Mae Denn Labordo

CASE 1: GESTATIONAL DIABETES

Patient Assignment

1. Student Nurse: Labordo, MD

PATIENT: KATRINA

A 34-year-old Katrina who is in her second pregnancy and has had one live birth and no abortions is seen for prenatal care at 24 weeks gestation. Her weight is 220 lb, and her blood pressure is 130/80
mmHg. Uterine size is appropriate for gestational age. The patient's past obstetric history includes the spontaneous vaginal delivery of a 9 lb, 8 oz. male infant at 40 weeks gestation, 8 years ago in Corazon
Locsin Montelibano Memorial Regional Hospital. The patient reports that the child is doing well. Her family history reveals that her mother has type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria
and negative ketones.

Doctor ordered 20 U of NPH (neutral protamine Hagedorn) insulin in the morning and 10U regular insulin (Humulin R) in the evening to be adjusted based on subsequent FBS readings in the next few weeks.

Her diet included 25 kcal/kg actual body weight divided into three meals and a bedtime snack. The diet emphasized complex carbohydrates with the avoidance of simple carbohydrates, self-monitoring of
blood glucose, performing tests while fasting and 2 hours after each meal.

1. What additional nursing assessment and history do you need to take from your patient to establish conclusive diagnoses?

 Obtain weight, height, and BMI

 Check blood glucose
 Check bilirubin levels and monitor for signs of jaundice
 Assess vital signs and status frequently
 Coordinate tasks for additional monitoring, including increased frequency of visits to with the provider and non-stress test

2. Using the Nursing Care Plan Template in your resources, make a nursing care plan for each nursing diagnoses you have identified (Minimum of 2. 1 actual, and 1 potential) .

Actual

Blocking : OB POSTPARTUM Area : _________ Weekdate: April 12-16. 2021

Shift :
Student Nurse: Mae Denn Labordo CPAC-SON

Patient’s Name: Katrina Actual/ Provisional Diagnosis:

Nursing Problem: Gestational Diabetes
Outcomes
Assessment Nursing Diagnosis Nursing Interventions Rationale Evaluation
/Objectives
Subjective Data: (PES) (SMART) OM(idc)E (Rationale for each Intervention)  Patient will
Her family history Risk for Altered Long Term Objective  Assess and record dietary pattern and  To help in evaluating client’s verbalize
 Ingest appropriate
reveals that her Nutrition: Less Than caloric intake using a 24-hour recall. understanding and/or compliance to understanding of
amounts of
mother has type 2 Body Requirements calories/nutrients  Assess understanding of the effect of a strict dietary regimen. individual
diabetes mellitus . stress on diabetes. Teach patient about  It is proven that stress can increase treatment
 Display usual stress management and relaxation serum blood glucose levels, creating regimen and the
energy level.
 Demonstrate
measures. variations in insulin requirements. need for
Objective Data:  Weigh the client every prenatal visit.  Weight gain serves as an indicator for frequent self-
stabilized weight
 A urine or gain toward Encourage the client to periodically determining caloric adjustments. monitoring.
dipstick shows usual/desired
monitor weight at home between  Nausea and vomiting may be  Patient will
3+ glycosuria range with normal
laboratory values. visits. brought about by a deficiency in maintain fasting
and negative
 Observe for the presence of nausea carbohydrates, which may result in serum blood
ketones
and vomiting, especially during the the metabolism of fats and glucose levels
 Weight is 220
first trimester. development of ketosis. between 60-100
lb, and her Short term Objectives
blood pressure After nursing action is  Teach the importance of regularity of  Eating very frequent small meals mg/dl and 1-
expected Nutrition 2x24 meals and snacks (e.g., three meals or improves insulin function. hour
is 130/80
hours patients met the
mmHg 4 snacks) when taking insulin.  Insulin needs for the day can be postprandial of
indicator:
 Serum albumin.  Teach and demonstrate client to adjusted based on periodic serum no higher than
 Pre serum monitor sugar using a finger-stick glucose readings. Note: Values 140 mg/dl.
albumin. method. obtained by reflectance meters may  Patient will gain
 Hematocrit.
 Provide information regarding any be 10-15% lower/higher than plasma at least 24-30 lbs
 Hemoglobin.
 Total iron binding required changes in diabetic levels. prenatally or as
capacity. management; e.g., use of human  Research suggest antibodies against appropriate for
 The number of insulin only, changing from oral insulin may cross the placenta, pre-pregnancy
lymphocytes.
diabetic drugs to insulin, self- causing inappropriate fetal weight weight.
monitoring of serum blood glucose gain. The use of human insulin  Patient will be
levels at least twice a day (e.g., before decreased the development of these free of signs and
breakfast and before dinner) and antibodies. Reducing carbohydrates symptoms of
reducing/changing time for ingesting to less than 40% of the calories diabetic
carbohydrates. ingested reduces the degree of a ketoacidosis
 Provide information regarding the
signs and symptoms and difference of
hyperglycemia or hypoglycemia.
 Recommend monitoring urine ketones
on awakening and when a planned
meal or snack is delayed.
 Instruct client to treat symptomatic
hypoglycemia, if it occurs, with an 8-oz
glass of milk and to repeat in 15
minutes if serum glucose levels remain
below 70 mg/dl.
 Discuss the type of insulin, dosage and
schedule (e.g., usually 4 times/day:
7:30am-NPH; 10am-regular; 4pm-NPH;
6pm-regular).
 Adjust diet or insulin regimen to meet
individual needs.
 Refer to a registered dietician to
individualize diet and counsel
regarding dietary questions.
postprandial peak of hyperglycemia. (fruity-scented
Because pregnancy provides severe breath, excessive
morning glucose intolerance, the first thirst, frequent
meal of the day should be small, with urination,
minim Hypoglycemia may be more weakness,
sudden or severe during the first confusion).
trimester, owing to increased usage
of glucose and glycogen by a client
and developing fetus, as well as low
levels of the insulin antagonist
human placental lactogen (HPL).
 Maternal effects of hyperglycemia
can include hydramnios, vaginal and
urinary tract infections, hypertension
and spontaneous termination of
pregnancy. al carbohydrates.
 Insufficient caloric intake is reflected
by ketonuria, indicating a need for an
increased intake of carbohydrates or
additional snack in the dietary plan.
The presence of ketones during the
second trimester may reflect
“accelerated starvation” as the
diminished effectiveness of insulin
results in a catabolic state during
fasting periods (e.g., skipping meals),
causing maternal metabolism of fat.
Adjustment of insulin type, dosage,
and/or frequency must be required.
 Using plenty of simple carbohydrates
to treat hypoglycemia causes serum
glucose values to elevate. A
combination of complex
carbohydrates and protein maintains
normoglycemia longer and helps
 maintain the stability of serum
glucose throughout the day.
 Division of insulin dosage considers
basal maternal needs and mealtime
insulin-to-food ratio and allows more
freedom in meal-scheduling. The
total daily dosage is based on
gestational, current maternal body
weight, and serum glucose levels. A
mix of NPH and regular human
insulin helps mimic the normal
insulin release pattern of the
pancreas, minimizing “peak/valley”
effect of serum glucose level. Note:
Although some providers may
choose to manage clients with GDM
with oral hypoglycemic agents,
insulin is still the drug of choice.
 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 weeks gestation.
 Diet-specific to the individual is
necessary to maintain
normoglycemia and to obtained
desired weight gain. In-depth
teaching promotes understanding of
own needs and clarifies
misconceptions, especially for a
 client with gestational diabetes.
References: https://nurseslabs.com/diabetes-mellitus-nursing-care-plans/7/

Potential

Blocking : OB POSTPARTUM Area : _________ Weekdate: April 12-16,2021

Shift :

Student Nurse: Mae Denn Labordo CPAC-SON

Patient’s Name: Katrina Actual/ Provisional Diagnosis:

Nursing Problem: Gestational Diabetes

Assessment Nursing Diagnosis Outcomes /Objectives Nursing Interventions Rationale Evaluation

Subjective Data: (PES) (SMART) OM(idc)E (Rationale for each Intervention) Patient verbalized she
didn’t obtain any injury.
Her family history Risk for Maternal Long Term Objective  Instruct the patient in the principle of  Maceration between the toes
reveals that her mother Injury hygiene: wash the feet daily in warm predisposes the patient to infection.
Patient is free of injury. water using mild soap; avoid soaking
has type 2 diabetes The use of lotion replaces the
mellitus the feet. Dry carefully and gently, moisturizing effects lost by
Short term Objectives
especially between toes. Use autonomic neuropathy. The patient
 Patient will moisturizing lotion at least once daily. should select a lotion with a low
remain Avoid the area between the toes.
alcohol content to prevent drying.
normotensive.  Instruct the patient to inspect the feet
 All surfaces of the foot need to be
daily for cuts, scratches, and blisters. A
 Patient will examined, including the skin
mirror may be necessary to assess the
maintain between toes. Touch will identify skin
bottom of the foot. Instruct to use both
normoglycemia. surface alterations that are not
Objective Data: visual inspection and touch.
evident by sight.
• A urine dipstick shows  Teach the patient to inspect the shoes
 Reduces the risk of injury to the foot.
3+ glycosuria and daily by feeling the inside of the shoe
negative ketones for irregularities or sharp objects.  Keeping the feet covered to prevent
injuries to the foot.
• Weight is 220 lb, and  Instruct the patient to always wear
her blood pressure is protective footwear; never go barefoot.  Helps avoid injury to the toes when
130/80 mmHg self-care cannot be provided.
 Instruct the patient to trim nails
straight across and to file sharp corners  Soft cotton or wool absorbs moisture
to match the contour of the toe. from perspiration and discourages an
environment in which fungus can
 Instruct the patient to wear clean, well-
thrive.
fitting stockings made from soft cotton,
synthetic blend, or wool.  For patients with type 1 diabetes
presenting with persistent glycosuria
 Perform urine ketone testing, as
and hyperglycemia, urine ketone
indicated.
testing should be initiated.
References: https://nurseslabs.com/diabetes-mellitus-nursing-care-plans/7/

3. Do a drug study on the medications given. (Use Drug Study Template)

Generic/ Classification Indication Dosage Mechanism of Action Side Effects Nursing Consideration Rationale
Trade Name

1. Novolin N, Antidiabetics, NPH insulin is an 20 U Regulates glucose  Hypoglycemia  Assess for  Appropriate
Humulin N, Insulins; intermediate-acting metabolism  Lipodystrophy contraindications monitoring and
Insulatard Antidiabetics, insulin given to help  Lipohypertrophy or cautions. dose adjustments
Intermediate- control blood sugar levels  Local allergic  Perform a physical can be completed.
Acting in people with diabetes. It reaction assessment.  To establish a
Insulins is used by injection under  Hypokalemia  Assess skin lesions; baseline before
the skin once to twice a  Muscle weakness orientation and beginning therapy.
day. Onset of effects is  Paresthesia reflexes; blood  Could indicate a
 typically in 90 minutes and  Tremor pressure, pulse, response to high or
they last for 24 hours.  Edema respiration and low glucose levels
 Pain adventitious breath and potential risk
 Itching sounds factors in giving
 Nausea  Inspect skin areas insulin.
 Hunger that will be used for  Which could
 Numbness of injection; note any interfere with
mouth areas that are insulin absorption
bruised, thickened, and alter
or scarred. anticipated
10 U  Obtain blood response to insulin
2. Humulin R stimulates uptake of glucose levels as therapy.
Antidiabetics, glucose into muscle and fat ordered.  To monitor
Insulins; cells, inhibits production of  Assess activity response to insulin.
Antidiabetics, hyperglycemia with glucose in the liver, level, including  Which can alter
Short-Acting diabetes type 1 and 2, prevents breakdown of fat amount and degree serum glucose
Insulins diabetic ketoacidosis l and protein of exercise, levels and need for
 headache,  Monitor the results these drugs.
 hunger, of laboratory tests,  For evidence of
 weakness, including urinalysis, glycosuria
 sweating,
 tremors,  Assess for  To prevent any
 irritability, symptoms of harm to the patient
 trouble hypoglycemia or  To check if the
concentrating, hyperglycemia patient has the
 rapid breathing,  Monitor body appropriate weight,
 fast heartbeat, weight over time
 fainting, or  May cause
 seizure (severe decreased inorganic
hypoglycemia can phosphates,
be fatal). potassium, and
magnesium
 Monitor blood
sugars every 6
hours, monitor A1C
every 3-6 months
References: https://reference.medscape.com/drug/humulin-n-novolin-n-insulin-nph-999006#10
https://nurseslabs.com/insulin/#nursing_considerations
https://reference.medscape.com/drug/humulin-r-novolin-r-insulin-regular-human-999007#10

4. What are the significant Laboratory tests (if there are any) and what is the interpretation of the test results

Date/ Specimen Rationale Normal Values for Age Test Results Significance Reference
Name of Test
Oral Glucose Blood measures your body's Children: below 140 mg/dL Normal https://www.very
Tolerance Test response to sugar Younger than 6 years old mg/dL wellhealth.com/th
(OGTT) Fasting 80-180 140 and 199 mg/dL Prediabetes or IGT e-oral-glucose-
Before meal 100-180 tolerance-test-
1-2 hours after eating ~180 200 mg/dL and above Diabetes 1087684#interpr
Bedtime 110-200 eting-the-results

Adolescents: https://www.singl
Age 6-12 mg/dL ecare.com/blog/n
Fasting 80-180 ormal-blood-
Before meal 90-180 glucose-levels/
1-2 hours after eating Up to 140
Bedtime 100-180

Teens:
Age 13-19 mg/dL
Fasting 70-150
Before meal 90-130
1-2 hours after eating Up to 140
Bedtime 90-150

Adults:
20+ years of age mg/dL
Fasting Less than 100
Before meal 70-130
1-2 hours after eating Less than 180
Bedtime 00-140