NCP 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.