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 present client and/or fetal well-being.
- Risk for Altered Nutrition: Less Than Body Requirements
- Risk For Maternal Injury
- Risk For Fetal Injury
- Deficient Knowledge
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.
- Inability to utilize nutrients appropriately.
Possibly evidenced by
- [Not applicable]
- 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).
|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.
|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.|
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Maternal and Newborn Care Plans
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