CASE PRESENTATION

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CASE PRESENTATION
GESTATIONAL DIABETES

• PREPARED BY JYOTHIS JAMES

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DEMOGRAPHIC DATA

• CASE NO 185
• NAME MS. M.A
• AGE 19 YRS
• SEX FEMALE
• Primigravida with pregnancy 40 wks by LMP
• DIAGNOSIS GESTATIONAL DIABETES

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PHYSICAL ASSESSMENT
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GENERAL

• The patient is 19years of age, FEMALE, weighs 75
  kg.
• She is conscious, coherent, with the following
  Vital Signs
• BP 112/60mmHg
• PR78bpm
• RR 20cpm
• Temp37.2 C
• SPO² 96

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SKIN

• Fair complexion
• No palpable masses or lesions, moist, with good
  turgor

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HEAD

• Maxillary, frontal, and ethmoid sinuses are not
  tender.
• No palpable masses and lesions
• No areas of deformity

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LEVEL OF CONSCIOUSNESS AND ORIENTATION

• Awake and alert
• Oriented to persons
• (knows some of our name)
• Place
• ( she can tell where she is)
• Time
• ( knows the day, date and always asking the
  time)
• She knows the function of something like BP
  apparatus

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EYES

• Pink conjunctivae and no dryness
• Pupils equally round and reactive to light

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EARS

• No usual discharges noted

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NOSE

• Pink nasal mucosa
• No unusual nasal discharges
• No tenderness in sinuses

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MOUTH

• Pale and dry oral mucosa and free of swelling and
  lesions

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NECK AND THROAT

• No palpable lymph nodes
• No masses and lesions seen

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CHEST AND LUNGS

• Equal chest expansion
• No retraction
• Clear breath sounds

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HEART

• Regular rhythm

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ABDOMEN

• Globular abdomen
• Leopolds Maneuver done fetus in cephalic
  presentation, head is round and hard, fetal back
  is facing left side, engaged

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GENITALS

• No leaking per vagina

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EXREMITIES

• Pulse full and equal
• No lesions noted

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PATIENT HISTORY

• No special past medical history

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PRESENT MEDICAL HISTORY

• MEDICAL HISTORY
• Primigravida with pregnancy 40 wks by LMP, GDM
  (Gestational Diabetes) on diet .No history of
  Diabetes at Pre-pregnancy state.
• ON EXAMINATION
• BP 112/60mmHg, PR 78 bpm, RR 20
• cpm, Temp37 .2C SPO²96 .
• RBS 140 mg/dl
•  

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PRESENT MEDICAL HISTORY

• INVESTIGATION
•  

Test Result Reference range
Hgb 9.2g/dl 11.2-15.7g/dl
WBC 5.79 3.98-10.04
PT 14.4sec 10.9-16.3sec
RBS 148 mg/dl
Glucose Random 4.9 mmol/L 3.9-7.8 mmol/L
Blood Group O positive
Antibody screening Negative
RPR Non- Reactive
Rubella Antibody IgG Positive
Urinalysis Pus cells 0-2/ hpf, RBC 0-1/ hpf
HBsAg negative
HIV Negative
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MEDICATION
Calcium Tablet 600mg PO Calcium supplement
FeSO4 Tablet 100mg PO Iron supplement
Oxytocin (Pitocin) Mix 10 U in 500 ml of IV solution, begin infusion at 1 mU/min and increase 12 mU/min q 30 min IV To stimulate uterine And mammary gland smooth muscles.
Methergin 0.2mg/ml IM Increase motor activity of the uterus by direct stimulation of the smooth muscle ,shortening the third stage of labour and reducing blood loss.
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INTRODUCTION

• INTRODUCTION
• Gestational diabetes is a condition characterized
  by high blood sugar (glucose) levels that is
  first recognized during pregnancy
• The condition occurs in approximately 4 of all
  pregnancies

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INTRODUCTION

• Causes, incidence, and risk factors
• Pregnancy hormones can block insulin from doing
  its job. When this happens, glucose levels may
  increase in a pregnant woman's blood.

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INTRODUCTION

• RISK FACTORS
• Are older than 25 when you are pregnant
• Have a family history of diabetes
• Gave birth to a baby that weighed more than 9
  pounds or had a birth defect
• Have high blood pressure
• Have too much amniotic fluid
• Have had an unexplained miscarriage or stillbirth
• Were overweight before your pregnancy

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ANATOMY AND PHYSIOLOGY
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ETIOLOGY
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• ETIOLOGY

RISK FACTOR Have a family history of diabetes
Dietary Factor
Obesity
Increased sugar Level in the Blood of the mother
Increased sugar Level in the Blood of the Baby
Overweight of the Baby
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SIGNS SYMPTOMS

• Symptoms
• Usually there are no symptoms, or the symptoms
  are mild and not life threatening to the pregnant
  woman. The blood sugar (glucose) level usually
  returns to normal after delivery. Symptoms may
  include
• Blurred vision
• Fatigue
• Frequent infections, including those of the
  bladder, vagina, and skin
• Increased thirst
• Increased urination
• Nausea and vomiting
• Weight loss despite increased appetite

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SIGNS SYMPTOMS

• Signs and tests
• Gestational diabetes usually starts halfway
  through the pregnancy. All pregnant women should
  receive an oral glucose tolerance test between
  the 24th and 28th week of pregnancy to screen for
  the condition.
• Women who have risk factors for gestational
  diabetes may have this test earlier in the
  pregnancy.
• Once you are diagnosed with gestational diabetes,
  you can see how well you are doing by testing
  your glucose level at home.
• The most common way involves pricking your finger
  and putting a drop of your blood on a machine
  that will give you a glucose reading.

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Oral Glucose Test Values (Fasting Plasma
Glucose Values) for Pregnancy 
Test Type Pregnancy Glucose Level (mg/dl)
Fasting 1 Hour 2hours 3 hours 95 180 155 140
Following a 100 g glucose load. Rate is abnormal if two values are exceeded   Following a 100 g glucose load. Rate is abnormal if two values are exceeded  
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VIII. NURSING INTERVENTION

• Improving Nutrition
• Teaching about Insulin
• Preventing Injury
• Improving Activity tolerance
• Providing information about medications
• Maintaining Skin Integrity
• Improving Coping Strategies
• Reducing fear and anxiety

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STANDARDS OF CARE GUIDELINES

• Assess level of knowledge of disease and ability
  to care for self
• Assess adherence to diet therapy, monitoring
  procedures, medication treatment, and exercise
  regimen
• Assess for signs of hyperglycemia polyuria,
  polydipsia, polyphagia, weight loss, fatigue,
  blurred vision
• Assess for signs of hypoglycemia sweating,
  tremor, nervousness, tachycardia, light-
  headedness, confusion
• Perform thorough skin and extremity assessment
  for peripheral neuropathy or peripheral vascular
  disease and any injury to the feet or lower
  extremities

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STANDARDS OF CARE GUIDELINES

• 6. Assess for trends in blood glucose and other
  laboratory results
• 7. Make sure that appropriate insulin dosage is
  given at the right time and in relation to meals
  and exercise
• 8. Make sure patient has adequate knowledge of
  diet, exercise, and medication treatment
• 9. Immediately report any signs of skin or soft
  tissue infection ( redness, swelling, warmth,
  tenderness, drainage)
• 10. Get help immediately for signs of
  hypoglycemia that do not respond to usual glucose
  replacement
• 11. Get help immediately for patient presenting
  with signs of either ketoacidosis or hyperosmolar
  hyperglycemic nonketotic syndrome
•  
•  

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TREATMENT

• The goals of treatment are to keep blood sugar
  (glucose) levels within normal limits during the
  pregnancy, and to make sure that the growing baby
  is healthy.

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TREATMENT

• WATCHING YOUR BABY
• Your health care provider should closely check
  both you and your baby throughout the pregnancy.
  Fetal monitoring will check the size and health
  of the fetus.
• A non stress test is a very simple, painless test
  for you and your baby.
• A machine that hears and displays your baby's
  heartbeat (electronic fetal monitor) is placed on
  your abdomen.
• Your health care provider can compare the pattern
  of your baby's heartbeat to movements and find
  out whether the baby is doing well.

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TREATMENT

• DIET AND EXERCISE
• The best way to improve your diet is by eating a
  variety of healthy foods. You should learn how to
  read food labels, and check them when making food
  decisions. Talk to your doctor or dietitian if
  you are a vegetarian or on some other special
  diet.
• In general, when you have gestational diabetes
  your diet should
• Be moderate in fat and protein
• Provide your carbohydrates through foods that
  include fruits, vegetables, and complex
  carbohydrates (such as bread, cereal, pasta, and
  rice)
• Be low in foods that contain a lot of sugar, such
  as soft drinks, fruit juices, and pastries
• If managing your diet does not control blood
  sugar (glucose) levels, you may be prescribed
  diabetes medicine by mouth or insulin therapy.
• Most women who develop gestational diabetes will
  not need diabetes medicines or insulin, but some
  will.

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COMPLICATIONS

• Diabetes can affect the developing fetus
  throughout the pregnancy. In early pregnancy, a
  mother's diabetes can result in birth defects and
  an increased rate of miscarriage. Many of the
  birth defects that occur affect major organs such
  as the brain and heart.
• During the second and third trimester, a mother's
  diabetes can lead to over-nutrition and excess
  growth of the baby. Having a large baby increases
  risks during labor and delivery. For example,
  large babies often require caesarean deliveries
  and if he or she is delivered vaginally, they are
  at increased risk for trauma to their shoulder.

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COMPLICATIONS

• In addition, when fetal over-nutrition occurs and
  hyperinsulinemia results, the baby's blood sugar
  can drop very low after birth, since it won't be
  receiving the high blood sugar from the mother.
• However, with proper treatment, you can deliver a
  healthy baby despite having diabetes.

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PRIORITIZATION OF NURSING PROBLEMS

1. Risk for ineffective tissue perfusion related to
   reduced vascular flow
2. Imbalanced nutrition, less than body
   requirements, related to inability to use glucose
3. Risk for fetal injury related to elevated
   maternal serum glucose level.
4. Knowledge Deficit the diabetic condition,
   prognosis and the need for action
5. Deficient knowledge related to therapeutic
   regimen necessary during pregnancy
6. Risk for ineffective coping related to required
   change in lifestyle
7. Risk for infection related to impaired healing
   accompanying condition
8. Deficient fluid volume related to polyuria
   accompanying disorder
9. Deficient knowledge related to difficult and
   complex health problem
10. Health- seeking behaviors related to voiced need
    to learn home glucose monitoring

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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
SUBJECTIVE Ana taban as verbalized by the patient OBJECTIVE 1. Fatigue, tiredness 2. Pale mucous membrane 3.Cold extremities V/S taken as follows BP 90/60 mmHg PR 122 bpm RR 18 cpm Temp. 36C Imbalanced nutrition less than body requirements, related to inability to use glucose After 12 hours of nursing interventions, the patient will relief from fatigue To monitor and document vital signs. To assess daily weight monitoring. 3. Encouraged intake of oral fluid. 4. Provided psychological support. 5. Provided calm place to the patient via quiet environment. 6. Administered IV fluid per order. To identify physical responses associated with both medical and emotional conditions. To facilitate accurate measurement and follow trends to prevent future episodes of inadequate intake Oral fluid replacement is indicated for mild fluid deficit To relieve psychological stress due to fatigue Reduce stress Provide comfort and to the patient Parenteral fluid replacement is indicated to prevent shock After 12 hours of nursing intervention, the goal was fully met as evidenced by Patient relief from fatigue. V/S taken as follows BP 120/90mmHg PR 92bpm RR 22/mt Temp 36.8C
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NURSING HEALTH TEACHING

• The nurse working with patients who are diagnosed
  with gestational diabetes mellitus is often
  responsible for teaching the patient how to
  self-monitor and record glucose and ketones at
  home. In addition, the nurse can teach patients
  about proper diet and safe exercise during
  pregnancy.
• During prenatal visits, the nurse reviews the
  blood glucose and diet logs to make
  recommendations about monitoring, medication
  administration, and diet. Patients may also need
  to learn how to self-administer insulin. The
  nurse should make sure the patient can
  comfortably and appropriately check blood glucose
  levels and administer insulin by requesting a
  return demonstration.

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NURSING HEALTH TEACHING

• It is imperative that the nurse teach patients
  with gestational diabetes the signs and symptoms
  of hypoglycemia. These signs and symptoms include
  shakiness, anxiety, headache, hunger, cold,
  clammy skin, and tingling around the mouth. The
  patient should be taught to closely monitor for
  hypoglycemia and to notify their healthcare
  provider immediately if signs and symptoms are
  noted. The patient can drink milk or juice or eat
  fruit to correct hypoglycemia (Leifer, 2007).
• Since the potential for developing diabetes is
  significant in patients with gestational
  diabetes, it is important that patients
  understand the need for follow-up evaluation
  after delivery. Patients should continue to watch
  for signs and symptoms of hypoglycemia and notify
  their healthcare provider if seen.

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CONCLUSION

• This is a case of a 19 y/o Primigravida with
  pregnancy 40 wks by LMP, GDM (Gestational
  Diabetes) on diet .No history of Diabetes at
  Pre-pregnancy state. Patient was advised for
  expectant management.
• Gestational diabetes is a condition characterized
  by high blood sugar (glucose) levels that is
  first recognized during pregnancy.

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CONCLUSION

• The condition occurs in approximately 4 of all
  pregnancies
• Criteria which are fulfilled by the patient,
  conservative management rendered such as
  investigations, nonstress test, diet and
  exercise.
• The goals of treatment are to keep blood sugar
  (glucose) levels within normal limits during the
  pregnancy, and to make sure that the growing baby
  is healthy.

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BIBLIOGRAPHY

• 5th Edition Maternal Child Health Nursing care
  of the Childbearing Childrearing Family pp.
  378-382
• Fischbach, F. (2004). A manual of laboratory and
  diagnostic tests (7th ed.) Philadelphia
  Lippincott Williams Wilkins
• Lippincott Manual of Nursing practice 9th Edition
  pp. 960-963
• http//www.nursingceu.com/courses/345/index_nceu.h
  tml

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• Thank you!! ?