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).

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Nursing Care Plan Gestational Diabetes Mellitus | Risk for Maternal Injury

This nursing care plan for gestational diabetes mellitus is designed for the nursing diagnosis of risk for maternal injury may be related to changes in diabetic control, abnormal blood profile/anemia, tissue hypoxia, altered immune response.

Desired Outcomes: Remain normotensive. Maintain normoglycemia, free of signs/symptoms of ketoacidosis. Be free of complications (e.g., infection, placental separation).

Nursing intervention with rationale:
1. Note White’s classification for diabetes. Assess degree of diabetic control (Pederson’s criteria).
Rationale: Client classified as D, E, or F is at higher risk for complications, as is client with PBSP.

2. Assess client for vaginal bleeding and abdominal tenderness.
Rationale: Vascular changes associated with diabetes place client at risk for abruptio placentae.


3. Monitor for signs and symptoms of preterm labor.
Rationale: Overdistension of uterus caused by macrosomia or hydramnios may predispose client to early labor.

4. Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day.
Rationale: Allows greater accuracy than urine testing because renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels.

5. Request that client check urine for ketones daily.
Rationale: Ketonuria indicates presence of starvation state, which may negatively affect the developing fetus.

6. Identify for episodes of hyperglycemia.
Rationale: Diet/insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements often double (may quadruple in third trimester).

7. Assess for and/or monitor presence of edema.
Rationale: Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of the vascular changes before pregnancy influences the extent and time of onset of PIH.

8. Determine fundal height; check for edema of extremities and dyspnea.
Rationale: Hydramnios occurs in 6%–25% of pregnant diabetic clients; may possibly be associated with increased fetal contribution to amniotic fluid, because hyperglycemia increases fetal urine output.

9. Instruct in insulin administration, as required. Ensure that client is adept at self-administration, either subcutaneously (SC) or with pump, depending on client’s needs or care setting.
Rationale: Insulin requirements are decreased in first trimester, then double and may even quadruple as the pregnancy progresses. Highly motivated and capable clients may do well with a continuous subcutaneous insulin infusion pump to more naturally meet insulin needs.

10. Start IV therapy with 5% dextrose; administer glucagon SC if client is hospitalized with insulin shock and is unconscious. Follow with protein-containing fluids/foods, e.g., 8 oz skim milk when client is able to swallow.
Rationale: Glucagon is a naturally occurring substance that acts on liver glycogen and converts it to glucose, which corrects hypoglycemic state. (Note: Hypertonic glucose [D50] administered IV may have negative effects on fetal brain tissue because of its hypertonic action.) Protein helps sustain normoglycemia over a longer period of time.

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