Sultanate of Oman

Ministry of Health
Maternal Health Nursing (Practicum)

Case study:

GDM
Gestational Diabetes Mellitus.

Student name:
Ruqia Said AL-saadi(3013)
Safa salim AL-kitani(3015)
Date of submission:
11/7/2012
 1. Personal information

Patient initials: N.M.R

Age: 41 Years old Address: Sur Hospital NO: 102830
Date of Admission/OPD Visit: 15/6/2021 Date of Discharge:16/6/2021

2. Family History:
Her mother with history of HTN and her father with diabetes.

3. Medical and Surgical History:

No medical history.

Pregnancy: history gravida 5, para3.

Patient with surgical history: done for her before at this hospital Operated on 30/07/15 for
Cutaneous abscess,furuncle and carbunde, unspecifled Incision And Drainage (Breast
Abcess) ,And operated on 11/9/2013 for left csom tympanoplasty with ossiculoplasty left
tympanoplasty with ossiculoplasty.

4. Obstetrical History:
5. Gravida: 5 Para: 3 Abortion: 1 Fetal Death: --
6. Died: - Alive:3
7. L.M.P: 10/9/2020 EDD (Scan): 15/6/2021 EDD:
(history):17/6/2021

8. Medical Diagnosis:
G5, P3 ,L3, A3,38weeks with diabetes mellitus arising pregnancy spontaneous vertex
delivery

9. Chief Complain
She has come with Labour and Leaking without pain p/v since 4.00pm today
15/6/21.

10. Definition of final diagnosis:

A mother is G5, P3, L3, A1, 38weeks with GDM, delivered by SVD.

GDM (gestational diabetes mellitus): is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. Women of average risk should have testing at
24-28 weeks of gestation.

11. Etiology of the disease:

According to text book In your patient

Overweight or obesity
Family history of diabetes
Age( women who are older than 25
years)
Reduced physical activity
Present she is obese.
Present, her father has diabetes.
Present, she is 40 years old.
Not present, she is working in her
house and like walking sport.
12. Clinical manifestations:

According to text book In your patient

Thirst Present
More frequent urination Present
Fatigue Present
Headache Not present
Blurred vision Not present

13. Management:

According to text book In your patient

Medical management Done, she follow diabetic diet
*Glucose monitoring and measure RBS and do
*Lifestyle change exercise(walking)
Pharmalogical management She took oral insulin when she
*Insulin therapy was pregnant.
 14. Pathophysiology of the disease:

Gestational diabetes mellitus is glucose intolerance with onset or first recognition during
pregnancy caused by insulin resistance or B-cell dysfunction. The risk factor for GDM
includes overweight and obesity, advanced maternal age, and family history. They may
cause insulin resistance that occurs when cells no longer adequately respond to insulin or B-
cell dysfunction that occur when it lose the ability to adequately sense blood glucose
concentration.

Insulin resistance or
B-cell dysfunction
Pregnancy Hormonal changes
caused by changes Gestational
occur (increased in human in hormones lead to
lactation, estrogen and Diabetes
increase glucose in
progesterone in blood) Mellitus
blood

*Thirst
*More frequent urination
*Fatigue
15. Investigation:

Investigation Result Normal Interpretation

finding
CBC Haemoglobin in 10.50 g/dL (11-14.5) Decreased.
blood meaning that she
has anaemia.
Hematocrite in 10.50% (34-43) Decreased. that
blood mean insufficient
supply of healthy
red blood cell
(anemia)
Lymphocytes % 19.40 (20-45) Decreased. It may
in blood indicate a
possible infection
or lymphopenia.
Platelet 251.00 10 (150-450) Normal
3/uL :nogestional
 thrombocytopeni
a
Red blood cell 4.67 10 6/ uL (4.1-5.4) Normal: on
anemia
White blood cell 8.64 10 3/uL (2.4-9.5) Normal: no
infection

16. Physical assessment (Head to toe):

Area Findings interpretation

face All face parts are sympatric, no edema No excessive fluid or hypertension,
,present of melasma Due to hormonal change
“melanocytes”

Hair No dandruff, no lesions, no masses, No medical or environment

no swelling and tenderness condition affect her hair, healthy
hair and nourished well.

eye eyebrows and eyelashes are black, Color according to genetic

normal distributed and symmetry to background , blood circulation good
the face and no congenital anomalies

Eyelids show skin is intact and no No hypertension or anomalies

 edema

Sclera is white No sign of jaundice or liver problem

No discharge No sign of infection

Pupils black in colour and dilated well No congenital anomalies

Nose Symmetrical to the face No congenital anomalies

Two nostrils
No edema No sign of infection or cold flu
No discharge

Mouth Lips: moist No sign of dehydration

there is tooth decay Not well teeth care.

Gums: No edema, no bleeding, no No signs of infection (gingivitis)

swelling, no redness

-Tongue: pink, no white patches, no Healthy

ulcer, can move very well No signs of infection
No congenital anomalies

Neck Thyroid gland: normal in size, no No signs of hyperthyroidism or

swelling or enlargement hypothyroidism

-Lymph nodes: normal and no No sign of infection

enlargement

Good neck movement (ROM) and No stiffen and no congenital

symmetric to the body anomalies

Chest No scar, mass palpation, redness or No previous operation

lesions No congenital anomalies

Chest move symmetry, well No breathing distress

movement

respiratory rate (20breath/min) is No Tachypnea or Bradypnea

 normal and regular and no crackle No respiratory disorder
sound

Abdomen There is no surgical scar No previous surgery

There is striae gravidarumt It is result from over stretched of

the abdomen muscle than body can
bear due to pregnancy

There is linea nigra because of hormonal change

during pregnancy

No mass No cancer or organs enlargement

No itching or redness No sign of infection

Breast Both two breast have same size and No congenital anomalies
symmetric

There is scar Due to Cutaneous abscess,furuncle

and carbunde, unspecifled Incision
And Drainage (Breast Abcess) 
No lesions, itching, second morula or
redness No sign of infection

Both nipples are erect Normal shape of nipples with no

No inverted ,flat, sore, cracked or sign of infection
abnormally large

Both two breast not engorgement Soft and colostrum is present.

 No lumps in both breast No breast cancer

Uterus
Height of fundus is 37 cm. The fundus height is correlation
with gestational aga..

Elimination She pass clear urine ,no pain or No infection ,o kidney problem
burning sensation during urination
No constipation or diarrhea .
No blood in stool .

Lower and No edema( pitting edema) especially No presence of hypertension

upper no edema in both ankle
extremities No green vein redness and signs of Good blood circulation.
varicosities
Well capillary refill
No calf muscle pain, tenderness or No sign of deep vein thrombosis
redness that mean no accumulation of
blood or fluid due to pressure of
uterus in extremities

17. Focused physical examination:

Abdominal Result
examination
*Inspection

Size

Corresponding with the gestational age.

 Shape Round
Fetal lie Longitudinal
Movement of fetal The movement of fetal is good ,fetal is wellbeing
Skin

–striae gravidarum -present in the abdominal

_linea nigra - present ( from extend from upper umbilical’s to symphysis ,due to
hormones change of pregnancy ) .

-no present of scar,no previous surgery ,no section and wasm marks .
-Scars
-No itching
-Redness
*palpation
Fundal height 37 cm (Corresponding with the gestational age) .
Fundal palpation Presentation : cephalic (head first part enter the pelvis )

Lie: longitudinal

Lateral palpation The position of the fetal is LOA.

Pawlik’s grip The fetus not engagement.

Pelvic palpation Confirm the presentation (cephalic presentation).

Use Doppler The fetal heart beat is 140 pbm.

18. Medications:

Drug Dose Route Frequency Classification Action Side effect Nursing responsibility
name
ampicillin 500Mg injectio QID anti-infectives Binds to diarrhea, - Assess for infection
n bacterial cell nausea, (vital signs; appearan
wall, causing vomiting, of wound, sputum,
cell death. seizures, urine, and stool; WBC
Bactericidal allergic at beginning of and
action;
 spectrum is reaction throughout therapy.
broader than
- Observe for signs an
penicillins
symptoms of
anaphylaxis
Mefenami 500Mg oral TID NSAID Inhibits headache, Assess for signs and
c Acid prostaglandin dizziness, symptoms of GI
synthesis. drowsiness bleeding, Assess patie
Decreased constipation for skin rash frequent
pain and , dyspepsia, during therapy. Asse
inflammation nausea, GI pain (note type,
. Reduction bleeding, location, and intensity
of fever allergic prior to and 1– 2 hr
reaction following
administration
Fefol 150Mg oral OO Folic acid Iron is an Vomiting, Assess patient for sign
capsul essential Nausea, of megaloblastic anem
trace Diarrhoea, a (fatigue,
element that Gastric weakness, dyspnea)
is required irritation before and periodical
for the throughout therapy.
formation of
haemoglobin
and
myoglobin
important
components
of the blood.
Fefol tablets
also contain a
sufficient
amount of
 folic acid to
prevent the
development
of folate
deficiency
during
pregnancy.

19. List all nursing diagnosis with prioritization use PES format:
_ Anxiety related to lack of knowledge regarding symptoms, progression of
condition, and treatment as manifested by feeling discomfort and restlessness.
_ Deficient knowledge related to lack of information as manifested by development
of preventable complication.
-fatigue related to increased energy requirement as manifested by verbalization.
_ Risk for Altered nutrition: less than body requirement related to thirst and
dizziness as manifested by increased blood glucose level

_ Risk for fatal injury related to elevated maternal serum glucose levels.
_ Risk for maternal infection related to rupture of amniotic membrane

20. Nursing care plan:

Assessme Diagnosis Goals Interventions Rationale Evaluation
nt
*Objective Anxiety related After 1- Listen to mother's 1- To assess for any The gaol was
data: to lack of nursing concern and feeling. misconception or met, a
Mother is knowledge interventio 2- providing health misinformation that woman was
feeling regarding n, women education for the may be contributing identified
discomfort symptoms, will be mother to anxiety. source of
and progression of identify 3- Encourage 2- To reduce anxiety anxiety and
restlessne condition, and source of mother to share and correct any report feeling
ss and treatment as anxiety and concern with her misinformation. less anxiety.
facial manifested by report health care team. 3- To promote
expression feeling feeling less 4- Promote open collaboration in her
shows discomfort and anxiety. relationship with care.
that she restlessness. women through 4. To promote trust.
has therapeutic
anxiety communication.
*Subjectiv
e data:
she said
that she
has
anxiety
because
she has
leaking
with 3cm
dilation.
*Objective Deficient After 1- Assess women's 1- To provide The gaol was
data: knowledge nursing current knowledge database for further met, mother
mother is related to lack interventio base regarding the teaching was able to
the first of information n, mother disease process and verbalize
pregnancy about GDM as will be able management. important
that has manifested by to verbalize 2- demonstrate 2- To establish information
GDM mother's important procedure for blood woman's comfort and regarding
*Subjectiv question and information glucose monitoring competence with gestational
e data: concern. regarding 3- review sign and procedure diabetes, its
Mother gestational symptom of management
asks diabetes, its hypoglycaemia and and potential
questions manageme hyperglycaemia and 3- To promote prompt effect is on
And has nt and appropriate recognition of that is on the
statement potential intervention for complication and self- pregnancy
of effect is on both. management. and fetus.
misconcep that is on 4- provide contact
tion. the number for health 4. To promote
pregnancy care team for comfort
and fetus. prompt intervention
and answers to
questions on on
going basis. 5- To allay anxiety and
5- review expected enlist cooperation of
plan of care. woman in her care.
Risk for During 1. Monitor vital sign 1. To be as evidence The goal was
(maternal) hospitalizati especially for intra-amniotic met, the
on, the temperature and infection. mother was
infection related
mother will white blood cell. free from
to rupture of
be free 2. Promote thorough sign of
amniotic
from sign of hand washing when 2, To Prevent infection.as
membrane.
infection. touching the genital contamination. evidence
Outcome: area. 3. Facilitate the labour 1. normal
1. normal 3. Administer process. body
body oxytocin infusion as temperature
temperatur order. 4. Because frequent 2. Capillary
e 4. Perform initial vaginal examination refill within 2
 2. Capillary vaginal examination. can lead to the second.
refill within 5. Encourage incidence of 3. good skin
2 second. perineal care after ascending tract turgor
3. good skin elimination infection.
turgor 5. To reduce
. ascending tract
infection

21. Health education:

I will advise pregnant mother with GDM about the following:
1-Monitor your blood glucose levels:
* Advise the mother to measure the glucose levels in the
blood every day before and after the mealsThis is in order to
measure the level of glucose in the blood
.
* Educate mother how to do RBS to be independently do it in
home. This is done by using the device and slides to measure
the level of sugar in the blood
.
2- Exercise:
*Ask mother to do walking exercise around her house that
enough and corresponded with her condition. The best form of
exercise for women with getatational diabetes is to build
walking into their daily routine Exercising is one of the
basics of controlling gestational diabetes, as it lowers blood
sugar levels by burning calories and reducing insulin
resistance.
.
*Advise mother to do leg exercise (Rotation ,flexion ,extension ) to prevent other
complication such as DVT ,also to promote blood circulation .
3- Diet:
Following a healthy eating plan is important in managing gestational diabetes:
*Encourage mother to increase fluid intake to (6-8 cups/day),to prevent constipation,
*ask mother to increase taking of food with iron like green leafy vegetables ,meat and liver
because this food very importance to produce RBC and increase haemoglobin in level of
blood
*told mother to avoid take food with calcium after or before taking food with iron to make
easily absorption of iron and get benefit.
*Eat small amounts often and try not to put on too much weight.
*A healthy diet for women with gestational diabetes includes:
- a carbohydrate with every meal and snack (spread your carbohydrate intake over 3 small
meals and 2 to 3 snacks each day)
- a variety of foods that contain the nutrients you need during pregnancy
- high-fiber foods
- avoiding foods and drinks that contain a lot of sugar
- limiting fat, especially saturated fats
4- After pregnancy:
Gestational diabetes normally disappears when your pregnancy is over, although you will
need to be tested 6 to 12 weeks after the delivery. You should also have regular tests for
type 2 diabetes every year if you are planning another pregnancy or if you’re not feeling
well. If you are not planning another pregnancy you should have a test every 3 years.
*Breastfeeding is recommended for women who have had gestational diabetes because it
helps to regular both your weight and the weight of baby.
*To reduce your risk of developing type 2 diabetes:
keep to a healthy weight
eat a healthy diet
be physically active
check your blood glucose levels
.
22. Evidence:
Prevention of gestational diabetes with a pre-pregnancy lifestyle intervention –
findings from a randomised controlled trial

1. How it is related to my patient:

My patient also has GDM

2. Summary
Population: high risk women planning pregnancy.

 Intervention: A randomized controlled trial was conducted in four Finnish

maternity hospitals between the years 2008 and 2014. Altogether 228 high-risk
women planning pregnancy were randomized to an intervention (n=116) or a control
group (n=112). The risk factors were body mass index ≥30 kg/m2 (n=46), prior GDM
(n=120), or both (n=62), without manifest diabetes at study inclusion. Trained study
nurses provided individualized lifestyle counseling every 3 months in addition to a
group session with a dietician. The control group received standard antenatal care.
GDM was defined as one or more pathological glucose values in a 75 g 2-hour oral
glucose tolerance test, performed between 12 and 16 weeks of gestation and if
normal repeated between 24 and 28 weeks of gestation
Comparison: compare between effect of intervention before pregnancy with high
risk woman and those with out any intervention done

Outcome:
Within 12 months, 67% of the women (n=72) in the intervention group and 63% of
the women (n=71) in the control group (p=0.84) became pregnant. The cumulative
incidence of GDM among the women available for the final analyses was 60%
(n=39/65) in the intervention group and 54% (n=34/63) in the control group
(p=0.49). GDM was diagnosed already before 20 weeks of gestation in 60%
(n=44/73) of the cases.

3. Compare literature finding:

Actually maintaining good life style will reduce incident of many disease, GDM one of
these disease . But some time GDM happen with healthy women with good lifestyle .

4. Implications of practice:
My patient has GDM. The intervention of a good lifestyle like diet and exercise to
prevent GDM is good to prevent gestational diabetes mellitus in the next pregnancy.
I go to mother and I inroduce my self. Then, I advise the mother pre-pregnancy
lifestyle intervention to prevent gestational diabetes mellitus in the next pregnancy.
But, in some it may not benefit because there are many reasons for gestational
diabetes in pregnancy to occur.

5. My learning experience:
I learn that maintaining a good life style on all live may reduce incident of GDM but
maintaining good live style before pregnancy only may not be effected that match
 23. Reflection:

Introduction:

On Sunday 27, June I was posted on OBG. The nurse asked me to do ECG for
pregnant women. I went to her and introduced myself to her. I asked her permission
to do the procedure for her. At first time, her facial expression showed that she
refused to do the procedure because the nurse said she was more shy. I said for her I
will connect ECG for you only. She said you are a student and I want a nurse. I asked
the nurse to persuade her to be comfortable. Then, I connect the ECG in the wrong
places as it is my first time to do this procedure. The mother was cooperative and
understood my situation. Then the nurses came and taught me how to do it
perfectly. Then I did it by myself and the chart reading was .correct
Feeling and thought:
In this situation, I was too worried to have this experience and deal with anxiety
mother. However, at the end of the procedure I was happy to have new experience
and new facts about ECG. Also, I was happy about what mothers did in this situation
and how kind she was. She was cooperative and didn't stop me when I did wrong. I
was happy about my .confidence and experience
Evaluation:
I think my performance was good and the situation happened in a good way. I was
thankful to the nurse who was teaching me. I benefited from her teaching more.
Also, my performance was better in doing the procedure for second time and make
me confident more.
Analysis:
My wrong was I didn't know the places where I will put the ECG
connection( electrodes). In fact, During an ECG, up to 12 sensors (electrodes) will be
attached to the chest and limbs. The electrodes are sticky patches with wires that
connect to a monitor. They record the electrical signals that make your heart beat. A
computer records the information and displays it as waves on a monitor or on paper.
Apply the six chest electrodes in the following locations: V1: 4th intercostal space at
the right sternal edge. V2: 4th intercostal space at the left sternal edge. V3: midway
between the V2 and V4 electrodes. V4: 5th intercostal space in the midclavicular
line. V5: left anterior axillary line at the same horizontal level as V4. V6: left mid-
axillary line at the same horizontal level as V4 and V5.
Conclusion:
Now , I Have new information about something different . I can able to do ECG
without an assistant. Action plan: In the future, I will do ECG for any patient without
any problem. I have to have good deal with patient and persuasion in advising
patient to have any type of procedure.

24. References:
1: Pregnancybirthbaby.org.au. 2021. Managing gestational diabetes. [online]
Available at: <https://www.pregnancybirthbaby.org.au/managing-gestational-
diabetes> [Accessed 10 July 2021].
2: Geeky Medics. 2021. How to Record an ECG - OSCE Guide | Procedure | Geeky
Medics. [online] Available at: <https://geekymedics.com/record-ecg/> [Accessed 10
July 2021].
3: Mayoclinic.org. 2021. Mayo Clinic - Mayo Clinic. [online] Available at:
<https://www.mayoclinic.org/> [Accessed 10 July 2021].
4: News-Medical.net. 2021. Gestational Diabetes Pathophysiology. [online] Available at:
<https://www.news-medical.net/amp/health/Gestational-Diabetes-
Pathophysiology.aspx> [Accessed 10 July 2021].
5: Care.diabetesjournals.org. 2021. Home | Diabetes Care. [online] Available at:
<https://care.diabetesjournals.org> [Accessed 10 July 2021].

25. Organization of case study: