Gestational Diabetes - Case Study #5 - Copy PDF

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Chapter l Obstetrical Cases 17 GWS SET CASE #5 LISA LAWRENCE

Learning Objectives 1. Explain the diagnosis and treatment of the gestational diabetic. 2. Identify signs and symptoms of hypoglycemia and hyperglycemia. 3. Differentiate between NPH and regular insulin. 4. Explain blood sugar changes and insulin needs throughout pregnancy and postpartum. 5. Identify common complications of the gestational diabetic and her baby, as well as appropriate assessments and interventions. NEWSY RASS HET...ARE ... Lisa Lawrence is a 32-year-old primipara. According to her EDC she is 24 weeks gestation. During this pregnancy she has experienced no complications except that her pre-pregnant weight was above normal. Her family history indicates that her maternal aunt and maternal grandmother have Type II or non-insulin dependant diabetes mellitus (NIDDM). There is no known history of birth defects or other chronic illness in the family. During her examination today she is told that her routine glucose challenge test was positive and that she will need to return for a 3-hour glucose tolerance test to rule out gestational diabetes. Lisa asks, "Does this mean I have to take those pills my aunt and grandma do?" Focus Questions 1. How would the nurse respond to Lisa? . explain to the patient that we should complete a 3 hour GTT to confirm if she has gestational diabetes. If it comes back that the patient has it, explain we can control with insulin and diet

2. How would the nurse prepare Lisa for the 3-hour GTT? - The patient will have to drink 75g glucose solution, then a venous blood sample will be taken 1-3 hr after to determine her glucose levels

" Lisa's test shows that she has gestational diabetes. Since her blood sugars are high and uncon trolled, the physician has started her on 15 u. Humulin NPH insulin and 5 u. Humulin regular insulin this morning and a 2,000 calorie diabetic diet. Evening blood sugars (5 P.M.) are to be reported to the physician for an evening insulin order. The physician explains that she may be 18 Unfolding Case Studies: Experiencing the Realities of Clinical Nursing Practice on insulin for the rest of her pregnancy. Later, Lisa asks the nurse, "How long do I have to fol low these rules?" Focus Questions 1. How should the nurse explain Lisa's insulin needs throughout her pregnancy and postpartum? Explain that in early pregnancy it might be necessary to take insulin and later on may need to increase intake to keep up with glucose control 2. Explain how the nurse will teach Lisa to administer two types of insulin (NPH 15 u. and regular 5u.) together. Explain to patient you will draw up 15 units of air into need and push in vial of NPH, then draw 5 units of air and push into regular vial Draw 5 units of regular making sure their are no air bubbles and then 15 of NPH with a total of 20units

3. What kinds of insulin have been ordered? How are they different and why are they both ordered?

Humulin which is short acting and onset of 30-60min and lasts 5-8hr

Humulin NPH is long acting and has an onset within 1-2 hr and lasts 18-24 hr

4. When during her pregnancy will Lisa be most prone to hypoglycemia and hyperglycemia?

Early and later during pregnancy based on fetus absorption, need increased and metabolic rate of absorption

5. Explain the signs of hypoglycemia and hyperglycemia and how each are treated. Hypoglycemic: shakiness, dizzy, irritability, fast heartbeat, confusion, difficulty concentrating, cold sweats Snacks like graham crackers and a glass of milk will help bring the glucose up Hyperglycemic: fruity smelling breath, N/V, SOB, dry mouth, weakness, confusion, coma, abdominal pain, extreme thirst Check glucose to determine how much regular insulin is needed to bring back to normal range 6. What other complications are possible for Lisa to encounter because of her diabetes? Preclampsia, macrosomia, infections, miscarriage, postpartum hemorrhage . Lisa's blood sugars have been elevated to 130-140 during her pregnancy. She complains that she always feels hungry. Lisa goes into labor at 37 weeks and experiences a difficult labor last ing 16 hours. She has a forceps delivery resulting in a fourth degree laceration, and she deliv ers a 12-1b. baby boy with evidence of paralysis of the left side of his face and left arm. Lisa is tired and upset and states, "My baby is fat and looks like he has been beaten up. I'm embar rassed to let my family and friends visit." She points to the baby in the crib next to her bed, "Look, his arms and legs shake funny, too."

Focus Questions 1. How would the nurse explain to Lisa why her baby weighed 12 lbs.? Her baby was born with macrosomia caused by maternal DM during her pregnancy and was not controlled It caused her baby to gain weight which was stored as fat

2. If Lisa had been a diabetic for 10 years, what could the baby be expected to be like in contrast to the gestational diabetic's baby? Risks for abnormalities are greater if the patient is diabetic and glucose is not kept under control Defects could include heart, kidney, GI, brain/spinal defects, limb deficiencies 3. What assessments of Lisa should the nurse make to monitor for potential complications after delivery and why? Diabetic focus assessment, vitals, vascular/neurologic assessment, lower extremities, check for infection of delivery site

Unfolding Case Studies: Experiencing the Realities of Clinical Nursing Practice 4. What complications does Lisa's baby have and what additional complications might the nurse anticipate? How might the nurse intervene? Respiratory distress, hypoglycemia, injury caused by macrosomia Monitor infants glucose, monitor breathing and give O2 if needed Give glucose if infants is low Check infants clavicle since he was bigger for fracture as he could have gotten injured during the birthing process

5. How will the nurse encourage maternal infant bonding? Placing the baby skin to skin on mothers chest, encouraging breastfeeding

Reflective Writing Lisa says to the nurse, “I'm sure glad this is all over and I won't have to deal with having dia betes anymore." How would you respond? Get tested every 6-12 weeks after the birth of child and then ever 1-3 years to make sure she does not develop type 2 DM

Reference Wong, D. & Perry, S. (1998). Maternal child nursing care. St. Louis: Mosby....