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Diabetes Mellitus Prepregnancy/Gestational - Nursing Care Plan (NCP)

This disorder of carbohydrate metabolism of variable severity may be preexisting (pregestational insulindependent diabetes mellitus [IDDM] or non–insulin-dependent diabetes mellitus [NIDDM]), or may develop during pregnancy (gestational diabetes mellitus [GDM]).
Gestational Diabetes Mellitus

NURSING PRIORITIES
1. Determine immediate and previous 8-wk diabetic control.
2. Evaluate ongoing client/fetal well-being.
3. Achieve and maintain normoglycemia (euglycemia).
4. Provide client/couple with appropriate information.

Nursing diagnosis: Nutrition: altered, risk for less than body requirements may be related to inability to ingest/utilize nutrients appropriately.

Desired Outcomes
1. Gain 24–30 lb prenatally, or as appropriate for prepregnancy weight.
2. Maintain fasting serum glucose levels between 60–100 mg/dL and 1 hr postprandial no higher than 140 mg/dL.
3. Be free of signs/symptoms of ketoacidosis.
4. Verbalize understanding of individual treatment regimen and need for frequent self-monitoring.

Nursing intervention with rationale:
1. Weigh client each prenatal visit. Encourage client to periodically monitor weight at home between visits.
Rationale: Weight gain is the key index for deciding caloric adjustments.

2. Assess caloric intake and dietary pattern using 24-hr recall.
Rationale: Aids in evaluating client’s understanding of and/or adherence to dietary regimen.

3. Review/provide information regarding any required changes in diabetic management; e.g., switch from oral agents to insulin, use of Humulin insulin only, self-monitoring of serum glucose levels at least 4 times/day (e.g., before breakfast and 2 hr after each meal), and reducing/changing time for ingesting carbohydrates.
Rationale: Metabolism and fetal/maternal needs change greatly during gestation, requiring close monitoring and adaptation. Research suggests antibodies against insulin may cross the placenta, causing inappropriate fetal weight gain. The use of human insulin decreases the development of these antibodies. Reducing carbohydrates to less than 40% of the calories ingested decreases the degree of the postprandial glucose peak of hyperglycemia. Because pregnancy produces severe morning carbohydrate intolerance, the first meal of the day should be small, with minimal carbohydrates.

4. Review importance of regularity of meals and snacks (e.g., 3 meals/3 or 4 snacks) when taking insulin.
Rationale: Small, frequent meals avoid postprandial hyperglycemia and fasting/starvation ketosis.

5. Note presence of nausea and vomiting, especially in first trimester.
Rationale: Nausea and vomiting may result in carbohydrate

6. Assess understanding of the effect of stress on diabetes. Provide information about stress management and relaxation.
Rationale: Stress can elevate serum glucose levels, creating fluctuations in insulin needs.

7. Teach client finger-stick method for self-monitoring of glucose. Have client demonstrate procedure.
Rationale: 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 values.

8. Recommend monitoring urine for ketones on awakening and when a planned meal or snack is delayed.
Rationale: Insufficient caloric intake is reflected by ketonuria, indicating need for an increase of carbohydrates or addition of an extra snack in the dietary plan (e.g., recurrent presence of ketonuria on awakening may be eliminated by a 3 AM glass of milk). Presence of ketones during second half of pregnancy may reflect “accelerated starvation” as diminished effectiveness of insulin results in a catabolic state during fasting periods (e.g., skipping meals), causing maternal metabolism of fat. Adjustment of insulin frequency/dosage/type must then be considered.

9. Review/discuss signs and symptoms and significance of hypoglycemia or hyperglycemia.
Rationale: Hypoglycemia may be more sudden or severe in first trimester, owing to increased usage of glucose and glycogen by client and developing fetus, as well as low levels of the insulin antagonist human placental lactogen (HPL). Ketoacidosis occurs more frequently in second and third trimesters because of the increased resistance to insulin and elevated HPL levels. Sustained or intermittent pulses of hyperglycemia are mutagenic and teratogenic for the fetus during the first trimester; may also cause fetal hyperinsulinemia, macrosomia, inhibition of lung maturity, cardiac dysrhythmias, neonatal hypoglycemia, and risk of permanent neurological damage. Maternal effects of hyperglycemia can include hydramnios, UTI and/or vaginal infections, hypertension, and spontaneous termination of pregnancy.

10. Instruct client to treat symptomatic hypoglycemia, if it occurs, with an 8-oz glass of milk and to repeat in 15 min if serum glucose levels remains below 70 mg/dL.
Rationale: Using large amounts of simple carbohydrates to treat hypoglycemia causes serum glucose values to overshoot. A combination of complex
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