5. 6. Analysis/nursing diagnosis:
      1. Knowledge deficit related to pathophysiology, interactions with pregnancy, management (e.g., insulin administration).
      2. Altered nutrition, more or less than body requirements, related to weight gain.
      3. High-risk pregnancy: high risk for infection, ketosis, perinatal wastage, fetal macrosomia, cephalopelvic disproportion, polyhydramnios, preterm labor and birth, congenita) anomalies.
   7. Nursing care plan/implementation:
      1. Goal: health teaching.
         1. Pathophysiology of diabetes, as necessary; effect of pregnancy on management.
         2. Signs and symptoms of hyperglycemia, hypoglycemia; appropriate management of symptoms.
         3. Hygiene - to reduce probability of infection.
         4. Exercise - needed to control serumglucose levels, to regulate weight gain, and for feeling of well-being.
         5. Need for close monitoring during pregnancy.
         6. Insulin regulation:
            1. Requirements vary through pregnancy: first trimester - may decrease with some periods of hypoglycemia due to fetal drain; second trimester - increased need for insulin; third trimester - needs may be triple prepregnant dose; acidosis more common in late pregnancy (precipitated by emotional stress, infection).
            2. Serum-glucose testing - dextrometer, Acucheck, or other.
            3. Preparation and self-administration of insulin injection, as necessary.
            4. Prompt reporting of fluctuating serum-glucose levels.
         7. Diagnostic testing/hospitalization:
            1. Nonstress test.
            2. Sonography.
            3. Amniocentesis.
      2. Goal: dietary counseling.
         1. Optimal weight gain - about 24 lb.
         2. Needs 35 calories/kg of ideal body weight.
         3. Protein - 20% (2 g/kg, or about 70 g daily).
         4. Carbohydrates: 30-45% in complex form (milk, bread).
         5. Fats - unsaturate
         6. Appropriate exchanges.
      3. Medical management: hospitalize woman for:
         1. Regulation of insulin (oral hypoglycémies contraindicated in pregnancy, due to teratogenicity; crosses placental barrier).
         2. Control of infection.
         3. Determination of fetal jeopardy or indications for early termination of pregnancy.
   8. Evaluation/outcome criteria:
      1. Understands and accepts diagnosis of diabetes.
      2. Actively participates in effective management of diabetes and pregnancy.
      3. Maintains serum-glucose levels within acceptable parameters (e.g., 70-120 mg/dl).
         1. Monitors serum-glucose levels accurately (dextrometer, Acucheck, urine testing).
         2. Prepares and self-administers insulin appropriately.
         3. Complies with dietary regimen.
   9. Antepartal hospitalization
      1. Assessment:
         1. Medical evaluation - procedures:
            1. Serum-glucose levels (↓12O mg).
            2. Sonography for fetal growth: biophysical profile (BPP) evaluates fetal physical well-being and volume of amniotic fluid
            3. Nonstress testing/contraction stress testing.
            4. Amniocentesis for fetal maturity (Note: L/S ratio may be elevated in diabetic women; phosphatidylglycerol [PG] more accurate for diabetic women.)
         2. Nursing assessment:
            1. Daily weight, vital signs, FHR q4h, I&O.
            2. Fundal height and Leopold’s maneuvers on admission.
      2. Nursing care plan/implementation. Goal: emotional support - to reduce anxiety and tension, which contribute to insulin imbalance
         1. Explain all procedures.
         2. Assist with tests for fetal status.
         3. Prepare for possibility of preterm or cesarean birth.
   10. Anticipatory planning - management of labor.
       1. Assessment: continuous.
          1. Signs and symptoms of hyperglycemia, hypoglycemia.
          2. Electronic fetal monitoring - to identify signs of fetal distress.
          3. Other - as for any laboring woman.
       2. Nursing care plan/implementation: Goal: safeguard maternal/fetal status.
       3. Position: lateral Sims’ - to reduce compression of inferior vena cava and aorta due to polyhydramnios or LGA baby. (Supine hypotensive syndrome results from compression; reduced placental perfusion increases incidence of fetal hypoxia/anoxia)
       4. Medical management - varies widely.
          1. Timing - amniocentesis to determine PG and phosphatidylinositol levels (estimate fetal pulmonary surfactant).
          2. Insulin added to intravenous infusion of 0.9 NaCl and titrated to maintain serum glucose approximately 100 mg/dl. 5-10% D/W I.V. needed to prevent hypoglycemia that may lead to maternal ketoacidosis; hyperglycemia may result in newborn hypoglycemi
          3. Ultrasound or x-ray pelvimetry to identify CPD.
   11. Anticipatory planning - management of postpartum
       1. Factors influencing serum-glucose levels:
          1. Loss of placental hormones that degrade insulin.
          2. Lower metabolic rat Woman requiring large doses of insulin may need to triple caloric intake and decrease insulin by one-half
       2. Assessment:
          1. Observe for:
             1. Hypoglycemia
             2. Infection.
             3. Preeclampsia/eclampsia (higher incidence in diabetic women).
             4. Hemorrhage (associated with polyhydramnios, macrosomia, induction of labor, forceps birth, or cesarean birth).
          2. Monitor healing of episiotomy/ abdominal incision.
       3. Nursing care plan/implementation:
          1. Medical management: insulin calibration - requirement may drop to onehalf or two-thirds pregnant dosage on first postpartum day if woman is on full diet (due to loss of human placental lactogen and conversion of serum glucose to lactose).
          2. Nursing management
             1. Goal: euglycemi Acucheck, insulin as ordere
             2. Goal: avoid trauma, reduce risk of UTI. Avoid catheterization, where possibl
             3. Goal: health teachin Nipple care - to prevent fissures and possible mastitis.
             4. Goal: reduce serum-glucose and insulin needs. Encourage/support breastfeeding —> antidiabetogenic effect. Note: If acetonuria occurs, stop breastfeeding while physician readjusts diet/insulin balance; may pump breasts to maintain lactation. If hypoglycemic, adrenalin level rises decreased milk supply and letdown reflex.
   12. Anticipatory guidance - discharge plan/implementation
       1. Goal: counselin Reinforce recommendations of physicians/genetic counselors.
          1. Risk of infant inheriting gene for diabetes is greater if mother has earlyonset, non-insulin-dependent diseas
          2. Increased risk of congenital disorders.
       2. Goal: family planning
          1. Oral contraceptives are controversial because they decrease carbohydrate tolerance; may be cautiously prescribed for women with no vascular disease and who are nonsmokers. IUD contraindicated because of impaired response to infection. Barrier contraceptives (diaphragm or condoms with spermicides) recommended
          2. Tubal ligation: if mother has vascular involvement, i., retinopathy or nephropathy, increased risk with later pregnancies.
       3. Goal: health teachin
          1. Self-care measures.
          2. Importance of eating on time, even if infant must wait to breastfeed or bottle feed
          3. Importance of adequate rest and exercise to maintain insulin/glucose balance
          4. Organize schedule to care for infant, other children, and her diabetes. Allow time for self.
       4. Evaluation/outcome criteria:
          1. Successfully completes an uneventful pregnancy, labor, and birth of a normal, healthy newborn.
          2. Makes informed judgments regarding parenting, family planning, management of her diabetes.