University of Santo Tomas - Legazpi

COLLEGE OF HEALTH SCIENCES

Legazpi City

BACHELOR OF SCIENCE IN NURSING

NCM 109: CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS, ACUTE AND CHRONIC

DEMOGRAPHIC DATA OF YOUR PATIENT

NAME: _____N/A_____ AGE: ______N/A_______ RM./ BED NO.______N/A________ MEDICAL RECORD NO._______N/A____________

DR: _______________N/A______________ DIAGNOSIS: KETONURIA

NURSING PROBLEM: BABY OF A DIABETIC MOM

ASSESSMENT BACKGROUND
DATE NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE SUBJECTIVE KNOWLEDGE

-Frequent -Excessive Alteration in Ketonuria is a After 2-3 days -Determine To help in

After 2-3
urination Thirst nutrition needs: Less medical of Nursing client’s evaluating days of
than body requirements condition in Intervention, dietary client’s Nursing
Marc -Vomiting -Nausea
r/t insufficiency of which ketone the following program and level of Intervention
h 9, -Fruity-scente -Dehydratio bodies are usual pattern understandin , the
insulin are to be
2021 d breath n present in the g and/or following
established:
urine. It is compliance to goals were
-Confusion -Heavy -Verbalized
seen in a strict established:
breathing understanding
-High urine conditions in dietary

Page 1 of 7

NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

ketone levels -Dilated which the body of regiment of regimen. -Achieved

pupils produces condition. normal blood
-Hyperglycemia Possible result of
excess ketones glucose
, -Reports of diagnostic procedures: -Maintain level.
as an
usually >400mg/ Blurry fasting serum
-FINGER-STICK KETONE indication -Monitor Electrolyte
gL vision blood glucose -Normal fluid
BLOOD TEST: that it is fluid and imbalances
levels between and
-Metabolic -Weakness using an electrolyte can lead to
60-100 mg/dl electrolyte
acidosis with and fatigue Under alternative balance to further
Normal balance.
elevated anion 0.6 source of -Increase in prevent complication
urine
gap millimole energy. It is weight at least dehydration s and cardiac -Client will
ketone level
s per liter seen during 24-30 pounds or and arrhythmias. be visiting
-Kussmaul
starvation or as appropriate complication diabetic
breathing
Higher than more commonly s such as clinic for
0.6 to 1.5 -Improved fluid better
normal; test in type 1 decreased
millimole and electrolyte ongoing
again in 2 to diabetes sodium,
s per liter balance diabetes
4 hours mellitus. potassium,
management.
Production of -Patient will calcium, and
1.6 to 3.0 Moderate ketone bodies be free from the magnesium.
-Client will

Page 2 of 7

NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

is a normal signs and -Monitor Consistently report less

millimole urine
response to a symptoms of blood glucose high blood physical
s per liter ketone
shortage of ketonuria levels and glucose discomfort.
level; call
glucose, meant (fruity-scente administer levels, over
your doctor
to provide an d breath, insulin as 400 mg/dL, are
immediately
alternate excessive appropriate the primary
source of fuel thirst, indicator of
Above Dangerousl
from fatty frequent ketone
3.0 y high level;
acids. urination, production.
millimole go to the ER
Ketonuria is weakness,
s per liter immediately
most common in confusion).
individuals
who have
-URINE STRIP TEST will
diabetes,
show that you have:
particularly
-No ketones type 1 diabetes
-Trace amounts of mellitus. It
ketones can also occur
-Moderate levels of in women who
ketones are pregnant or
-Large amounts of breastfeeding
ketones . If ketone
levels rise too
high for too
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NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

-KETONE BLOOD TEST long, your

RESULT: blood becomes
acidic. This
Below 0.6 mmol/L-
can harm your
Normal range.
health.
0.6 to 1.5 mmol/L-
Presence of ketones in
blood
Above 1.5 mmol/L-
Greater risk for
developing
ketoacidosis.

-Monitor Weight gain

weight daily serves as an
or as indicator for
indicated. determining
caloric
adjustments.

Page 4 of 7

NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

INTERVENTION RATIONALE

-Auscultate bowel sounds, noting the presence of abdominal pain or Abdominal pain is an indication of Ketonuria. Nausea and vomiting may
abdominal bloating, nausea, or vomiting be brought about by a deficiency in carbohydrates, which may result in
the metabolism of fats and development of ketosis.

-Maintain on NPO status as indicated Further carbohydrate and/or fat ingestion have the potential for
undermining efforts to eliminate ketoacids and control blood glucose
levels, and there is an increased risk of vomiting and aspiration

-Monitor laboratory status (Serum glucose, pH, HCO3, acetone) Incidence of fetal and newborn abnormalities is decreased when fasting
blood sugar levels range between 60 and 100 mg/dl, pre-prandial levels
between 60 and 105 mg/dl

- Instruct and teach client to monitor sugar using a finger-stick method. Testing the blood for ketones gives us an earlier warning because ketones
show up in the blood earlier than in urine. This is helpful because
sometimes you cannot give a urine sample due to dehydration.

- Adjust diet or insulin regimen to meet individual needs. Prenatal metabolic needs change throughout the trimesters, and
adjustment is determined by weight gain and laboratory test results.
Insulin needs in the first trimester are 0.7 unit/kg of body weight.
Between 18-24 weeks of gestation, it increases to 0.8 unit/kg; at 34
weeks’ gestation, 0.9 unit/kg, and 1.0 unit/kg by 36- week gestation.

- Teach the importance of regularity of meals and snacks (e.g., three Eating very frequent small meals improves insulin function.
meals or 4 snacks) when taking insulin.

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NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

-Administer glucose solution such as dextrose and half normal saline IV dextrose is added to avoid the development of cerebral edema. In
addition, the rate of insulin infusion may need to be slowed down to
between 0.02 and 0.05 units/kg/hr.

-Provide a diet consisting of 60% carbohydrates, 20% fats, 20% proteins, Diet-specific to the individual is necessary to maintain normoglycemia
in designated number of meals and to obtain desired weight gain. In-depth teaching promotes
understanding of own needs and clarifies misconceptions, especially for
a client with gestational diabetes.

Recommend monitoring urine ketones on awakening and when a planned meal Insufficient caloric intake is reflected by ketonuria, indicating a need
or snack is delayed for an increased intake of carbohydrates or additional snack in the
dietary plan (e.g., recurrent presence of ketonuria on awakening may
be eliminated by 3 am a glass of milk).

Provide information regarding the signs and symptoms and difference of
hyperglycemia or hypoglycemia.
Hyperglycemia in pregnancy is a medical condition resulting from either
pre-existing diabetes or insulin resistance developed during pregnancy.
Transfer of glucose across the placenta stimulates fetal pancreatic
insulin secretion, and insulin acts as an essential growth hormone. If
resistance to maternal insulin action becomes too pronounced, maternal
hyperglycemia occurs and gestational diabetes mellitus (GDM) may be
present.

A blood sugar reading of less than 60 milligrams per deciliter (mg/dL)

is considered hypoglycemia. Hypoglycemia during pregnancy happens most
often in women with diabetes. Hypoglycemia can occur in pregnant women
without diabetes, but it’s much more likely to be seen in women taking

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NGO, AMIEL SIMON S. / 2BSN1

 University of Santo Tomas - Legazpi
COLLEGE OF HEALTH SCIENCES
Legazpi City

insulin.
Prepare for hospitalization if diabetes is not controlled. Infant morbidity is linked to maternal hyperglycemia-induced fetal
hyperinsulinemia.

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NGO, AMIEL SIMON S. / 2BSN1