CHAPTER I: ASSESSMENT

A. Health Nursing History

1. Personal Data

Date of Admission: May 1, 2011 Age: 35

Name: Ma. Diwata C. Reyes Marital Status: Married

Gender: Female Religion: Catholic

Date of Birth: Address: Unit 215 bldg. 2 Hura

Homes Brgy. Vosra Quezon City

2. Chief Complaint

The client’s chief complaint was a mild uterine contraction.

3. Present Medical History

The client is in 38 weeks of pregnancy. Gravida 3 Para 2. The last menstrual

period of the client is August 8, 2010 and her expected date of confinement is
May 15, 2011. The client’s vital signs upon admission are 130/80 mmHg
blood pressure, temp. 36.7°, respiration 20 cpm, and the pulse is 72 bpm.

4. Past Medical History

The client had a previous Cesarean Section twice, her 1st was in the year 2001
because of fetal distress, and her 2nd was year 2005. She was diagnosed of
Gestational
 5. Family Health History

She doesn’t have any family history of hypertension, diabetes nor asthma.

6. Social History

The client is a government employee; she lives in a condominium with her

two children and husband in Quezon City.

B. Physical Examination

 Conscious

 Coherent

 Ambulatory

 Pinkish conjunctiva

 Anecteric sclera

 Globularly enlarged abdomen

 Fetal Height: 32 cm.

 Fetal Heart Tone: 148 bpm

C. Diagnostic/Laboratory Procedures
Procedure Definition Indication Normal Result Interpretation Nursing
Values Responsibilities
HBA1C The amount of This blood 4.8-5.9 % 6.20 % Above normal Monitor blood
hemoglobin that test helps in value may sugar
has a glucose determining have diabetes.
attached to it. the efficacy
of the sugar
control
measures
and the
medication
taken for
diabetes.
Hematology: The diagnosis,
treatment, Decreased
Hemoglobin and prevention of 125-165 g/L 120 hemoglobin
diseases of the
blood and bone 3.3-5.8x10
Tot. red cell marrow as well as ^12/L 4.12
of the
immunologic,
hemostatic (blood 5-10x10^3/c
Tot. clotting) and 6.6
leukocytes vascular systems. 0.37-0.47
Because of the
Hematocrit nature of blood, 150- 0.36
the science of 400x10^3/L
Platelet count hematology Adequate
profoundly affects 0.55-0.65
Neutrophil the understanding
of many diseases. 0.02-0.04 0.85
Eisinophils
0.25-0.35 -
Lymphocytes
0.35

D. Anatomy and Physiology

Almost all women have some degree of impaired glucose intolerance during pregnancy as a
result of hormonal changes that occur during pregnancy. That means that their blood sugar may
be higher than normal, but not high enough to have diabetes. During the later part of pregnancy
(the third trimester), these hormonal changes place pregnant woman at risk for gestational
diabetes.

During pregnancy, increased levels of certain hormones made in the placenta (the organ that
connects the baby by the umbilical cord to the uterus) help shift nutrients from the mother to the
developing fetus. Other hormones are produced by the placenta to help prevent the mother from
developing low blood sugar. They work by stopping the actions of insulin.

Over the course of the pregnancy, these hormones lead to progressive impaired glucose
intolerance (higher blood glucose levels). To try to decrease the glucose levels, the body makes
more insulin to shuttle glucose into cells.

Usually the mother's pancreas is able to produce more insulin (about three times the normal
amount) to overcome the effect of the pregnancy hormones on glucose levels. If, however, the
pancreas cannot produce enough insulin to overcome the effect of the increased hormones during
pregnancy, glucose levels will rise, resulting in gestational diabetes.

CHAPTER II: PLANNING

A. Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation

Dx

Elevated Risk for After 2 hour Assess fetal Fetal After 2 hour
glucose fetal of nursing movement movement and of nursing
level injury intervention and FHR FHR may be intervention
the Fetal negatively the Fetal
HBA1C: heart rate is as indicated. heart rate
6.20 % normal (Refer to CP: was normal
Third
Trimester,
affected when
placental
insufficiency
and maternal
ND: Injury,
risk for fetal.)
Encourage
Provide client to
information ketosis occur
and reinforce
procedure Decreased
for home fetal/newborn
blood mortality and
glucose morbidity
monitoring complications
and diabetic and congenital
management anomalies are
associated with
optimal FBS
levels between
70 and 96
mg/dL, and 2-
hr postprandial
glucose level
of less than
120 mg/dL.
Frequent
monitoring is
necessary to
maintain this
tight range and
to reduce
incidence
Provide of fetal
information hypoglycemia
about or
possible hyperglycemia.
effect of
diabetes Helps client to
make informed
 decisions about
on fetal growth
and
development.
managing
regimen and
Monitor for may increase
signs of PIH cooperation.
(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.

Assessment Nursing Planning Intervention Rationale Evaluation

Dx
Imbalanc After 2 Assess current After 2
ed hour of timing and hour of
Nutrition: nursing content of nursing
More interventio meals. intervention
than n the the patient
Body patient Advise patient Reducing intake was able to
Requirem understan on the of carbohydrates understand
ents d proper importance of may benefit proper way
related to way o an some patients; to gain
intake in gain individualized however, fad weight
excess of weight meal plan in diets or diet appropriatel
activity appropriat meeting plans that stress y for her
expenditu ely for her weight-loss one food group pregnancy.
res pregnancy goals. and eliminate
. another are
generally not
recommended.

Setting a goal of
Discuss the a 10% (of
goals of patient’s actual
dietary body weight)
therapy for weight loss over
the patient. several months is
usually
achievable and
effective in
reducing blood
sugar and other
metabolic
parameters.

Emphasize that
Assist patient lifestyle changes
to identify should be
problems that maintainable for
may have an life.
impact on
dietary
adherence and
possible
solutions to
these
problems.

Explain the • Caloric

importance of expenditu
exercise in re for
maintaining/re energy in
ducing body exercise
weight. • Carryove
r of
enhanced
Assist patient metabolic
to establish rate and
goals for efficient
weekly food
weight loss utilizatio
and incentives n.
to assist in
 achieving
them.

Strategize
with patient to
address the
potential
social pitfalls
of weight
reduction.

Assessment Nursing Planning Intervention Rationale Evaluation

Dx

Knowled After 2 Assess Clients with After 2

ge hours of client’s/couple’ either hours of
deficit nursing s knowledge of preexisting nursing
[regardin intervention disease diabetes or intervention
g the patient GDM the patient
diabetic will process and was able to
conditio participate treatment, participate
n, in including in
prognosi managemen relationships managemen
s, and t during are at risk for t during
self care pregnancy ineffective pregnancy
treatmen glucose
t needs 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
Discuss cell by a
importance of hypertonic
home serum concentration
glucose of glucose
monitoring within
using the serum.
reflectance Pregnancy
meter, and the alters insulin
need for requirements
frequent drastically
readings (at and
least 4 necessitates
times/day), as more intense
indicated. control,
Demonstrate requiring the
procedure. client/couple
to take a very
Explain normal active role.
weight gain to Informed
client. decisions can
Encourage be made only
home when there is
monitoring a
between visits clear
understandin
g of both the
disease
process and
the rationale
for
management.

Frequent
blood glucose
measurement
s allow client
to recognize
the impact of
her diet and
exercise on
serum
glucose levels
and promote
tighter
control of
glucose levels
 Total gain in
the first
trimester
should be
2.5–4.5 lb,
then 0.8–0.9
lb/wk
thereafter.
Caloric
restriction
with resulting
ketonemia
may cause
fetal
damage and
inhibit
optimal
protein
utilization.

CHAPTER III: IMPLEMENTATION

A. Medical Management

1. Medications

Drug Action Administration Indication Contraindication Adverse Nsg. Res.

Name Effect
Management of Hypoglycemia. Hypoglycemi
Wosulin Wosulin- SC inj Diabetes type I & II a, edema,
30/70 is a Type 1 0.5-1 diabetes (who are hyperglycemi
mixture of iu/kg/day. Type not equally a&
insulin 2 0.3-0.6 controlled by diet ketoacidosis,
human iu/kg/day. &/or oral allergy to
regular hypoglycemic insulin,
injection agents) & lipoatrophy
30% with gestational &
isophane diabetes. For the lipodystrophy
insulin initial stabilization & insulin
human of diabetes in resistance.
suspension patients
70% w/ diabetic
providing ketoacidosis,
an hyperosmolar
intermediat nonketotic
e-acting syndrome &
insulin during periods of
with an stress eg severe
onset of infections & major
action surgery in diabetic
similar to patients.
regular
insulin (0.5
hrs).
Insulin is a
hormone
produced
by the
pancreas, a
large gland
that lies
near the
stomach.
This
hormone is
necessary
for the
body's
correct use
of food,
especially
sugar.
Diabetes
occurs
when the
pancreas
does not
make
enough
insulin to
meet the
body's
needs.

To control
diabetes,
the doctor
has to
prescribe
injections
of insulin
products to
keep blood
glucose at a
near-
normal
level. The
patient
should be
instructed
to test the
blood
and/or
urine
regularly
for glucose.
Studies
have
shown that
some
chronic
complicatio
ns of
diabetes eg,
eye, kidney
and nerve
diseases
can be
significantl
y reduced
if the blood
sugar is
maintained
as close to
normal as
possible.
Despite
diabetes,
patients
can lead an
active and
healthy life
if they will
eat a
balanced
 diet,
exercise
regularly
and take
insulin
injections
as
prescribed.
The patient
should
always
keep an
extra
supply of
insulin as
well as
spare
syringe and
needle
handy.

Oxytocin prostagland Induction or Induction or Hypertonic Uterine

in, enhancement of stimulation of uterine spasm in low
inhalation labor IV drip labor in hypotonic contraction, doses. High
anesthetics infusion 10 iu uterine inertia. mechanical doses may
eg added to 1 L Prevention & obstruction to result in
cyclopropa physiologic treatment of delivery, fetal uterine
ne or saline postpartum uterine distress. overstimulati
halothane, electrolyte soln. atony Significant on that may
sympathom For patients & hemorrhage. cephalopelvic cause fetal
imetic whom infusion Early stages of disproportion, distress,
vasoconstri of NaCl must be pregnancy as an fetal asphyxia &
ctor agent. avoided use 5% adjunctive therapy malpresentation, death, or may
dextrose soln as for the placenta previa, lead to
diluent. Initial management of placental hypertonicity,
infusion rate 1- incomplete, abruption, cord tetanic
4 mU/min (2-8 inevitable or presentation or contractions,
drops/min). missed abortion. prolapse, soft tissue
Gradually overdistension or damage or
increase at impaired rupture of the
intervals not resistance of the uterus. Rapid
<20 min, until a uterus to rupture IV bolus inj
contraction as in multiple may cause
pattern similar pregnancy, short-lasting
to that of polyhydramnios, hypotension
normal labor is grand multiparity accompanied
established. & in uterine scar. w/ flushing &
Max rate: 20 Do not use for reflex
mU/min (40 prolonged period tachycardia.
drops/min). Cae in patients w/
sarean section 5 oxytocin-resistant
iu by slow IV uterine inertia,
inj immediately severe pre-
after eclamptic
delivery. Preven toxemia or severe
tion of post- CV disorder.
partum
uterine hemorrh
age5 iu slow IV
after delivery of
the
placenta. Treat
ment of post-
partum uterine
hemorrhage 5-
10 iu IM or 5 iu
slow IV
followed in
severe cases by
IV infusion of
5-20 iu of
oxytocin in 500
mL of non-
hydrating
diluent. Missed
abortion 5 iu IM
or slowly IV. If
necessary,
follow by IV
infusion 20-40
mU/min.
Methergi Avoid Active Active Pregnancy; 1st & Common:
ne concomitan management of management of the 2nd stage of labor Headache,
t use w/ the 3rd stage of 3rd stage of & before HTN, skin
potent labor 100-200 labor 100-200 mcg crowning of the eruptions,
CYP3A mcg slow slow IV.Delivery head; severe abdominal
inhibitors IV.Delivery under general HTN, pain (caused
eg under general anesth 200 mcg preeclampsia & by uterine
macrolides, anesth 200 mcg slow IV. Uterine eclampsia; contractions).
HIV slow atony/hemorrhage occlusive Uncommon:
protease or IV. Uterine 200 mcg IM or vascular disease; Dizziness,
reverse atony/hemorrha 100-200 mcg slow sepsis. Not to be convulsions,
transcriptas ge 200 mcg IM IV. May repeat at used for induction chest pain,
e inhibitors or 100-200 mcg 2-4 hrly intervals or enhancement hypotension,
or azole slow IV. May to a max of 5 of labor. nausea,
antifungals. repeat at 2-4 doses in 24 Hypersensitivity vomiting,
Enhances hrly intervals to hr. Subinvolution, to ergot alkaloids. hyperhidrosis
vasoconstri a max of 5 lochiometra, . Rare:
ctor effects doses in 24 puerperal Bradycardia,
of triptans hr. Subinvolutio bleeding 125-250 tachycardia,
(5HT1B/1D- n, lochiometra, mcg orally or 100- palpitations,
receptor puerperal 200 mcg SC or arterial spasm
agonists), bleeding 125- IM, up to tid. (peripheral ).
sympathom 250 mcg orally Very rarely,
imetics & or 100-200 mcg hallucination
other ergot SC or IM, up to s,
alkaloids. tid. anaphylactic
Anesth eg reactions, MI,
halothane coronary
& arteriospasm,
methoxyflu thrombophle
rane may bitis, nasal
reduce the congestion,
oxytocic diarrhea,
effect of muscle
Methergin. cramp.
Reduction of
milk
secretion;
passes into
breast milk &
may in
isolated cases
affect the
child.
Morphine Morphine May be taken Chronic pain Respiratory Convulsions;
is a with or without Adult: Initially, depression, acute nausea,
phenanthre food. (May be 15-30 mg or severe asthma; vomiting, dry
ne taken w/ meals suppository every paralytic ileus; mouth,
derivative to reduce GI 4 hr, adjusted obstructive constipation;
which acts discomfort.) according to airway disease; urinary
mainly on response. acute liver retention;
the CNS disease; comatose headache,
and smooth patients; vertigo;
muscles. It increased palpitations;
binds to intracranial hypothermia;
opiate pressure; acute pruritus,
receptors in alcoholism. urticaria;
the CNS Pulmonary tachycardia,
altering oedema resulting bradycardia;
pain from a chemical blurred
perception respiratory vision;
and irritant. miosis;
response. dependency;
Analgesia, drowsiness;
euphoria lightheadedn
and ess;
dependence dizziness;
are thought sweating;
to be due to dysphoria;
its action at euphoria.
the mu-1 Potentially
receptors Fatal: Respira
while tory
respiratory depression;
depression circulatory
and failure;
inhibition hypotension;
of deepening
intestinal coma;
movements anaphylactic
are due to reactions.
action at
the mu-2
receptors.
Spinal
analgesia is
mediated
by
morphine
agonist
action at
the K
receptor.
Cough is
suppressed
by direct
action on
cough
centre.
Onset: 1 hr
(oral); 5-10
minutes
(IV); 20-60
minutes
(rectal);
50-90
minutes
(SC); 30-
60 minutes
(IM).
Duration: 4
hr.
Absorption
: Variably
absorbed
from the GI
tract (oral);
readily
absorbed
into blood
(IM/SC).
Distributio
n: Kidneys,
liver,
lungs,
spleen,
brain and
muscles
(low
concentrati
ons);
crosses the
blood-brain
barrier and
placenta;
 enters
breast milk.
Protein-
binding:
20-35%.
Metabolis
m: Hepatic
and gut by
glucuronid
ation;
extensive
first-pass
metabolism
.
Excretion:
Faeces,
urine (as
metabolites
and
unchanged
drug)
Elimination
half-life of
around 2 hr
but varies
between
individuals.

Midazola Enhance May be taken Tab Disturbances Premature infants. Rarely

m sedative with or without of sleep Myasthenia cardioresp
effects of food rhythm, insomnia gravis. adverse
neuroleptic esp difficulty in events,
s, Tab Adult ½-1 falling asleep nausea,
tranquilizer tab before either initially or vomiting,
s, retiring. IM Pre after premature headache,
antidepress med for awakening. Tab/In hiccoughs,
ants, sleep- operation Adult j Sedation in laryngospasm
inducing 10-15 mg 20-30 premed before , dyspnoea,
drugs, min before surgical or hallucination,
analgesics induction of diagnostic oversedation,
& anesth. anesth. Childn procedures, drowsiness,
Avoid alco 150-200 mcg/kg induction & ataxia, rash,
hol. Effect body maintenance of paradoxical
potentiated wt.Induction of anesth. reactions,
by erythro anesth 150-200 amnesic
mycin, keto mcg/kg body wt episodes.
 conazole, it w/ ketamine IM
raconazole, (4-8 mg/kg
diltiazem,v body
erapamil, ci wt). IV Sedation
metidine & in intervention
hepatic carried out
enzymes under local
inhibitors anesth Adult
(CYP450 <60 yr 2.5 mg
IIIA). IV, 5-10 min
before start of
the operation,
alone or in
combination w/
IV administered
anticholinergics
.

2. Treatment

Treatment Description Indication Nursing resposibilities

D5LR Each 100 mL of 5% This solution is

Dextrose in Lactated indicated for use in
Ringer's Injection adults and pediatric
contains: patients as a source of
Hydrous Dextrose electrolytes, calories
USP 5 g; Sodium and water for
Chloride USP 0.6 g hydration.
Sodium Lactate 0.31
g; Potassium Chloride
USP 0.03 g
Calcium Chloride
Dihydrate USP 0.02 g
Water for Injection
USP qs

pH adjusted with
Hydrochloric Acid NF
pH: 4.6 (4.0–6.0)
Calories per liter: 170
Calculated
Osmolarity: 530
mOsmol/liter,
 hypertonic

Concentration of
Electrolytes
(mEq/liter): Sodium
130 Potassium 4
Calcium
3 Chloride
112 Lactate
(CH3CH(OH)COO−)
28

5% Dextrose in
Lactated Ringer's
Injection is sterile,
nonpyrogenic and
contains no
bacteriostatic or
antimicrobial agents.
This product is
intended for
intravenous
administration.

3. Diet

 300 calories per day

 Eat rich in carbohydrates

 Eat rich in protein, less fat

4. Activity and Excersice

 Walking

 Swimming
CHAPTER IV: EVALUATION

A. Discharge Planning Instruction

M- Take medicine as prescribe by the doctor

E- Walk every morning for about 30 mins, for exercise.

T-

H- Clean the wound every day, if soak change the dressing immediately to prevent
infection

O- Follow up check up after 1 week for the check up of the baby and as well as for the

D- Eat high in protein to help in wound healing.

S- Watch out for signs and symptoms of infection. Swelling, pain, redness.