W) available.
• Use insulin pens or vials dedicated to a single patient to prevent medication errors and cross-contamination. Nursing Procedure & Medication Flow Procedure: Administering Preoperative Sliding Scale Insulin
1. Verify order and patient identity (two identifiers).
2. Perform hand hygiene and gather supplies (glucometer, test strip, lancet, alcohol swab, insulin syringe/vial/pen, gloves).
3. Obtain blood glucose via fingerstick.
4. Compare result to the sliding scale table in the MAR.
5. Draw up the exact dose of insulin. Have a second nurse verify the dose if required by policy (common for insulin).
6. Select an injection site (abdomen preferred), clean with alcohol, and administer subcutaneously at a 90-degree angle (or per device instructions).
7. Do not massage the site.
8. Dispose of the sharps in a puncture-proof container.
9. Re-check BG as ordered (often in 1-2 hours).
10. Document all steps. A Word from Your Senior Nurse "In the fast-paced preoperative environment, it's easy to get caught up in checklists and forget the 'why.' That BG of 190 isn't just a number—it's a warning sign that your patient's body is under stress and at higher risk for infection in that new knee joint. By taking the initiative to correct it safely and promptly, you're not just following an order; you're actively protecting your patient. This kind of critical thinking—assessing a finding, knowing the evidence-based target, and implementing the correct intervention—is what separates a task-completer from a true patient advocate. Carry this mindset into every clinical decision!"

핵심 개념

  • Sliding Scale Insulin — A protocol for administering subcutaneous rapid- or short-acting insulin based on pre-meal or scheduled blood glucose readings to correct hyperglycemia.
  • Perioperative Glycemic Control — The management of blood glucose levels before, during, and after surgery to reduce the risk of complications like infection and poor wound healing.
  • NPO (Nothing by Mouth) — A medical instruction for a patient to abstain from eating or drinking, typically before surgery or procedures to prevent aspiration.
  • Surgical Site Infection — An infection that occurs after surgery in the part of the body where the surgery took place. Hyperglycemia is a major modifiable risk factor.
  • Hyperosmolar Hyperglycemic State — A serious complication of Type 2 DM characterized by extreme hyperglycemia, severe dehydration, and altered mental status without significant ketoacidosis.

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