NCP Diabetes Mellitus Pre-pregnancy Gestational

Diabetes Mellitus Prepregnancy/Gestational
This disorder of carbohydrate metabolism of variable severity may be preexisting (pregestational insulin-dependent diabetes mellitus [IDDM] or non–insulin-dependent diabetes mellitus [NIDDM]), or may develop during pregnancy (gestational diabetes mellitus [GDM]).
(This plan of care is to be used in conjunction with the Trimesters and the High-Risk Pregnancy.)
CLIENT ASSESSMENT DATA BASE
circulation
Pedal pulse and capillary refill of extremities may be diminished or slowed (with diabetes of long duration).
Edema, elevated BP (PIH).
Elimination
May have history of pyelonephritis, recurrent UTI, nephropathy
Polyuria
Food/Fluid
Polydipsia, polyphagia.
Nausea and vomiting.
Obesity; excessive or inadequate weight gain (client with GDM is usually obese; client with IDDM is not usually obese before pregnancy).
Abdominal tenderness.
May report episodes of hypoglycemia, glycosuria.
Safety
Skin integrity/sensation of arms, thighs, buttocks, and abdomen may be altered from frequent injections of insulin.
Visual impairment/retinopathy may be present.
History of symptoms of infection and/or positive cultures for infection, especially urinary or vaginal.
Sexuality
Fundal height may be higher or lower than normal for gestational age (hydramnios, inappropriate fetal growth).
History of large for gestational age (LGA) neonate, hydramnios, congenital anomalies, unexplained stillbirth.
Social Interaction
Socioeconomic concerns/factors can increase risk of complications.
Inadequate or lack of committed support system (may adversely affect diabetic control).
Teaching/Learning
Client’s own birth weight may have been 9 lb or more.
May report recent problems/change in stability of diabetic control.
Family history of diabetes, GDM, PIH, infertility problem; LGA infant, history of neonatal death(s), stillbirth, congenital anomalies, spontaneous abortion, hydramnios, macrosomia (greater than 4000 g or 9 lb at birth).
DIAGNOSTIC STUDIES
Glucose Tolerance Test (GTT): Elevated above 140 mg/dL at 24–28 weeks’ gestation. Clients with specific risk factors are screened at first prenatal visit. (If screening result is positive,
3-hr glucose challenge or oral glucose tolerance test [OGTT] test done to make diagnosis.)
Glycosylated Hemoglobin (HbA1c): Reveals glucose control over previous 4–8 wk. Levels greater than 8.5%, especially before pregnancy, puts the fetus at risk for congenital anomalies.
Random Serum Glucose Level: Determines immediate diabetic control.
Urine Ketone Levels: Determines nutritional state.
Glycosylated Albumin: Reflects glucose control over last several days as possible screening test for GDM.
Urine Culture: Identifies asymptomatic UTI.
Vaginal Culture: May be positive for Candida albicans (Monilia infection).
Protein and Creatinine Clearance (24 hr): Verify level of kidney function, especially in diabetes of long duration.
Thyroid Function Tests: Establish baseline and/or identify coexisting hypothyroidism or hyperthryoidism.
Hemoglobin (Hb)/Hematocrit (Hct): May reveal anemia.
Triglycerides and Cholesterol Levels: May be elevated.
Estriol Level: Indicates level of placental function.
Electrocardiogram (ECG): May reveal altered cardiovascular function in diabetes of long duration.
Nonstress Test (NST): May demonstrate reduced fetal response to maternal activity.
Serial Ultrasonography: Determines presence of macrosomia or IUGR.
Contraction Stress Test (CST), Oxytocin Challenge Test (OCT): Positive results indicate placental insufficiency.
Amniocentesis: Ascertains fetal lung maturity using lecithin to sphingomyelin (L/S) ratio or presence of phosphatidylglycerol (PG).
BPP Criteria: Assesses fetal well-being/maturity.
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
Risk Factors May Include:                                                             Inability to ingest/utilize nutrients appropriately
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Gain 24–30 lb prenatally, or as appropriate for
CRITERIA—CLIENT WILL:                                                     prepregnancy weight.
Maintain fasting serum glucose levels between 60–100 mg/dL and 1 hr postprandial no higher than 140 mg/dL.
Be free of signs/symptoms of ketoacidosis.
Verbalize understanding of individual treatment regimen and need for frequent self-monitoring.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Weigh client each prenatal visit. Encourage client                                Weight gain is the key index for deciding caloric
to periodically monitor weight at home between                                   adjustments.
visits.
Assess caloric intake and dietary pattern using                                      Aids in evaluating client’s understanding of
24-hr recall.                                                                                             and/or adherence to dietary regimen.
Review/provide information regarding any                                           Metabolism and fetal/maternal needs change
required changes in diabetic management;                                             greatly during gestation, requiring close
e.g., switch from oral agents to insulin, use                                           monitoring and adaptation. Research suggests
of Humulin insulin only, self-monitoring of                                          antibodies against insulin may cross the placenta,
serum glucose levels at least 4 times/day                                               causing inappropriate fetal weight gain. The use of
(e.g., before breakfast and 2 hr after each meal),                                   human insulin decreases the development of these
and reducing/changing time for ingesting                                              antibodies. Reducing carbohydrates to less than
carbohydrates.                                                                                         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.
Review importance of regularity of meals and                                      Small, frequent meals avoid postprandial
snacks (e.g., 3 meals/3 or 4 snacks) when taking                                   hyperglycemia and fasting/starvation ketosis.
insulin.                                                                                                    Note: Bedtime snack should contain both protein and
complex carbohydrates to prevent nighttime
hypoglycemia.
Note presence of nausea and vomiting, especially                                 Nausea and vomiting may result in carbohydrate
in first trimester.                                                                                      deficiency, which may lead to metabolism of fats and
development of ketosis.
Assess understanding of the effect of stress on                                      Stress can elevate serum glucose levels, creating
diabetes. Provide information about stress                                             fluctuations in insulin needs.
management and relaxation. (Refer to CP: The
High-Risk Pregnancy.)
Teach client finger-stick method for self-monitoring                            Insulin needs for the day can be adjusted based on
of glucose. Have client demonstrate procedure.                                     periodic serum glucose readings. Note: Values
obtained by reflectance meters may be 10%–15%
lower/higher than plasma values.
Recommend monitoring urine for ketones on                                        Insufficient caloric intake is reflected by ketonuria,
awakening and when a planned meal or                                                 indicating need for an increase of carbohydrates or
snack is delayed.                                                                                     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.
Review/discuss signs and symptoms and                                               Hypoglycemia may be more sudden or severe in
significance of hypoglycemia or hyperglycemia.                                   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.
Instruct client to treat symptomatic hypoglycemia,                               Using large amounts of simple carbohydrates to
if it occurs, with an 8-oz glass of milk and to repeat                              treat hypoglycemia causes serum glucose values to
in 15 min if serum glucose levels remains                                             overshoot. A combination of complex
below 70 mg/dL.                                                                                     carbohydrates and protein maintains normoglycemia
longer and helps maintain stability of serum glucose
throughout the day.
Collaborative
Participate in/coordinate multispecialty care                                         Provides opportunity to review management of
conference as appropriate.                                                                      both pregnancy and diabetic condition, and to plan
for special needs during intrapartum and postpartum
periods.
Discuss dosage, schedule, and type of insulin                                        Division of insulin dosage considers maternal
(e.g., usually 4 times/day: 7:30 am—NPH;                                           basal needs and mealtime insulin-to-food ratio,
10 am—regular; 4 pm—NPH; 6 pm—regular).                                      and allows more freedom in meal scheduling.
Total daily dosage is based on gestational age,
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 agents,
insulin is still the drug of choice.
Adjust diet or insulin regimen to meet                                                   Prenatal metabolic needs change throughout the
individual needs.                                                                                     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 and 24 weeks’ 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.
Refer to registered dietitian to individualize diet                                   Diet specific to the individual is necessary to
and counsel regarding dietary questions.                                                maintain normoglycemia and to obtain desired
weight gain. In-depth teaching promotes
understanding of own needs and clarifies
misconceptions, especially for client with GDM.
Note: New recommendations (Peterson & Peterson,
1992) set dietary needs at 25 kcal/kg dependent on
the client’s current pregnant weight.
Monitor serum glucose levels (FBS, preprandial,                                  Incidence of fetal and newborn abnormalities is
1 and 2 hr postprandial) on initial visit, then as                                     decreased when FBS levels range between 60 and
indicated by client’s condition.                                                               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 2–4 wk.                                            Provides accurate picture of average serum glucose
control during the preceding 60 days. Serum glucose
control takes 6 wk to stabilize.
Prepare for hospitalization if diabetes is not controlled.                         Infant morbidity is linked to maternal
hyperglycemia-induced fetal hyperinsulinemia.
NURSING DIAGNOSIS:                                                               Injury, risk for fetal
Risk Factors May Include:                                                             Elevated maternal serum glucose levels, changes in circulation
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display normally reactive NST and negative OCT
CRITERIA—FETUS WILL:                                                        and/or CST.
Be full-term, with size appropriate for gestational age.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine White’s classification for diabetes;                                      Fetus is at less risk if White’s classification is A, B,
explain classification and significance to                                               or C. The client with classification D, E, or F who
client/couple.                                                                                           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
Pederson’s prognostically bad signs of pregnancy
(PBSP), which include acidosis, mild/severe toxemia,
and pyelonephritis. The National Diabetes Data Group
Classification, which includes diabetes mellitus (type I,
insulin-dependent; type II, non–insulin-dependent),
impaired glucose tolerance, and gestational diabetes
mellitus, has not yet had prognostic significance in
predicting perinatal outcomes.
Note client’s diabetic control before conception.                                   Strict control (normal HbA1c levels) before conception
helps reduce the risk of fetal mortality and congenital
anomalies.
Assess fetal movement and FHR each visit                                           Fetal movement and FHR may be negatively
as indicated. (Refer to CP: Third Trimester,                                          affected when placental insufficiency and maternal
ND: Injury, risk for fetal.) Encourage client to                                      ketosis occur.
periodically count/record fetal movements
beginning about 18 weeks’ gestation, then
daily from 34 weeks’ gestation on.
Monitor fundal height each visit.                                                            Useful in identifying abnormal growth pattern
(macrosomia or IUGR, small or large for gestational
age [SGA/LGA]).
Monitor urine for ketones. Note fruity breath.                                       Irreparable CNS damage or fetal death can occur as
result of maternal ketonemia, especially in the third
trimester.
Provide information and reinforce procedure                                        Decreased fetal/newborn mortality and morbidity
for home blood glucose monitoring and                                                 complications and congenital anomalies are associated
diabetic management. (Refer to NDs: Knowledge                                 with optimal FBS levels between 70 and 96 mg/dL,
Deficit [Learning Need]; Nutrition: altered,                                           and 2-hr postprandial glucose level of less than
risk for less than body requirements.)                                                     120 mg/dL. Frequent monitoring is necessary to
maintain this tight range and to reduce incidence
of fetal hypoglycemia or hyperglycemia.
Monitor for signs of PIH (edema, proteinuria,                                       About 12%–13% of diabetic individuals develop
increased blood pressure).                                                                      hypertensive disorders owing to cardiovascular
changes associated with diabetes. These disorders
negatively affect placental perfusion and fetal status.
Provide information about possible effect of diabetes                           Helps client to make informed decisions about
on fetal growth and development.                                                           managing regimen and may increase cooperation.
Review procedure and rationale for periodic NSTs                               Fetal activity and movement are good predictors
(e.g., weekly NST after 30 weeks’ gestation, twice-                              of fetal wellness. Activity level decreases before
weekly NST after 36 weeks’ gestation).                                                 alterations in FHR occur.
Discuss rationale/procedure for carrying out                                         CST assesses placental perfusion of oxygen and
periodic OCT/CST beginning at 30–32 weeks’                                     nutrients to fetus. Positive results indicate
gestation, depending on diagnosis of IDDM or GDM.                          placental insufficiency, in which case fetus may
(Refer to CP: Third Trimester; ND: Injury,                                           need to be delivered surgically.
risk for fetal.)
Review procedure and rationale for amniocentesis                                When maternal/placental functioning is impaired
using L/S ratio and presence of PG. (Refer to CP:                                 before term, fetal lung maturity is criterion used to
Second Trimester; ND: Injury, risk for fetal.)                                        determine whether survival is possible. Hyper-
insulinemia inhibits and interferes with surfactant
production; therefore, in the diabetic client, testing for
presence of PG is more accurate than using L/S ratio.
Collaborative
Assess HbA1c every 2–4 wk, 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.
Assess glycolysated albumin level at 24–28 weeks’                              Serum test for glycolysated albumin reflects
gestation, especially for client in high-risk category                              glycemia over several days and may gain
(history of macrosomic infants, previous GDM,                                    acceptance as screening tool for GDM because it
or positive family history of GDM). Follow with                                  does not involve potentially harmful glucose
OGTT if test results are positive.                                                            loading as does OGTT.
Verify AFP levels are obtained at 14–16 weeks’                                   Although AFP screen is recommended for all
gestation.                                                                                                 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.
Prepare for ultrasonography at 8, 12, 18, 28, and                                  Ultrasonography is useful in confirming gestation
36–38 weeks’ gestation, as indicated.                                                     date and helps to evaluate IUGR.
Perform NST and OCT/CST, as appropriate.                                         Assesses fetal well-being and adequacy of placental
perfusion.
Review periodic creatinine clearance levels.                                          There is a slight parallel between renal vascular
damage and impaired uterine blood flow.
Obtain sequential serum or 24-hr urinary specimen                              Although estriol levels are not used as often now,
for estriol levels after 30 weeks’ gestation.                                            falling levels may indicate decreased placental
functioning, leading to possibility of IUGR and
stillbirth.
Assist as necessary with 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 need for further evaluation and
retesting, and a score of 0–3 is ominous.
Assist with preparation for delivery of fetus                                          Helps ensure positive outcome for neonate.
vaginally or surgically if test results indicate                                         Incidence of stillbirths increases significantly with
placental aging and insufficiency.                                                           gestation more than 36 wk. Macrosomia often causes
dystocia with cephalopelvic disproportion (CPD).
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Changes in diabetic control, abnormal blood profile/anemia, tissue hypoxia, altered immune response
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes in actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Remain normotensive.
CRITERIA—CLIENT WILL:                                                     Maintain normoglycemia, free of signs/symptoms of ketoacidosis.
Be free of complications (e.g., infection, placental separation).
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note White’s classification for diabetes. Assess                                    Client classified as D, E, or F is at higher risk for
degree of diabetic control (Pederson’s criteria).                                     complications, as is client with PBSP.
(Refer to ND: Injury, risk for fetal.)
Assess client for vaginal bleeding and                                                   Vascular changes associated with diabetes place
abdominal tenderness.                                                                            client at risk for abruptio placentae.
Monitor for signs and symptoms of preterm labor.                                Overdistension of uterus caused by macrosomia or hydramnios may predispose client to early labor.
Assist client in learning home monitoring of                                         Allows greater accuracy than urine testing because
blood glucose, to be done a minimum of                                               renal threshold for glucose is lowered during
4 times/day. (Refer to NDs: Nutrition: altered,                                      pregnancy. Facilitates tighter control of serum
risk for less than body requirements; Knowledge                                  glucose levels.
deficit [Learning Need].)
Request that client check urine for ketones daily.                                  Ketonuria indicates presence of starvation state,
which may negatively affect the developing fetus.
Identify for hypoglycemic episodes occurring at home.                        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.
Identify for episodes of hyperglycemia.                                                  Diet/insulin regulation is necessary for
normoglycemia, especially in second and third
trimesters, when insulin requirements often double
(may quadruple in third trimester).
Assess for and/or monitor presence of edema.                                       Because of vascular changes, the diabetic client is
(Refer to CP: Pregnancy-Induced Hypertension;                                   prone to excess fluid retention and PIH. The
ND: Fluid Volume deficit.)                                                                     severity of the vascular changes before pregnancy
influences the extent and time of onset of PIH.
Determine fundal height; check for edema of                                        Hydramnios occurs in 6%–25% of pregnant
extremities and dyspnea.                                                                        diabetic clients; may possibly be associated with
increased fetal contribution to amniotic fluid, because
hyperglycemia increases fetal urine output.
Assess for, and review with client, signs and                                         Early detection of UTI may prevent pyelonephritis,
symptoms if UTI.                                                                                   which is thought to contribute to premature labor.
Determine nature of any vaginal discharge.                                           If glycosuria is present, client is more likely to develop
monilial vulvovaginitis, which is caused by Candida
albicans and may result in oral thrush in newborn.
Monitor client closely if tocolytic drugs are                                          Tocolytic drugs may elevate serum glucose and
used to arrest labor.                                                                                 insulin levels.
Collaborative
Monitor serum glucose levels each visit.                                                Detects impending ketoacidosis; helps determine
times of day during which client is prone to
hypoglycemia.
Obtain HbA1c every 2–4 wk, as indicated.                                            Allows accurate assessment of glucose control for
past 60 days.
Assess Hb/Hct on initial visit, then during second                                 Anemia may be present in client with vascular
trimester and at term.                                                                              involvement.
Instruct in insulin administration, as required.                                       Insulin requirements are decreased in first
Ensure that client is adept at self-administration,                                   trimester, then double and may even quadruple as
either subcutaneously (SC) or with pump,                                             the pregnancy progresses. Highly motivated and
depending on client’s needs or care setting.                                           capable clients may do well with a continuous
subcutaneous insulin infusion pump to more
naturally meet insulin needs.
Obtain urinalysis and urine culture; administer                                     Helps prevent or treat pyelonephritis. Note: Some
antibiotic as indicated.                                                                             antibiotics might be contraindicated because of
danger of teratogenic effects.
Obtain culture of vaginal discharge, if present.                                      Candida vulvovaginitis can cause oral thrush in the
newborn.
Collect specimens for total protein excretion,                                        Progressive vascular changes may impair renal
creatinine clearance, BUN, and uric acid levels.                                    function in clients with severe or long-standing
diabetes.
Schedule ophthalmologic examination during                                       Owing to severe vascular involvement,
first trimester for all clients, and in second and                                     background retinopathy may progress during
third trimesters if client is class D, E, F.                                                pregnancy. Laser coagulation therapy may improve
client’s condition and reduce optic fibrosis.
Prepare client for ultrasonography at 8, 12, 18, 26,                               Determines fetal size using biparietal diameter,
and 36–38 weeks’ gestation as indicated.                                               femur length, and estimated fetal weight. Client is at
increased risk for CPD and dystocia due to
macrosomia.
Start IV therapy with 5% dextrose; administer                                      Glucagon is a naturally occurring substance that
glucagon SC if client is hospitalized with insulin                                  acts on liver glycogen and converts it to glucose,
shock and is unconscious. Follow with protein-                                     which corrects hypoglycemic state. (Note:
containing fluids/foods, e.g., 8 oz skim milk                                         Hypertonic glucose [D50] administered IV may
when client is able to swallow.                                                               have negative effects on fetal brain tissue because of
its hypertonic action.) Protein helps sustain
normoglycemia over a longer period of time.
NURSING DIAGNOSIS:                                                               Knowledge deficit [Learning Need], regarding diabetic condition, prognosis, and self care treatment needs
May Be Related To:                                                                        Lack of exposure to information, misinformation, lack of recall, unfamiliarity with information resources
Possibly Evidenced By:                                                                   Questions, statement of misconception, inaccurate follow-through of instructions, development of preventable complications
DESIRED OUTCOMES/EVALUATION                                    Participate in the management of diabetes during
CRITERIA—CLIENT WILL:                                                     pregnancy.
Verbalize understanding of the procedures, laboratory tests, and activities involved in controlling diabetes.
Demonstrate proficiency in self-monitoring and insulin administration.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess client’s/couple’s knowledge of disease                                      Clients with either preexisting diabetes or GDM
process and treatment, including relationships                                       are at risk for ineffective glucose uptake within the
between diet, exercise, illness, stress, and                                              cells, excess utilization of fats/proteins for energy,
insulin requirements.                                                                               and cellular dehydration as water is drawn from the
cell by a hypertonic concentration of glucose within
the serum. Pregnancy alters insulin requirements
drastically and necessitates more intense control,
requiring the client/couple to take a very active role.
Informed decisions can be made only when there is a
clear understanding of both the disease process and
the rationale for management.
Discuss importance of home serum glucose                                          Frequent blood glucose measurements allow client
monitoring using reflectance meter, and the need                                  to recognize the impact of her diet and exercise on
for frequent readings (at least 4 times/day),                                           serum glucose levels and promote tighter control
as indicated. Demonstrate procedure, then                                             of glucose levels.
observe return demonstration by the client.
Review reasons why oral hypoglycemic medications                            Although insulin does not cross the placenta, oral
should be avoided, even though they may have                                     hypoglycemic agents do and are potentially
been used by the class A client, to control diabetes                               harmful to the fetus, necessitating a change in
before pregnancy.                                                                                   diabetic management. Although some clinical sources report use of    oral agents in clients with GDM, this is not recommended during               pregnancy.
Provide information about action and adverse                                       Prenatal metabolic changes cause insulin
effects of insulin. Assist client to learn administration                          requirements to change. In the first trimester,
by injection, insulin pump, or nasal spray                                              insulin requirements are lower, but they double
(experimental technique) as indicated.                                                    and then may quadruple during second and third
trimesters.
Explain normal weight gain to client. Encourage                                  Total gain in the first trimester should be 2.5–
home monitoring between visits.                                                            4.5 lb, then 0.8–0.9 lb/wk thereafter. Caloric
restriction with resulting ketonemia may cause fetal
damage and inhibit optimal protein utilization. (Refer
to ND: Injury, risk for fetal.)
Provide information about need for regular daily                                  Regular exercise may decrease insulin
mild exercise program (regularly, 20 min after                                      requirements, while radical fluctuations in
meals). Warn against exercising if glucose                                            physical activity can adversely affect glucose
exceeds 300 mg/dL.                                                                                control. Client should exercise after meals to help
prevent hypoglycemia and to stabilize glucose
excursion, unless excessive elevation of glucose is
present, in which case exercise promotes
ketoacidosis.
Provide information regarding the impact of                                         Increased knowledge may decrease fear of the
pregnancy on the diabetic condition and                                                unknown, may increase likelihood of
future expectations.                                                                                 participation, and may help reduce fetal/maternal
complications. About 70% of clients diagnosed with
GDM will develop NIDDM within 15 yr.
Discuss how client can recognize signs of infection.                             Important to seek medical help early to avoid
Caution client not to treat self with OTC                                               complications. Choice of self-treatment may be
vaginal creams.                                                                                       inappropriate/mask infection.
Recommend client maintain a diary of home                                         When reviewed by healthcare practitioner(s),
assessment of serum glucose levels, insulin                                           client’s diary can assist with evaluation and
dosage, diet, exercise, reactions, general feelings                                  alteration of therapy.
of well-being, and any other pertinent thoughts.
Provide contact numbers for health team members.                               Client needs to be assured that questions will be
answered and problems dealt with immediately on a
24-hr–day basis.
Review Hb/Hct levels. Provide dietary information                               Anemias are of greater concern in clients with pre-
about sources of iron and the need for                                                   existing diabetes because elevated glucose levels
iron supplements.                                                                                    replace oxygen in the Hb molecule, resulting in
reduced oxygen-carrying capacity.
Assist client/family to learn glucagon administration.                           Presence of symptoms of hypoglycemia
Instruct client to follow with protein source, such                                 (diaphoresis, tingling sensation, palpitations) with
as 8 oz of milk, then recheck glucose level in 15 min.                           a serum glucose level under 70 mg/dL requires
prompt intervention. Use of glucagon in combination
with milk can increase the serum glucose level
without the risk of rebound hyperglycemia.
Glucagon is also useful during periods of morning
sickness/vomiting when food intake is curtailed and
serum glucose levels fall.
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