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Introduction

Gestational Diabetes Mellitus is a type of diabetes that develops during pregnancy and
usually disappears after delivery. Having GDM increases the risk of developing diabetes later on in
life, it occurs in as many as 14% of pregnant women and increase their risk for hypertensive
disorders during pregnancy, Mothers with GDM have a 50% chance of developing type 2 diabetes
mellitus (T2DM) for the 20 years following their diagnosis of GDM.

Women who are considered to be at high risk for GDM and who should be screened by
blood glucose testing at their first prenatal visit are those with marked obesity, a personal history
of GDM, glycosuria, or a strong family history of diabetes. High-risk ethnic groups include Hispanic
Americans, Native Americans, Asian Americans, African Americans, and Pacific Islanders. If these
high-risk patients do not have GDM at initial screening, they should be retested between 24 and 28
weeks of gestation. Women of average risk should be tested at 24 to 28 weeks of gestation. Testing
is not specifically recommended for women identified as being at low risk.

 
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Importance of the Case study

In the part of the client:

This case will inform the client of what her condition is all about. This will also help her
understand the treatments and tests being introduced to her for the benefit of the promotion of her
health.

In the part of the student:

This case will help the students gain knowledge regarding on the disease, the causative
factors, environmental factors, lifestyle factors and many other factors that precipitate the disease.

In the College of Nursing:

This case may be used as guide to other nursing students to have information with regards
to Gestational Diabetes Mellitus.

On the other side of the Nursing profession:

This will serve as another source of information to further the knowledge of other
researchers on what Gestational Diabetes Mellitus is.

 
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Objectives
General Objectives

Client Centered

‡To assess the health of the patient

‡To develop, implement, and evaluate plans for health promotion

Nurse Centered

‡To apply the nursing process in the care of the pregnant patient based on the community

Specific Objectives

Client-Centered

‡Discuss indications for and management of pregnant clients

‡Discuss nursing implications for medications commonly prescribed for pregnant women
‡Describe nursing care for the client
‡Support client and family, and encourage them to ask questions so that information could be
clarified and understood

Nurse-Centered

‡Identify major risk factors influencing the said condition.

‡Identify the risk factor contributing to the occurrence of the disease.
‡Learn the pathophysiology and manifestations of gestational diabetes mellitus.
‡Identify and describe nursing measure to promote awareness in the condition

 
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Patients Profile
Name of Client: ³JN´ Age: 24
Civil Status: Married Usual Source of Medical Care: Sasa Health Center
Occupation: None
Place of Birth: Samal
Address: Km.9 Upper del Carmen Sasa Davao city
Date of visitation: Feb 17, 2011
Date of last hospital admission: March 17, 2006 Reason: Pregnancy

Physical Assessment
1. Clinical Data
Her height is 4¶11´, and weighs 72kg when we visited her, also her Blood pressure was 90/80 in
sitting position, her pulse rate was at 83bpm these data were taken at 10:10am
2. Respiratory/Circulatory
JN has a respiration of 19 cycles per minute at that time, she also had a cough with no presence of
mucus secretions
3. Metabolic-Integumentary
Skin
Her skin is Brown in complexion, has normal temperature, skin turgor is within normal limits, has
no signs and presence of Edema, Lesions, Bruises, Reddened and Pruritus.
Mouth
Gums and teeth are normal, also has no dentures installed
Abdomen
She has presence of Bowel sounds
4. Neurosensory
Both of her pupils are equal both are also reactive to light, upon assessment both eyes are clear
5. Musculo-Skeletal
She has Full range of motion, has a steady balance and gait, Hand grasps are equal, both leg
muscles are also equal

Health maintenance-perception pattern

The patient does not smoke neither her husband and also does not drink alcoholic beverages, she
is allergic to Shrimps, the reaction to her is Itching

Activity/Exercise pattern
The patient is dependent on doing household chores.
Buying ingredients and can cook Food.
She has no need for assistive devices, but she needs assistance from her husband for home
maintenance.

 
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Nutrition/Metabolic pattern
She has no diet restrictions and Her Appetite increased as mentioned by JN.
She also gained 22kgs, and has no difficulty in swallowing.

Elimination pattern
The patient told us that she only goes to the bathroom once a day, but she has problems with
constipation due to her medication.
Her bladder habits are within normal limits, and she does not feel any incontinence after urinating.

Sleep/Rest pattern
JN sleeps 7hrs a day and feels rested after her sleep, she has no time to take naps because she is
busy taking care of her children

Cognitive-Perceptual pattern
When we arrived at the house of JN, she was Alert, Awake and Oriented, her Speech is normal, she
speaks Bisaya, Tagalog, and English, she can also read, write, and comprehend English as well.
She has no problems in Hearing, her vision is 20/20. She has no Discomfort or pain

Coping stress tolerance/Self-perception/Self-concept patterns

She has problems with regards to their financial aspects, and she is afraid of Violence

Sexuality/Reproductive pattern
Her last menstrual period was on June 14, 2010, with an OB score of G3P2, and is pregnant for 35
weeks and 3 days

Role-Relationship pattern
JN patient is a plain housewife and she depends on her husband¶s income who works at BMEG to
support their 2 kids and her 35weeks old unborn child

Value-Belief pattern
The family¶s religion is Four square, but we weren¶t able to ask whether their religion has some
restrictions with their lifestyle.

 
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PAST HEALTH HISTORY

JN has completed all her immunizations and including the tetanus toxoid, she is allergic in shrimps.

FAMILY HEALTH HISTORY

On JN¶s maternal side her grandmother has hypertension and on her Paternal side her grandfather had
hypertension.

PRESENT HEALTH HISTORY

JN is 8 months pregnant (35 weeks and 3days of gestational age), she sometimes experience Dyspnea
during night time around 12am to 2am in the morning, she also had a cough with no presence of mucus
secretions.
She has taken prescribed ferrous sulfate regularly at home for she is pregnant.

 
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GENOGRAM
Maternal Side Paternal Side
   
   

 
  



 
 
 
 



 
 


Legend:

Female

Male

+Hypertension

Deceased

The Patient

 
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Interpretation of The Genogram

On JN¶s Maternal side her grandfather has Hypertension while on her
Paternal side her Grandmother has also Hypertension and her
grandfather on the paternal side died at the age of 60.

According to JN Her Aunts and Uncles didn¶t have any signs of

Hypertension and also her 28 year old sister did not portray any
signs of the hereditary disease

 
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Anatomy and Physiology

External Parts of the Female Reproductive Organ

The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the
internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

’ Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the
labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-
secreting glands. After puberty, the labia majora are covered with hair.
’ Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the
labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body)
and Urethra (the tube that carries urine from the bladder to the outside of the body).
’ Bartholin¶s glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.
’ Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The
clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the
clitoris is very sensitive to stimulation and can become erect.

 
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Internal Parts of the Female Reproductive Organ

The internal reproductive organs include:

’ Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth
canal.
’ Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two
parts: the Cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The
corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to
exit.
’ Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and
hormones.
’ Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg
cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian
tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall.

 
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Parts and Functions of the Liver

The Parts of the Liver and Nearby Organs

’ Îiliary tree: A network of tubes that carry bile out of

the liver and into the duodenum.
’ Îile ducts: Tubes between the liver and small intestine.
Bile drains into them from the liver.
’ common bile duct: The duct from the liver (hepatic
duct) and the duct from the gallbladder (cystic duct)
meet to form the common bile duct. The common bile
duct carries bile to the duodenum.
’ ÷uodenum: The first part of the small intestine. When
bile leaves the liver, it flows through the bile ducts into
the duodenum. Here, bile starts mixing with food to
help digestion.
’ ›allbladder: An organ that stores bile.
’ - leen: An organ that filters blood. It also helps keep
the body healthy and free of infection, as part of the
immune system.
’ - lenic vein: A blood vessel that carries blood from
the spleen to the portal vein.
’ Portal vein: A blood vessel that carries nutrient-rich
blood from the digestive tract and spleen into the liver.
’ Mnferior vena cava: A large vein that carries blood
from the liver, legs, and kidneys to the heart.
’ e atic veins: Blood vessels that carry blood out of
the liver to the inferior vena cava

’ e atic artery: A blood vessel that carries blood into

the liver from the heart.

 
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Parts and Functions of the Kidneys

Renal Cortex-This is the outer pale red colored layer. It contains the malphigian corpuscles, the proximal and distal parts of the renal
tubule.
Renal Medulla-This forms the inner dark red zone and contains the Henle's loop and the collecting tubules, present in the form of renal
pyramids. The conical pyramids project into the renal pelvis.
Renal Pelvis-This is a large funnel-shaped region behind the renal medulla. Urine flows into the renal pelvis through minute openings at
the tips or papillae of the pyramids.
The urine that is collected is passed down to the ureters into the bladder. Each kidney consists of a large number of microscopic filtering
units called nephrons. There are more than 1,250,000 nephrons in each kidney. Each nephron is about 30 - 40 mm. in length,
originating in the cortex and extending into the medulla.

 
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Pathophysiology of GDM
Precipitating Factors: Predisposing factors:
-Pregnant Women -Lifestyle
-Presence of Human placental Hormones -Increased caloric intake
-High level of Cortisol, Estrogen, -Obese women
Progesterone, and Catecholamines -Sedentary lifestyle
-MultiGravid patients
-History of unexplained perinatal loss

Placental Insulinase
Occurs

S/Sx:
Continuous use of Increased Breakdown or Degradation of insulin
Hypoglycemia
glucose by the fetus

Glucose cannot be used by body cells

Hypoglycemia of the
fetus occurs
Cells register their Glucose wants
S/Sx:
Polyhydramnios S/Sx:
upon Increase urine Signals the Liver to quickly convert Hypoglycemia
BioPhysical productivity occurs stored glycogen to glucose
Screening
(BPS)
Increase Glomerular filtration of Glucose

The Kidneys begin to excrete quantities of glucose in S/Sx:

the urine to attempt to lower the serum glucose level Glycosuria

Osmotic action occurs thus reducing fluid absorption

in the kidneys

 
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Dehydration occurs
Excessive Thirst
occurs (Polydipsia)
If treated:
Medical management:
-increase insulin dosage
beginning at about 24th
weak age of gestation
If not treated (Fetal effect):
Glucose Overload
Additional subcutaneous fat
deposit
Macrosomic infant
Other Problems might encounter:
-Still Birth
-Congenital Anomalies
-Respiratory Distress Syndrome
(RDS)
 

Large quantities of fluid are lost S/Sx:
Polyuria
Blood Serum becomes Blood Volume may fall
concentrated
Reduce blood Flow S/Sx:
*Vascular narrowing
may occur
If not treated (Maternal effect): *Eye problem, retinal
Polyphagia
Anaerobic metabolic reaction dysfunction
occurs *Increased BP
Large stores of lactic acid
pour out of muscle and into
the bloodstream
Lowers Blood pH level
S/Sx:
Ammonia Like breath
Metabolic Acidosis Occurs odor
Protein are tapped by the body to produce energy for cells
Cell Catabolism occurs
Loss of potassium & sodium in the body
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Name: JN Age: 24 Gender: Female

Cues Nursing Nursing Goals/Objectives Nursing Rationale Evaluation

Diagnosis Background Intervention
Subjective Objective
Within 3 hours span of *Establish Rapport *To gain patients M Goal Met
³Mag lisod my care the patient will cooperation
kog Libang, Constipation related Decrease in normal be able to: ___________ *After 3 hours
nya sakit siya to iron supplement frequency of ___________ *To note deficits span of my care
i-gawas´ as Hypoactive defecation -Verbalize understanding the patient was
*Determine fluid
verbalized by bowel accompanied by of etiology and able to verbalize
the patient sounds difficult or appropriate intake ___________ understand the
incomplete passage interventions/solutions ___________ *To help patient etiology and
Dark, Hard of stool and/ or for individual situation *Note factors that identify appropriate
stool as passage of usually stimulate causative factors interventions/
described by excessively hard, dry bowel activity and solutions for
the patient stool any interferences ___________ individuals
present *To know if the situation
___________ patients food are
*Review current contributing to
fluid/dietary intake the condition
___________
*To improve
___________ consistency of
*Encourage balanced stool and
fiber and bulk in diet facilitate
passage through
colon
___________
___________ *To promote
*Promote adequate soft/moist stool
fluid intake, including
high-fiber fruit juices

*To stimulate
*Encourage contractions of

 
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activity/exercise the intestines
within limits of
individual ability ___________
___________ *To let the
*Provide information patient know the
about relationship of importance of
diet, exercise, fluid, each mentioned
and appropriate use activities
of laxatives as ___________
indicated *To facilitate
___________ monitoring of
*Encourage patient to long-term
maintain elimination problem
diary if appropriate
___________
___________ *To promote
*Identify specific timely
actions to be taken if intervention,
problem recurs enhancing
client¶s
independence

Anna Marie V. Belinario, R.N Francis Peter Lahora, S.N

Clinical instructor Signature of student over printed name

Mar 01, 2011 Mar 01, 2011

Date Date

 
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Name: JN Age: 24 Gender: Female

Cues Nursing Nursing Goals/Objectives Nursing Rationale Evaluation

Diagnosis Background Intervention
Subjective Objective
Within 3 hours span of *Establish Rapport *To gain patients M Goal Partially
my care the patient will cooperation met
³Kuntahay Risk for infection At increased risk for be able to:
ma CS ko Curiosity if related to insufficient being invaded by ___________ ___________ *Within 4hrs the
karon sa surgical knowledge to avoid pathogens -Demonstrate patient was able
*Note signs and *To enumerate
ikatulo incision is exposure to techniques, lifestyle to Demonstrate
nakong anak, applied upon pathogens changes to promote safe symptoms of sepsis possible techniques to
unsa akong delivery environment (systemic infection): conditions related promote safe
angay fever, chills, and to the signs and environment
bantayan?´ diaphoresis symptoms
as verbalized
by the patient ___________ ___________
*Stress proper *First line of
handwashing defense against
teachings cross
contaminations
___________ ___________
*Maintain adequate *To avoid bladder
hydration , stand/sit distention
to void
___________ ___________
*Review individual *To know if the
nutritional needs, patients current
appropriate exercise program is suited
program, and need for her or not
for rest

___________ ___________
*Instruct Client in *To provide
techniques to information on how
prevent the spread of to minimize the
infection spread of infection

 
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*To minimize the
*Instruct SO¶s in risk of infection to
techniques in the patient
prevention of spread
of infection
___________
___________ *To increase
*Involve in awareness of
appropriate spread/prevention
community education of communicable
programs diseases
___________
___________ *To provide
* Indentify resources information to the
available to the patient where to
individual proceed if she
contracted a
certain disease

Anna Marie V. Belinario, R.N Francis Peter Lahora, S.N

Clinical instructor Signature of student over printed name

Mar 01, 2011 Mar 01, 2011

Date Date

 
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Name: JN Age: 24 Gender: Female

Cues Nursing Nursing Goals/Objectives Nursing Rationale Evaluation
Diagnosis Background Intervention
Subjective Objective
Within 3 hours span of *Establish Rapport *To gain patients M Goal Met
my care the patient will cooperation
Deficiency of be able to: ___________ *After 3 hours
³Naka-limot Inaccurate cognitive information ___________ *To know if span of my care
man gud ko follow related to lack of -Verbalize understanding the patient was
*Determine clients patient is
sa gi-ingon sa through of Deficient knowledge information of condition/disease able to Verbalize
akoa bahin sa instruction related to Lack of necessary for process and treatment. ability to learn capable at this understanding of
akong recall clients/SO¶s to make time the condition, and
condition..´ informed choices -Initiate necessary ___________ initiated some
As verbalized regarding condition, lifestyle changes and ___________ *To further their necessary lifestyle
by the patient treatment, and participate in treatment *identify support information on changes after the
lifestyle changes regimen persons requiring the current health teaching
information condition of the
patient

___________
*To avoid
__________ language and
*Give information learning barrier
using Layman¶s term
___________
*To improve the
___________ clients
*Identify motivating concentration
factors for the and to keep the
individual motivation level
high
___________
*To encourage
___________ continuation of
* Provide Positive efforts
enforcement

 
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*To promote
easy to recall
*Provide information terms
that is easy to recall ___________
___________ *To catch their
*Utilize visual aids attention
while health teaching
___________ ___________
*Provide Written *To reinforce
information for client learning process
to refer to as
necessary
___________ ___________
*Provide contact *To answer
information to a follow up
certain person in the questions by the
health center client when we
are not around

Anna Marie V. Belinario, R.N Francis Peter Lahora, S.N

Clinical instructor Signature of student over printed name

Mar 01, 2011 Mar 01, 2011

Date Date

 
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Patient name: JN Attending Physician:
Generic Brand name Classification Dosage Mechanism of Indications Contraindications Side effects/Adverse Nursing
name Action effects Implications
responsibilities
*Contraindicated in *Swallow the whole
Chemical Effect: patients Gi: anorexia, black stools, tablet
Provides hypersensitive to constipation, diarrhea,
elemental iron, drug or its epigastric pain, nausea, *Do not crush or chew
an essential ingredients; vomiting.
United Once component in patients with *Do not double the
Ferrous Home formation of primary Other: temporary staining of dose if missed, but
a day hemoglobin hemochromatosis, teeth (drops, suspension) take it as soon
Sulfate Ferrous Oral Iron Iron
Supplement hemosiderosis, as remembered
Sulfate 400mg Therapeutic Deficiency hemolytic anemia
Tablet effect: Relives (unless IDA is also *Avoid taking the drug
iron deficiency present), peptic with certain foods that
ulcer disease, may impair oral
regional enteritis, or iron absorption like
ulcerative colitis; yogurt, cheese, eggs,
and patients milk, cereals tea and
receiving repeated coffee
blood transfusions.

Anna Marie V. Belinario, R.N Nawal Samuel, S.N

Clinical Instructor Signature over printed name of student

Feb 25, 2011 Feb 25, 2011

Date Date

 
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Patient name: JN Attending Physician:
Generic Brand name Classification Dosage Mechanism of Indications Contraindications Side effects/Adverse Nursing
name Action effects Implications
responsibilities
*Although most
Chemical Effect: *Contraindicated in CV: Facial flushing patients take drug
may stimulate patients GI: Epigastric fullness, once daily, patient
insulin release Adjunct to hypersensitive to heartburn, nausea taking more than
from pancreas, diet to lower the drug or any of Hematologic: 10mg daily may
Once a reduce glucose glucose level its components, in Agranulocytosis, aplastic achieve better results
output by liver, in patients those with diabetic anemia, thrombocytopenia with twice-daily
day increase ketoacidosis, and in Hepatic: Cholestatic dosage
Glyburide DiaBeta Antidiabetic with type 2
peripheral DM those with allergies jaundice
(Glibencla Orally sensitivity to to sulfonamides or Metabolic: Hypoglycemia *For hypoglycemic
mide) insulin, and To Replace thiazide diuretics. Skin: Pruritus, Rash reaction, give oral
2.5mg cause mild insulin form of fast-acting
diuresis therapy *Use cautiously in carbohydrates or, if
Tablet patients with patient cat swallow or
Therapeutic hepatic or renal is comatose,
effect: Lowers impairment and in glucagon or I.V
glucose levels debilitated or glucose. Then give
malnourished patient a complex
patients carbohydrate snack
when patient is
conscious, and
determine cause of
reaction

Anna Marie V. Belinario, R.N Nawal Samuel, S.N

Clinical Instructor Signature over printed name of student

Mar 01, 2011 Mar 01, 2011

Date Date

 
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Patient name: JN Attending Physician:
Generic Brand name Classification Dosage Mechanism Indications Contraindications Side effects/Adverse Nursing
name of Action effects Implications
responsibilities
*Give subcutaneously
Chemical *Contraindicated Metabolic: Hyperkalemia, into the abdominal
effects: binds during episodes of Hypoglycemia wall, thigh, or upper
to insulin Control of hypoglycemia and arm. Rotate site to
receptors on hyperglycemi in patients Skin: Lipodystrophy, minimize
Once a muscle and a in diabetes hypersensitive to Pruritus, rash lipodystrophies.
fat cells, lower mellitus NovoLog or its
day glucose level, excipients. Other: Allergic reactions, *Look at insulin vial
Insulin NovoLog Antidiabetic
facilitates the injection site reactions before use. NovoLog
aspart SQ cellular *Use cautiously in should appear as
uptake of patients prone to clear, colorless
(rDNA 10mL vial glucose, and hypoglycemia and solution, it should
origin) inhibits the Hypokalemia, such never contain
for output of as patients who are particulate matter,
injection glucose from fasting, have appear cloudy or
the liver autonomic viscous, or be
neuropathy, or are discolored
Therapeutic using potassium-
effect: Lowers lowering drugs or
glucose level drugs sensitive to
potassium levels

Anna Marie V. Belinario, R.N Nawal Samuel, S.N

Clinical Instructor Signature over printed name of student

Mar 01, 2011 Mar 01, 2011

Date Date

 
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References:

Springhouse Nurse¶s Drug guide 2008

Textbook of Medical-Surgical by Brunner & Suddarth
www.Medscape.com
www.Scribd.com
Nurse¶s Pocket guide 10th Edition by Moorhouse and Doenges
MIMS 2008