Gestational Diabetes Nursing Care Plan & Management

Notes

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Description
  1. Gestational diabetes is abnormal carbohydrate, fat, and protein metabolism that is first diagnosed during pregnancy, regardless of the severity.Gestational Diabetes
  2. Gestational diabetes is further classified as:
    • Gestational diabetes characterized by an abnormal glucose tolerance test (GTT) without other symptoms. Fasting glucose is normal and the diabetes is controlled by diet (A1).
    • Gestational diabetes characterized by abnormal glucose tolerance test and elevated fasting glucose. This type of gestational diabetes must be controlled by insulin (A2).
  3. About 15,000 infants are born to mothers with diabetes each year. Since 1980, the International Workshop-Conference on gestational Diabetes and the American Diabetic Association has recommended universal screening for gestational diabetes between 24 and 28 weeks of gestation.
Etiology
  • Gestational diabetes is a disorder of late pregnancy (typically), caused by the increased pancreatic stimulation associated with pregnancy.

Pathophysiology
  1. In gestational diabetes mellitus (type III, GDM), insulin antagonism by placental hormones, human placental lactogen, progesterone, cortisol, and prolactin leads to increased blood glucose levels. The effect of these hormones peaks at about 26 weeks’ gestation. This is called the diabetogenic effect of pregnancy.
  2. The pancreatic beta cell functions are impaired in response to the increased pancreatic stimulation and induced insulin resistance.
  3. Pregnancy complicated by diabetes puts the mother at increased risk for the development of complications, such as spontaneous abortion, hypertensive disorders, and preterm labor, infection, and birth complications.
  4. The effects of diabetes on the fetus include hypoglycemia, hyperglycemia, and ketoacidosis. Hyperglycemic effects can include:
    1. Congenital defects
    2. Macrosomia
    3. Intrauterine growth restriction
    4. Intrauterine fetal death
    5. Delayed lung maturity
    6. Neonatal hypoglycemia
    7. Neonatal hyperbilirubinemia
Assessment Findings
  1. Associated findings include a poor obstetric history, including spontaneous abortions, unexplained stillbirth, unexplained hydramnios, premature birth, low birth weight or birth weight exceeding 4,000 g (8lb, 13 oz), and birth of a newborn with congenital anomalies.
  2. Common clinical manifestations include:
    • Glycosuria on two successive office visits
    • Recurrent monilial vaginitis
    • Macrosomia of the fetus on ultrasound
    • Polyhydramnios
  3. Laboratory and diagnostic study findings.
    • Fasting blood sugar test will reveal elevated blood glucose levels.
    • A 50-g glucose screen (blood glucose level is measured 1 hour after client ingests a 50-g glucose drink) reveals elevated blood glucose levels. The normal plasma threshold is 135 to 140 mg/dL.
    • A 3- hour oral glucose tolerance test (performed if 50-g glucose screen results are abnormal) reveals elevated blood glucose levels. (Table 1)
    • The glycosylated hemoglobin (HbA 1c) test (measures glycemic control in the 4 to 8 weeks before the test is performed; performed on women with pre-existing diabetes) results reflect enzymatic bonding of glucose to hemoglobin A amino acids. This is a useful indicator of overall blood glucose control. The upper normal level of HbA1c is 6% of total hemoglobin.
    • Screens for fetal (and later, neonatal) complications, including:
      • Maternal serum alpha-fetoprotein level to assess risk for neural tube defects in newborn.
      • Ultrasonography to detect fetal structural anomalies, macrosomia, and hydramnios.
      • Nonstress test (as early as 30 weeks), contraction stress test, and biophysical profile because of risk of unexplained intrauterine fetal demise in the antepartum period.
      • Lung maturity studies (by amniocentesis) to determine lecithinsphingomyelin (L/S) ratio and to detect phosphatidylglycerol (PG); the adequacy of L/S and PG, predictor of the newborn’s ability to avoid respiratory distress

Nursing Management
  1. Establish an initial database, and maintain serial documentation of test results throughout the pregnancy.
  2. Provide client and family teaching.
  • Assess the client’s understanding of GDM and its implications for daily life.
  • As needed, explain the effects of gestational diabetes on the mother and fetus.
  • Point out the need for frequent laboratory testing and follow-up for mother and fetus, for example, to prevent infection and assess other potential complications.
  • Discuss and demonstrate insulin self-injection
Table 1
Normal Glucose Tolerance Test Values
 TEST TIMING  VENOUS PLASMA  WHOLE BLOOD  PREGNANT
 Fasting  <105 mg/dL  <90 mg/dL  105 mg/dL
 1 hr  <190 mg/dL  <170 mg/dL  190 mg/dL
 2 hr  <165 mg/dL  <145 mg/dL  165 mg/dL
 3 hr  <145 mg/dL  <125 mg/dL  145 mg/dL
  • Demonstrate how to self-monitor blood glucose level. Explain that blood is generally tested daily before meals and at bedtime.
  • Explain the need to test urine for ketones, which are harmful to the fetus.
  • Point out the importance of keeping daily records of blood glucose values, insulin dose, dietary intake, periods of exercise, periods of hypoglycemia, kind and amount of treatment, and daily urine test results.
  • Discuss potential complications and their management.
    • Diabetic ketoacidosis is a multisystem disorder resulting from hyperglycemia in which plasma glucose levels exceed 350 mg/dL. (Table 3)
    • Hypoglycemia is a disorder caused by too much insulin, insufficient food, excess exercise, diarrhea, or vomiting. Client and Family Teaching Table 4 list signs and symptoms of hypoglycemia and hyperglycemia.
      • (a) Discuss the management of hypoglycemia by administering 12 fluid oz of orange juice (or 20 g of carbohydrates) and waiting 20 minutes before repeating the procedure.
      • (b) Report the episode to the health care provider as soon as possible.
  • Explain the need for continued evaluation during the postpartum period until blood glucose levels are within normal limits.
3. Arrange for the client to consult with a dietitian to discuss the prescribed diabetic diet and to ensure adequate caloric intake(Table 2)
Table 2
Generally recommended Caloric Intake for Pregnant Diabetic Women
 CATEGORY
 KCAL/LB PER DAY  TOTAL GAIN
 Adult  16.4  24-30 lb
 Adolescent  20.5  30 lb
 Underweight  22.7  30 lb
 Obese  13.6  20 lb

4. Address emotional and psychosocial needs. Intervene appropriately to allay anxiety regarding diabetes and childbirth.

5. Prepare the client for intensive frequent intrapartum assessment, which may include:

  • Fetal monitoring
  • Intravenous infusion of glucose, insulin, and oxytocin
  • Evaluation for diabetic ketoacidosis (signs and symptoms include altered level of consciousness, labored breath sounds, fruity breath odor, and ketonuria)
  • Intravenous fluid and electrolyte replacement therapy
  • Invasive maternal cardiac monitoring

6. Identify and make referral to support groups and resources available to the client and family.

Table 3
Laboratory Values in Diabetic Ketoacidosis (DKA)

 DEGREE OF DKA  TOTAL CO  pH
 Mild  21-28mEq/L  >7.30
 Moderate  11-20 mEq/L  7.10-7.30
 Severe  <10 mEq/L  <7.10

Table 4
Client and Family Teaching

 HYPOGLYCEMIA  HYPERGLYCEMIA
  • Shakiness, dizziness
  • Sweating
  • Pallor, cold, clammy skin
  • Disorientation, irritability
  • Headache
  • Hunger
  • Blurred vision
  • Nervousness
  • Weakness, fatigue
  • Shallow respirations, but normal pulse rate
  • Urine negative for glucose and acetone
  • Blood glucose level below 60 mg/dL
  • Fatigue
  • Flushed, hot skin
  • Dry mouth, excessive thirst
  • Frequent urination
  • Rapid, deep respirations, fruity odor
  • Depressed reflexes
  • Drowsiness, headache

Exam

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Nursing Care Plan


Risk For Maternal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

Risk factors
  • Altered immune response.
  • Anemia.
  • Changes in diabetic control.
  • Tissue hypoxia.
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • Patient will be free of signs and symptoms of diabetic ketoacidosis (fruity-scented breath, excessive thirst, frequent urination, weakness, confusion).
  • Patient will remain normotensive.
  • Patient will maintain normoglycemia.
Nursing Interventions Rationale
Assess client for vaginal bleeding and abdominal tenderness. Vascular changes associated with diabetes place client at risk for abruptio placenta.
Determine nature of any vaginal discharge. If glycosuria is present, a client is more likely to develop monilial vulvovaginitis, which is caused by Candida albicans and may lead in oral thrush in newborn.
Assess for any signs and symptoms of UTI. Early detection of UTI may prevent the occurrence of pyelonephritis, which can contribute to premature labor.
Assess and monitor for signs of edema. Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of the vascular changes prior pregnancy influences the extent and time of onset of PIH.
Determine fundal height; check for edema of extremities and dyspnea. Hydramnios occurs in 6%-25% of pregnant diabetic clients. May be associated with increased fetal contribution to amniotic fluid because hyperglycemia increases fetal urine output.
Identify for episodes of hyperglycemia. Diet and/or insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements usually doubled.
Identify for episodes of hypoglycemia. Hypoglycemic episodes occur most frequently in the first trimester, owing to continuous fetal drain on serum glucose and amino acids, and to low levels of HPL. In the presence of hypoglycemia, vomiting may lead to ketosis.
Monitor for signs and symptoms of pre term labor. Hydramnios may predispose the client to early labor. Overdistention of the uterus caused by macrosomia.
Note White’s classification for diabetes. Assess degree of diabetic control (Pederson’s Criteria). Client classified as D, E, or F is at high risk for complications, as is a client with PBSP.
Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day. Allows greater accuracy than urine testing because the renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels.
Request that client check urine for ketones daily. Ketonuria indicates a presence of starvation state, which may negatively affect the developing fetus.
Monitor client closely if tocolytic drugs are used to arrest labor. Tocolytic drugs may increase serum blood glucose and insulin levels.
Monitor serum glucose level each visits. Detects impending ketoacidosis; helps determine times of day during which client is prone to hypoglycemia.
Monitor Hematocrit and hemoglobin level on the initial visit, then during the second trimester and at term. Anemia may be present in a client with vascular involvement.
Obtain HbA1c every 2-4 week, as indicated. Allows accurate assessment of glucose control for the past 60 days.
Monitor for total protein excretion, creatinine clearance, BUN, and uric acid levels. Progressiive vascular changes may impair renal function in clients with severe or long-standing diabetes.
Obtain urinalysis and urine culture; administer antibiotic as indicated. Helps prevent or treat pyelonephritis. Note: Some antibiotics might be contraindicated because of the danger of teratogenic effects.
Obtain culture of vaginal discharge, if present. Candida vulvovaginitis can cause oral thrush in the newborn.
Prepare client for ultrasonography at 8, 12, 18, 26, and 36-38 weeks of gestation as indicated. Determines fetal size using biparietal diameter, femur length, and estimated fetal weight. The client is at risk for CPD and dystocia due to macrosomia.
Scheduled for ophthalmologic examination during the first trimester for all clients, and in second, and third trimesters if clients are at class D, E, F.. Owing to several vascular involvements, background retinopathy may progress during pregnancy. Laser coagulation therapy may improve client’s condition and reduce optic fibrosis.
Start IV therapy with 5% dextrose; administer glucagon SC if a client is hospitalized with insulin shock and is unconscious. Follow with protein-containing foods/fluids, e.g. 15 grams of beans. Glucagon is naturally occurring substance that acts on liver glycogen and converts it to glucose, which corrects hypoglycemic state. (Note: Hypertonic Glucose D50 administered IV may have negative effects on fetal brain tissue because of its hypertonic action). Protein helps sustain normoglycemia over a longer period.


Risk For Fetal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

Risk factors
  • Changes in circulation.
  • Elevated maternal serum blood glucose levels.
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • Fetus will normally display reactive normal stress test and negative OCT and CST.
Nursing Interventions Rationale
Determine White’s classification for diabetes; explain classification and significance to client/couple. Fetus is at less risk if White’s classification is A, B, or C. The client with classification DD, E, or F who develops kidney or acidotic problems or PIH is at high risk. As a means of determining prognosis for perinatal outcome, White’s classification has been used in conjunction with (1) evaluation of diabetic control or lack of control and (2) presence or absence of Pedersen’s prognostically bad signs of pregnancy (PBSP), which includes acidosis, mild/severe toxemia, and pyelonephritis.The National Diabetes Data Group Classification, which includes diabetes mellitus (type I, insulin-dependent; type II, noninsulin dependent), impaired glucose tolerance, and gestational diabetes mellitus, has not yet had prognostic significance in predicting perinatal outcomes.
Determine client’s diabetic control before conception. Strict control (normal HbA1c levels) before conception helps reduce the risk of fetal mortality and congenital abnormalities.
Monitor for signs of PIH (edema, hypertension, proteinuria). About 12-13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.
Monitor fundal height each visit. Useful in identifying abnormal growth pattern (macrosomia or IUGR, small or large gestational age [SGA/LGA]).
Assess fetal movement and fetal heart rate each visit as indicated. Encourage client to periodically record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on. Fetal movement and fetal heart rate may be negatively affected when placental insufficiency and maternal ketosis occur.
Monitor urine for ketones. Note for fruity-breath. Irreparable CNS damage or fetal death can occur as result of maternal ketonemia, especially in the third trimester.
Provide information about possible effects of diabetes on fetal growth and development. Helps client to make informed decisions about managing regimen and may increase cooperation.
Provide information and reinforce procedure for home blood glucose monitoring and diabetic management. Decreased fetal or newborn mortality and morbidity complications and congenital anomalies are associated with optimal FBS levels between 70 to 96 mg/dL, and 2-hr postprandial glucose level of less than 120 mg/dL. Frequent monitoring is important to maintain this tight range and to reduce an incidence of fetal hypoglycemia or hyperglycemia.
Discuss rationale/procedure for carrying out periodic Oxytocin Challenge Test (OCT) or Contraction Stress Test (CST) beginning at 30-32 weeks’ gestation, depending on the diagnosis of NIDDM or GDM. CST assesses placental perfusion of oxygen and nutrients to the fetus. Positive results indicate placental insufficiency, in which case fetus may need to be delivered surgically.
Review rationale and procedure for periodic NSTs (e.g., weekly NST after  30 weeks’ gestation, twice weekly NST after 36 weeks’ gestation). Fetal activity and movement are good predictors of fetal wellness. Activity level decreases before alterations in FHR occur.
Review rationale and procedure for amniocentesis using lecithin-sphingomyelin ratio (L/S) ratio and the presence of phosphatidylglycerol (PG). When there is impaired maternal/placental functioning before term, fetal lung maturity is a criterion used to determine whether survival is possible. Hyperinsulinemia inhibits and interferes with surfactant production; therefore, in the diabetic client, testing for the presence of PG is more accurate than using L/S ratio.
Assess glycosylated albumin level at 24-28 weeks’ gestation, especially for a client in a high-risk category (history of macrosomic infants, previous GDM, or positive family history of GDM). Follow with oral glucose tolerance test (OGTT) if test results are positive. Serum test for glycosylated albumin reflects glycemia over several days and may gain acceptance as a screening tool in determining GDM because it does not involve potentially harmful glucose loading as does with OGTT.
Assess HbA1c every 2-4 weeks, as indicated. Incidence of congenitally malformed infants is increased in women with high HbA1c level (greater than 8.5%) early in pregnancy or before conception. Note: HbA1c is not sensitive enough as a screening tool for GDM.
Obtain sequential serum or 24-hr urinary specimen for estriol levels after 30 weeks’ gestation. Although estriol levels are not used as often now, falling levels may indicate decreased placental functioning, leading to a possibility of intrauterine growth restriction (IUGR) and stillbirth.
Verify Alpha-fetoprotein (AFP) levels are obtained at 14-16 weeks’ gestation. Although AFP screen is recommended for all clients, it is especially important in this population because the incidence of neural tube defects is greater in diabetic clients than in nondiabetic clients, particularly if poor control existed before pregnancy.
Review periodic creatinine clearance levels. There is a slight parallel between renal vascular damage and impaired uterine blood flow.
Perform Nonstress test (NST) and Oxytocin Challenge Test (OCT)/Contraction Stress Test (CST), as appropriate. Assesses fetal well-being and adequacy of placental perfusion.
Prepare for ultrasonography at 8, 12, 18, 28, and 36-38 weeks’ gestation, as indicated. Ultrasonography is useful in confirming gestation date and helps to evaluate intrauterine growth restriction (IUGR).
Assist as necessary with biophysical profile (BPP) assessment. Provides a score to assess fetal well-being/risk, The criteria include NST results, fetal breathing movements, amniotic fluid volume, fetal tone, and fetal body movements. For each criterion met, a score of 2 is given. A total score of 8-10 is reassuring, a score of 4-7 indicates a need for further evaluation and retesting, and a score of 0-3 is ominous.
Assist with preparation for delivery of fetus vaginally or surgically if test results indicate placental aging and insufficiency. Helps ensure a positive outcome for neonate. The incidence of stillbirths increases significantly with gestation more than 36 weeks. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).

Risk for Altered Nutrition: Less Than Body Requirements

Risk for Altered Nutrition: Less Than Body Requirements: At risk for an intake of nutrients that is insufficient to meet metabolic needs.

Risk factors
  • Inability to utilize nutrients appropriately.
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • Patient will verbalize understanding of individual treatment regimen and the need for frequent self-monitoring.
  • Patient will maintain fasting serum blood glucose levels between 60-100 mg/dl and 1-hour postprandial of no higher than 140 mg/dl.
  • Patient will gain at least 24-30 lbs prenatally or as appropriate for pre-pregnancy weight.
  • Patient will be free of signs and symptoms of diabetic ketoacidosis (fruity-scented breath, excessive thirst, frequent urination, weakness, confusion).
Nursing Interventions Rationale
Assess and record dietary pattern and caloric intake using a 24-hour recall. To help in evaluating client’s understanding and/or compliance to a strict dietary regimen.
Assess understanding of the effect of stress on diabetes. Teach patient about stress management and relaxation measures. It is proven that stress can increase serum blood glucose levels, creating variations in insulin requirements.
Weigh the client every prenatal visit. Encourage the client to periodically monitor weight at home between visits. Weight gain serves as an indicator for determining caloric adjustments.
Observe for the presence of nausea and vomiting, especially during the first trimester. Nausea and vomiting may be brought about by a deficiency in carbohydrates, which may result in the metabolism of fats and development of ketosis.
Teach the importance of regularity of meals and snacks (e.g., three meals or 4 snacks) when taking insulin. Eating very frequent small meals improves insulin function.
Teach and demonstrate client to monitor sugar using a finger-stick method. Insulin needs for the day can be adjusted based on periodic serum glucose readings. Note: Values obtained by reflectance meters may be 10-15% lower/higher than plasma levels.
Provide information regarding any required changes in diabetic management; e.g., use of human insulin only, changing from oral diabetic drugs to insulin, self-monitoring of serum blood glucose levels at least twice a day (e.g., before breakfast and before dinner) and reducing/changing time for ingesting carbohydrates. Metabolism and maternal/fetal needs fluctuates during the gestation period, requiring close monitoring and adaptation. Research suggest antibodies against insulin may cross the placenta, causing inappropriate fetal weight gain. The use of human insulin decreased the development of these antibodies. Reducing carbohydrates to less than 40% of the calories ingested reduces the degree of a postprandial peak of hyperglycemia. Because pregnancy provides severe morning glucose intolerance, the first meal of the day should be small, with minimal carbohydrates.
Provide information regarding the signs and symptoms and difference of hyperglycemia or hypoglycemia. Hypoglycemia may be more sudden or severe during the first 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).Ketoacidosis occurs more frequently during the second and third trimester because of the resistance to insulin and elevated HPL levels.

Sustained or intermittent pulse of hyperglycemia re mutagenic and teratogenic for the fetus in the first trimester; may also cause fetal hyperinsulinemia, macrosomia, inhibition of lung maturity, cardiac dysrhythmia, neonatal hypoglycemia, and risk of permanent neurologic damage.

Maternal effects of hyperglycemia can include hydramnios, vaginal and urinary tract infections, hypertension and spontaneous termination of pregnancy.

Recommend monitoring urine ketones on awakening and when a planned meal or snack is delayed Insufficient caloric intake is reflected by ketonuria, indicating a need 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).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.
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. 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.
Discuss the type of insulin, dosage and schedule (e.g., usually 4 times/day: 7:30am-NPH; 10am-regular; 4pm-NPH; 6pm-regular). Division of insulin dosage considers basal maternal needs and mealtime insulin-to-food ratio and allows more freedom in meal-scheduling. 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.
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 weeks gestation.
Monitor serum blood glucose levels (Fasting blood sugar, preprandial 1 and two hr postprandial) on the first visit, then as indicated by client’s condition. Incidence of fetal and newborn abnormalities is decreased when fasting blood sugar levels range between 60 and 100 mg/dl, preprandial levels between 60 and 105 mg/dl, 1-hr postprandial remains below 140 mg/dl, and 2-hr postprandial is less than 120 mg/dl.
Ascertain results of HbA1c every 2-4weeks. Provide an accurate picture of average serum glucose control during the preceding 60 days. Serum glucose control takes six weeks to normalize.
Coordinate multispecialty care conference as appropriate. Provides an opportunity to review the management of both pregnancy and diabetic condition, and to plan for special needs during intrapartum and postpartum periods.
Refer to a registered dietician to individualize diet and counsel regarding dietary questions. 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. Note: New recommendations set dietary need at 255 kcal/kg dependent on the client’s current pregnant weight.
Prepare for hospitalization if diabetes is not controlled. Infant morbidity is linked to maternal hyperglycemia-induced fetal hyperinsulinemia.


Deficient Knowledge

May be related to
  • Lack of recall.
  • Lack of exposure to information.
  • Misinformation.
  • Unfamiliarity with information resources.
Possibly evidenced by
  • Questions, statement of misconception.
  • Inaccurate follow-through of instructions.
  • Development of preventable complications.
Desired Outcomes
  • Patient will verbalize understanding of the procedures, laboratory tests, and activities involved in controlling diabetes.
  • Patient will participate in the management of diabetes during pregnancy.
  • Patient will demonstrate proficiency in self-monitoring and insulin administration,
Nursing Interventions Rationale
Assess client’s and/or couple’s knowledge of the disease condition and treatment, including relationships between diet, exercise, stress, illness, and insulin requirements. When there is a clear understanding of both the disease condition and rationale for each management helps the client and/or couple make informed decisions.
Teach the client to have a serum glucose monitoring at home using a glucometer, and the need to record readings (usually at least 2-4 times/day). Recording blood glucose measurements at home allow the client to see the impact of her diet and exercise on serum blood glucose levels and to closely control of sugar levels.
Explain the difference of a normal/abnormal weight gain during the pregnancy. Facilitate home visits to check and monitor the weight. The normal total weight gain during the first trimester is 2.5-4.5 lbs, then 0.8-0.9 lb/week after that. Caloric restriction with resulting ketonemia may cause fetal damage and inhibit optimal protein utilization.
Discuss the reasons why oral hypoglycemic agents should be avoided, even though they may have been used by the class A client, to control diabetes before pregnancy. The oral hypoglycemic agent is not recommended to be taken during pregnancy because it crosses the placenta, that can potentially can harm the fetus.
Provide information regarding the use and action of insulin. Demonstrate on how to administer insulin (by injection, nasal spray or insulin pump) as indicated. Prenatal metabolic changes cause insulin requirement to change. In the first trimester, insulin requirements are lower, but they double or quadruple during the second and third trimester.
Provide contact numbers for health care team members. To give answers/enlighten the client with problems being dealt every day.
Review hematocrit and hemoglobin levels. Provide dietary instructions on the importance of intake iron rich foods. Anemia is a concern for diabetic clients because elevated glucose levels replace oxygen in the Hb molecule which can result in reduced oxygen-carrying capacity causing more problems.
Discuss how the client can recognize signs of infection. Caution the client not to self-medicate with vaginal creams available over-the-counter. Important to seek medical help early to avoid further complications. Choice of self-treatment may be inappropriate/mask infection.
Provide information regarding the impact of pregnancy on the diabetic condition and future expectations. Sufficient knowledge can decrease the fear of the unknown, may increase the likelihood of participation, and may help reduce fetal/maternal complications. Note: About 70% of GDM clients will likely develop NIDDM within 15 years.
Assist client and/or family to learn glucagon administration. Instruct the client to follow with protein rich food such as 8 oz of skim milk, then recheck blood glucose level in 15 minutes. The use of glucagon and milk can increase the serum glucose level without the risk of rebound hyperglycemia. Glucagon is also useful during periods of morning sickness or vomiting when food intake is decreased, and serum glucose levels drop.
Encourage the client to maintain a diary of home assessment of serum glucose levels, insulin dosage, reactions, general well-being, diet, exercise and other thoughts related to the disease condition. The use of a diary can help the health care provider to evaluate and alter the therapy provided as indicated.
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