Nursing Care Plan Gestational Diabetes Mellitus | Risk for Fetal Injury

Nursing Care Plan for Gestational Diabetes Mellitus

Nursing Diagnosis: Risk for fetal injury related to elevated maternal serum glucose levels, changes in circulation.

Desired Outcomes: Display normally reactive NST and negative OCT and/or CST. Be full-term, with size appropriate for gestational age.

Nursing intervention and rationale:
1. Determine White’s classification for diabetes; explain classification and significance to client/couple.
Rationale: Fetus is at less risk if White’s classification is A, B, or C. The client with classification D, E, or F who develops kidney or acidotic problems or PIH is at high risk. As a means of determining prognosis for perinatal outcome, White’s classification has been used in conjunction with (1) evaluation of diabetic control or lack of control and (2) presence or absence of Pederson’s prognostically bad signs of pregnancy (PBSP), which include acidosis, mild/severe toxemia, and pyelonephritis. The National Diabetes Data Group Classification, which includes diabetes mellitus (type I, insulin-dependent; type II, non–insulin-dependent), impaired glucose tolerance, and gestational diabetes mellitus, has not yet had prognostic significance in predicting perinatal outcomes.

2. Note client’s diabetic control before conception.
Rationale: Strict control (normal HbA1c levels) before conception helps reduce the risk of fetal mortality and congenital anomalies.

3. Assess fetal movement and FHR each visit as indicated. Encourage client to periodically count/record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on.
Rationale: Fetal movement and FHR may be negatively affected when placental insufficiency and maternal ketosis occur.

4. Monitor fundal height each visit.
Rationale: Useful in identifying abnormal growth pattern (macrosomia or IUGR, small or large for gestational age [SGA/LGA]).

5. Monitor urine for ketones. Note fruity breath.
Rationale: Irreparable CNS damage or fetal death can occur as result of maternal ketonemia, especially in the third trimester.

6. Provide information and reinforce procedure for home blood glucose monitoring and diabetic management.
Rationale: Decreased fetal/newborn mortality and morbidity complications and congenital 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 of fetal hypoglycemia or hyperglycemia.

7. Monitor for signs of pregnancy-induced hypertension (PIH) (edema, proteinuria, increased blood pressure).
Rationale: About 12%–13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.

8. Provide information about possible effect of diabetes on fetal growth and development.
Rationale: Helps client to make informed decisions about managing regimen and may increase cooperation.

9. Review procedure and rationale for amniocentesis using L/S ratio and presence of PG.
Rationale: When maternal/placental functioning is impaired before term, fetal lung maturity is criterion used to determine whether survival is possible. Hyperinsulinemia inhibits and interferes with surfactant production; therefore, in the diabetic client, testing for presence of PG is more accurate than using L/S ratio.

10. Assist with preparation for delivery of fetus vaginally or surgically if test results indicate placental aging and insufficiency.
Rationale: Helps ensure positive outcome for neonate. Incidence of stillbirths increases significantly with gestation more than 36 wk. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).