4 Gestational Diabetes Mellitus Nursing Care Plans

4 Gestational Diabetes Mellitus Nursing Care Plans

Gestational Diabetes Mellitus (GDM) is a condition of abnormal glucose metabolism that arises during pregnancy. Blood sugar usually returns to normal soon after delivery. But having gestational diabetes makes it more likely to develop type 2 diabetes.

Nursing Care Plans

The plan of nursing care involves providing client and/or couple with information regarding the disease condition, teaching the administration of insulin, achieving and maintaining normoglycemia and evaluating the present client and/or fetal well-being.

Here are four (4) nursing care plans and nursing diagnosis for gestational diabetes mellitus:

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

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 InterventionsRationale
Assess the client for vaginal bleeding and abdominal tenderness.Vascular changes associated with diabetes place the 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 to oral thrush in the 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 to 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 an 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 preterm labor. Hydramnios may predispose the client to early labor.Overdistention of the uterus caused by macrosomia.
Note White’s classification for diabetes. Assess the 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 the presence of a 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 visit.Detects impending ketoacidosis; helps determine times of day during which the 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 the 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 a 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 InterventionsRationale
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 the 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 a result of maternal ketonemia, especially in the third trimester.
Provide information about the possible effects of diabetes on fetal growth and development.Helps the 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 the 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 the neonate. The incidence of stillbirths increases significantly with gestation more than 36 weeks. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to a specific topic.

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 InterventionsRationale
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 between normal and abnormal weight gain during 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 an 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.
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.

See Also

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Maternal and Newborn Care Plans

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