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Analysis/nursing diagnosis:
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Knowledge deficit related to pathophysiology, interactions with pregnancy, management (e.g., insulin administration).
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Altered nutrition, more or less than body requirements, related to weight gain.
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High-risk pregnancy: high risk for infection, ketosis, perinatal wastage, fetal macrosomia, cephalopelvic disproportion, polyhydramnios, preterm labor and birth, congenita) anomalies.
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Nursing care plan/implementation:
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Goal:
health teaching.
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Pathophysiology of diabetes, as necessary; effect of pregnancy on management.
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Signs and symptoms of hyperglycemia, hypoglycemia; appropriate management of symptoms.
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Hygiene - to reduce probability of infection.
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Exercise - needed to control serumglucose levels, to regulate weight gain, and for feeling of well-being.
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Need for close monitoring during pregnancy.
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Insulin regulation:
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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).
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Serum-glucose testing - dextrometer, Acucheck, or other.
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Preparation and self-administration of insulin injection, as necessary.
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Prompt reporting of fluctuating serum-glucose levels.
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Diagnostic testing/hospitalization:
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Nonstress test.
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Sonography.
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Amniocentesis.
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Goal:
dietary counseling.
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Optimal weight gain - about 24 lb.
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Needs 35 calories/kg of ideal body weight.
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Protein - 20% (2 g/kg, or about 70 g daily).
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Carbohydrates: 30-45% in complex form (milk, bread).
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Fats - unsaturate
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Appropriate exchanges.
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Medical management: hospitalize woman for:
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Regulation of insulin (oral hypoglycémies contraindicated in pregnancy, due to teratogenicity; crosses placental barrier).
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Control of infection.
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Determination of fetal jeopardy or indications for early termination of pregnancy.
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Evaluation/outcome criteria:
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Understands and accepts diagnosis of diabetes.
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Actively participates in effective management of diabetes and pregnancy.
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Maintains serum-glucose levels within acceptable parameters (e.g., 70-120 mg/dl).
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Monitors serum-glucose levels accurately (dextrometer, Acucheck, urine testing).
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Prepares and self-administers insulin appropriately.
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Complies with dietary regimen.
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Antepartal hospitalization
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Assessment:
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Medical evaluation - procedures:
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Serum-glucose levels (↓12O mg).
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Sonography for fetal growth: biophysical profile (BPP) evaluates fetal physical well-being and volume of amniotic fluid
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Nonstress testing/contraction stress testing.
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Amniocentesis for fetal maturity
(Note:
L/S ratio may be elevated in diabetic women;
phosphatidylglycerol [PG]
more accurate for diabetic women.)
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Nursing assessment:
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Daily weight, vital signs, FHR q4h, I&O.
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Fundal height and Leopold’s maneuvers on admission.
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Nursing care plan/implementation.
Goal:
emotional support
- to reduce anxiety and tension, which contribute to insulin imbalance
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Explain all procedures.
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Assist with tests for fetal status.
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Prepare for possibility of preterm or cesarean birth.
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Anticipatory planning - management of labor.
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Assessment: continuous.
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Signs and symptoms of hyperglycemia, hypoglycemia.
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Electronic fetal monitoring - to identify signs of fetal distress.
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Other - as for any laboring woman.
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Nursing care plan/implementation: Goal: safeguard maternal/fetal status.
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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)
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Medical management - varies widely.
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Timing - amniocentesis to determine PG and phosphatidylinositol levels (estimate fetal pulmonary surfactant).
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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
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Ultrasound or x-ray pelvimetry to identify CPD.
- Anticipatory planning - management of postpartum
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Factors influencing serum-glucose levels:
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Loss of placental hormones that degrade insulin.
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Lower metabolic rat Woman requiring large doses of insulin may need to triple caloric intake and decrease insulin by one-half
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Assessment:
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Observe for:
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Hypoglycemia
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Infection.
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Preeclampsia/eclampsia (higher incidence in diabetic women).
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Hemorrhage (associated with polyhydramnios, macrosomia, induction of labor, forceps birth, or cesarean birth).
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Monitor healing of episiotomy/ abdominal incision.
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Nursing care plan/implementation:
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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).
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Nursing management
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Goal: euglycemi Acucheck, insulin as ordere
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Goal: avoid trauma, reduce risk of UTI. Avoid catheterization, where possibl
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Goal: health teachin Nipple care - to prevent fissures and possible mastitis.
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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.
- Anticipatory guidance - discharge plan/implementation
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Goal: counselin Reinforce recommendations of physicians/genetic counselors.
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Risk of infant inheriting gene for diabetes is greater if mother has earlyonset, non-insulin-dependent diseas
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Increased risk of congenital disorders.
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Goal: family planning
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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
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Tubal ligation: if mother has vascular involvement, i., retinopathy or nephropathy, increased risk with later pregnancies.
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Goal: health teachin
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Self-care measures.
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Importance of eating on time, even if infant must wait to breastfeed or bottle feed
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Importance of adequate rest and exercise to maintain insulin/glucose balance
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Organize schedule to care for infant, other children, and her diabetes. Allow time for self.
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Evaluation/outcome criteria:
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Successfully completes an uneventful pregnancy, labor, and birth of a normal, healthy newborn.
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Makes informed judgments regarding parenting, family planning, management of her diabetes.