A Case Presentation of an Adult with Gestational Diabetes Mellitus final

Document Content and Description Below

Republic of the Philippines CENTRAL MINDANAO UNIVERSITY COLLEGE OF NURSING University Town, Musuan, Maramag, Bukidnon E-mail: [email protected] A Case Presentation of an Adult with Gestationa... l Diabetes Mellitus A Case Study Presented to the Faculty of the College of Nursing, Central Mindanao University In Partial Fulfillment of the Requirements in NCM 66.1: MATERNAL AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) BSN2- B GROUP 2 Santos, Lea Marie Khristine, I. Orate, Eula Marie Victoria, V. Sabornido, Jastine Nicole, B. Dominguez, Ann Mariz, U. Gauran, Rogelen May, A. Tulang, Ana Domini, B. Manlangit, Kint, D. Balcos, Andrea, A. Andrada, Leah, S. Chu, Aubrey Mia CLINICAL INSTRUCTORS Itable, Emvie Loyd, RN Postrano, Fave Danielle, RN Postrano, Lhara Mae, RN Olila, Katreena Ness, RN MARCH 2021Acknowledgement The researchers would like to extend their deepest gratitude to the people who contributed and supported this study to be promising and fruitful. To their Clinical instructor, Ms. Fave Danielle V. Postrano, RN, for her valuable time and effort in suggesting, corrections, and inputs for the development of the case study; To the Clinical Instructors of Central Mindanao University College of Nursing for inputs, comments, and suggestions of the case study; And to the Almighty God for the blessing and giving the researchers the strength to conduct and finish the paper. Page 2 of 59Researchers Table of Contents Page PRELIMINARIES Acknowledgement 2 Table of Contents 3 I. INTRODUCTION 4 II. HEALTH HISTORY 8 III. PHYSICAL ASSESSMENT 10 IV. ANATOMY AND PHYSIOLOGY 12 V. CONCEPT MAP 18 VI. LABORATORY AND DIAGNOSTIC TESTS 27 VII. PHARMACOLOGIC STUDIES 34 VIII. NURSING CARE PLANS 47 IX. REFERENCES 54 Page 3 of 59Introduction Pregnancy has been recognized for a long time as a diabetic state in which insulin sensitivity decreases with advanced gestational age— those who cannot meet the increased demand develop diabetes. Diabetes is the most common medical complication of pregnancy. A 40-year-old multigravida woman named Julia Salazar is in her third pregnancy. She is at the clinic for prenatal care at the 30th-week gestation at the nearest primary hospital. Her weight is 200 pounds, indicating obesity on her ideal weight, and her blood pressure is 140/90 mmHg. Her family history reveals that her mother has type 2 diabetes mellitus. Results show that she has 3+ glycosuria and was diagnosed with Gestational Diabetes Mellitus. Gestational diabetes mellitus (GDM) happens when a placenta hormone prevents the body from using insulin effectively. Glucose accumulates in the blood instead of being absorbed by cells. Unlike type 1 diabetes, it is gestational diabetes not caused by a lack of insulin. It is caused by other hormones produced during pregnancy that can make insulin less effective. A condition referred to as insulin resistance. Women with GDM have decreased quality of life and increased risks of cesarean section, gestational hypertension, preeclampsia, and type 2 diabetes. Evidence showed that GDM poses a threat to adverse maternal and prenatal outcomes due to maternal Hyperglycemia (JIMÉNEZ‐ MOLEÓN, 2000). According to the study of Keshavarz 2005, hyperglycemia develops during pregnancy due to the secretion of placental hormones, which causes resistance to insulin. Gestational diabetes occurs in about 14% of pregnant women and increases their risk for hypertensive disorders. Women who are considered at high risk of GDM and who must undergo blood glucose tests at their first prenatal visit are those who have marked obesity, a personal history of GDM, glycosuria, or a strong family history of diabetes. Figure 1. Clinical Pathway Page 4 of 59Preferred screening and diagnostic 2-step from Diabetes Canada's 2018 guidelines is endorsed. All pregnant women should be offered screening between 24-28 weeks using a standardized non-fasting 50-g glucose challenge screening test (GCT) with plasma glucose (PG) measured 1 hour later. If the value is <7.8 mmol/L, no further testing is required. If the value of the GCT is 7.8–11.0, a 3-hour 100-g oral glucose tolerance test with fasting PG (FPG), 1-hour PG, 2-hour PG, and 3-hour PG should be performed. Gestational diabetes mellitus is diagnosed if one value is met or exceeded: (1) FPG ≥5.3 mmol/L (2) 1-hour PG ≥10.0 mmol/L (3) 2-hour PG ≥8.6 mmol/L (3) 3hour ≥7.8. If the value of the GCT is ≥11.1 mmol/L, gestational diabetes mellitus is diagnosed. The "alternative 1-step diagnostic" approach from Diabetes Canada's 2018 guidelines is acceptable. In this strategy, pregnant women should be offered testing between 24-28 weeks using a standardized 3-hour 100-g oral glucose tolerance test with fasting plasma glucose (FPG), 1-hour plasma glucose (PG), and 3-hour PG. Gestational diabetes mellitus is diagnosed if one value is met or exceeded: (1) FPG ≥5.3 mmol/L (2) 1-h PG ≥10.0 mmol/L (3) 2-h PG ≥8.6 mmol/L (3) 3hour ≥7.8. Statistics Global The study of Hood et al. (2013) indicates that the prevalence of high blood glucose (hyperglycemia) in pregnant women increases rapidly with age and is the highest in women over 45 years of age. An estimated 223 million women (20 to 79 years old) live with diabetes. This number expected to rise to 343 million by 2045. Twenty million or 16% of live births had some form of hyperglycemia during pregnancy. An estimated 84% was due to gestational diabetes. Like type 2 diabetes mellitus, its occurrence is increasing, reaching a global prevalence of 15% to 20% (Hu et al., 2018), while locally in the Philippines, it was reported to be at 14% (Litonjua et al., 1996). It carries the risk of adverse maternal, fetal, and neonatal outcomes, including increased birth weight above the 90th percentile and a higher incidence of neonatal hypoglycemia and primary cesarean section, demonstrated in the large-scale multinational cohort study called The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. It is estimated that GDM affects approximately 7-10% of all pregnancies worldwide (Xiong et al., 2001). However, prevalence is difficult to estimate since rates differ among studies due to the majority Page 5 of 59of different risk factors in the population, such as maternal age and BMI, the prevalence of diabetes, and ethnicity among women. National According to the Department of Health (DOH), the Philippines ' diabetes accounted for 6% (6%) of the total death of all ages. In 2017, out of more than 60 million Filipinos, almost four (4) million adult Filipinos have diabetes, or the equivalent of 6% (6%) of the total population. The university's annual medical and physical examination results in 2016 and 2017 showed that the number of employees with diabetes increased from 10% (10%) to 14% (14%) in a single year. Gestational diabetes (GMD) is predominant in the Philippines. Data published by the Asian Federation of Endocrine Societies Study Group on Diabetes in Pregnancy (ASGODIP) showed that the Philippines have a prevalence of GDM of 14% in 1203 pregnancies interviewed (Litonjua et al., 1996). Due to this high prevalence rate, the Unite for Diabetes Clinical Practice Guideline (CPG) recommends universal GDM screening for the Filipino population. Data from ASGODIP revealed that around 40.4% of high-risk women were positive for GDM when screening was performed after the 26th week of pregnancy (Litonjua et al., 1996). Although the cases of diabetes increase at both the regional and global levels, interventions that promote a healthy diet, physical activity, and weight loss can help prevent diabetes. A healthy diet for those diagnosed with diabetes or high blood sugars includes low-calorie intake, replacement of saturated fats with unsaturated fats or fiber-rich foods, and avoidance of sugar, tobacco, and alcohol. Objectives General objectives The case study seeks to demonstrate the student’s knowledge regarding the general health and disease condition of a patient with diagnosis, its disease process, possible complications, treatment plan, medical and nursing intervention. Specifically, this study aims to: 1. Systematically present the data pertinent to the case being gathered; 2. Present accurate personal and clinical information of the client, which will serve as the baseline information; 3. Provide an evidence-based overview of the case study; 4. Present accurate personal and clinical information of the client, which will serve as the baseline information; Page 6 of 595. Formulate a narrative health assessment including the findings that is specific, measurable, attainable, realistic, and timebounded; 6. Understand the role of drug therapy in managing the client’s related to the patient’s diagnosis; 7. Recognize the contributing factors associated with the development of the diagnosis; 8. Understand the pathophysiology and etiology of GDM; and 9. Efficiently provide an appropriate and proper nursing diagnosis in line with the client’s medical condition and skillfully formulate nursing care plans for the problems identified. Page 7 of 59Health History A. Biographical Data Name : Julia Salazar Height: 5’5 Age : 40 y/o Weight: 200lbs Sex : Female Blood Type: AB+ Civil Status : Married Vital Signs: Source of Income : Husband’s income from farming BP: 140/90 RR: 25cpm Occupation : House help PR: 102bpm Dx : Tachycardic & hypothermic Temp: 35.4°C B. Chief Complaint “Magpa prenatal raman unta ko pero nikalit lang ug kalian akong paminaw, nalipong ko ug kalit” C. OB History LMP : 06/15/2020 G : 3 EDD : 03/22/2021 P : 1 AOG : 30W (T : 1 Age of Menarche : 14y/o P : 0 Menstrual Cycle : 28-30 days A : 1 Duration : 3-5 days L) : 1 G1 : Blighted ovum @6W 5 years ago G2 : F, @40W of gestation w/ good APGAR score via NSVD last June 2019. The infant is doing well. G3 : Currently @30W of gestation, EDD: 03/22/2021 D. Antenatal History Julia has no other reported diseases. She reported that she was able to complete all of her immunization and she received a dose of tetanus toxoid from her in this pregnancy last December 2020. She is due for her TT2 dose this month. Page 8 of 59E. Family Genogram F. General Health History Julia Salazar is currently at her 30th week of gestation and when she was about to visit the nearest primary hospital for her prenatal check-up, she suddenly felt sick and dizzy. “Magpa prenatal raman unta ko pero nikalit lang ug kalian akong paminaw, nalipong ko ug kalit,” verbalized by Julia. Her profile showed that she is a 40-year-old multigravida woman, married, and works as a house help. Her husband’s source of income is farming. Her family’s health history revealed that her mother has type 2 diabetes mellitus and on her paternal side has hypertension and asthma. Upon the physical examination, her results disclosed her height as she stands 5ft and 5in (165cm) and weighs 200lbs (90.72kg). Her blood pressure runs 140/90mmHg, respiratory rate of 25cpm, pulse rate of 102bpm and temperature of 35.4°C. Her blood type is AB+. The patient is hypothermic and tachycardic. Julia’s past obstetric history includes her first pregnancy with blighted ovum at 6 weeks 5 years ago. Her second pregnancy is a female infant at 40-week gestation, with good APGAR score delivered via NSVD last June 2019, and reportedly the child is doing well. She’s currently at 30 weeks of her third pregnancy and she’s expected to give birth on March 22, 2021. She had her menarche at 14 years of age. She had a regular menstruation which falls from 28-30-day cycle lasting 3-5 days, in moderate to heavy flow. Her LMP was on June 15, 2020. Page 9 of 59She has no other reported diseases. She reported that she was able to complete all of her immunization and she received a dose of tetanus toxoid from her in this pregnancy last December 2020. She is due for her TT2 dose this month. Physical Assessment Date: February 20, 2021 Time: 7:00 AM SYSTEM/AREA FINDINGS IMPLICATIONS VITAL SIGNS BLOOD PRESSURE BP: 140/90 mmHg High blood pressure is twice more likely to strike a person with diabetes than a person without diabetes. If left untreated, high blood pressure can lead to heart disease and stroke. TEMPERATURE Temp: 35.4 degrees Celsius (hypothermia) Hypothermia is more frequent among patients with diabetes. Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes. PULSE RATE PR: 102 bpm (tachycardia) Conditions such as anemia and diabetes can put a strain on the heart or damages heart tissues and can increase your risk of tachycardia. RESPIRATORY RATE RR: 25 cpm Respiratory rate with 25 cpm could point to tachycardia, anxiety or other underlying conditions. WEIGHT Weight: 200lbs (Obese) Obesity increases risk of other diseases and health problems, such as heart disease, diabetes, and high blood pressure. INTEGUMENTARY SKIN Fair color complexion. Palmar erythema noted. Palmar erythema is a sign of an underlying medical concern. NAILS Capillary refill actively returns to its normal color in less than 2 seconds. Normal findings. Normal capillary refill time is usually less than 2 seconds. SKULL Rounded, normocephalic and symmetrical. Normal findings. The skull sounded, normocephalic and symmetrical, smooth and has uniform consistency. EYES AND VISION PALPEBRAL Pallor is noted. Pallor is caused by an Page 10 of 59CONJUNCTIVA illness, emotional shock or stress, stimulant use, or anemia, and a result of a reduced amount of oxyhaemoglobin. PUPILS Black and equal in size. Normal findings. Pupils must be round and equal in size. NECK Neck veins are visible, and no enlargement is noted. Neck muscles are equal in size, no palpable nodules. Normal findings. There should be no enlargement of thyroids and no palpable nodules. NOSE No presence of discharge or flaring, it is clear. Normal findings. It shows absence of infection or difficulty in breathing. FACE Mask of pregnancy is visible Normal findings. Mask of pregnancy (melalsma) is normal during pregnancy. It is caused by a melanocyte-stimulating hormone. ABDOMEN Globular and a faint lineanigra and stretch marks are still visibly noted. Abdomen has audible bowel sounds. Normal findings. Linea nigra and stretch marks are results of hormonal influences during pregnancy. BREASTS Symmetric, no dimpling and discoloration noted, nipples and areolas are dark in color, according to the patient her breast seems to appear larger and firmer. Normal findings. During pregnancy your nipples and areolae may become darker and larger, and then return to their normal color later on. THORAX AND LUNGS LUNGS Lungs have normal breath sounds without dyspnea. Clear to auscultation in all lobes. Normal findings. Lungs should have a normal breath sounds with the absence of dyspnea. POSTERIOR THORAX Chest is symmetrical. Normal findings. The normal chest is symmetrical. BREATHING Patient reported that once in a while, difficulty of breathing is experienced especially when she is lying flat on bed and doing household activity. Shortness of breath can be a sign of a serious disease. LOWER EXTREMITIES No edema was noted. Good range of motion, sometimes felt leg pain due to prolong standing at work and some varicosities were noted. Normal findings. Dependent edema is normal during third trimester. Varicose veins may also appear. Page 11 of 59MUSCULOSKELETAL No pelvic girdle pain or back pain was noted. Normal findings. Pelvic girdle pain or back pain can be experienced during pregnancy. RECTUM AND ANUS The patient is constipated, hemorrhoids are present. Normal findings. Haemorrhoids usually get bigger and more uncomfortable during pregnancy. URINE TEST Urine dipstick result shows 3+ glycosuria and negative ketones. Glycosuria is a common symptom of both type 1 diabetes and type 2 diabetes. Glycosuria can lead to excessive water loss into urine with resultant dehydration. Anatomy and Physiology THE ENDOCRINE SYSTEM The organs composing the endocrine system are called glands; they are small and unimpressive compared to the other organs present in the human body's different organ systems. Though the glands are small in size, their function, however, impacts the body significantly. The endocrine system is responsible for the body's water equilibrium, heart rate and blood pressure management, immune system control, growth, metabolism, and tissue maturation, reproductive function controls, blood glucose regulation, uterine contraction and milk release, ion management, second messenger system, and direct gene activation. Page 12 of 59HYPOTHALAMUS The hypothalamus is a component of the nervous system and is one of the significant endocrine glands - it secretes several hormones needed by the body to operate appropriately. The hypothalamus is an essential part of the autonomic nervous system and an endocrine control center of the brain situated inferior to the thalamus. PITUITARY GLAND The pituitary gland is thin and oval, approximately the size of a pea. It is situated behind the nose, close to the underside of the brain. It is attached to the hypothalamus by a stalk-like structure. It consists of two functional lobes: the anterior pituitary, sometimes referred to as the glandular tissue and the posterior pituitary, also called the nervous tissue. The pituitary gland's anterior lobe consists of many different cell types that generate and expel various hormones. The posterior lobe of the pituitary gland excretes hormones as well. These hormones are usually formed in the hypothalamus and processed in the posterior lobe before they are produced. THYROID GLAND The thyroid gland is placed at the bottom of the throat, where it can be effortlessly felt and palpated during a physical examination. It has two lobes connected by a mass or isthmus. The internal composition of a thyroid gland comprises hollow structures coined as follicles, which stores sticky colloidal material. The thyroid- produce hormone is known as the body’s primary metabolic hormone. These major metabolic hormones are specifically called thyroxine (T4) and triiodothyronine (T3). Both these hormones are active and are iodine-containing. Thyroxine is the main hormone excreted by the thyroid follicles, while triiodothyronine is formed at the target tissues upon conversion of thyroxine into triiodothyronine. Page 13 of 59 The hormones produced by the thyroid controls the rate at which glucose is being digested and is converted to body heat and chemical energy, used for cell growth and repair. PARATHYROID The parathyroid glands are four tiny masses of epithelial tissue that are found in the connective tissue capsule on the back of the thyroid. They are parathyroid glands, and they emit parathyroid or parathormone. Parathyroid hormone is an essential blood calcium regulator. The hormone is produced regarding insufficient calcium levels in the blood, which has the effect of increasing its levels. ADRENAL GLAND Adrenal glands, also identified as suprarenal glands, are small, triangular glands found on the top of both kidneys. Adrenal glands manufacture hormones that help control the metabolism, immune response, blood pressure level, response to stress, and other vital functions. Human adrenal glands are made of two parts; the cortex and the medulla, each of which is important for creating various hormones used in the body. PANCREAS The pancreas is an elongated, tapered organ situated around the back of the stomach. The right side of the organ, called the head, is the most comprehensive section of the organ and sits in the duodenum curve, the first Page 14 of 59section of the small intestine. The tapered left-hand stretches gently upward—called the pancreas' body—and stops at the spleen— referred to as the tail. The pancreas comprises two kinds of glands: the exocrine gland, which excretes the enzymes used for digestion, and the endocrine gland consists of the Islets of Langerhans, which expels hormones into the blood. Enzymes produced by the exocrine gland in the pancreas tend to break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes pass down the pancreatic duct to the bile duct in an inactive state. The enzymes become active as it enters the duodenum. The exocrine tissue also secretes bicarbonate to neutralize digestive acids in the duodenum. The principal hormone produced by the endocrine gland in the pancreas is insulin and glucagon, which control blood glucose levels and somatostatin, which inhibit insulin and glucagon release. PINEAL GLAND The pineal gland is also termed the pineal body. It is found below the corpus callosum that is located in the middle part of the brain. The pineal gland is responsible for bringing about the melatonin hormone— the hormone levels of melatonin change throughout the day and night. The body's melatonin level is at its peak levels during the night, which then triggers sleepiness. THYMUS GLAND The thymus is found in the upper part of the chest and contains white blood cells that combat infection and kill defective cells. This gland appears to be more prominent in infants and decreases in size as the individual matures. The thymus gland produces a hormone called thymosin that tends to be necessary for the average production of a specific group of white blood cells (T-lymphocytes or T-cells) and the body’s immune response. FEMALE GONAD Page 15 of 59The female gonads are referred to as “ovaries,” which are found on both sides of the uterus in the pelvic cavity. Aside from producing female sex hormones, the ovaries also excrete a couple of hormones called estrogen and progesterone. The estrogen is in charge of the growth and maturation of female sex characteristics upon puberty. Estrogen functions with progesterone in stimulating breast development and preparing the uterine lining for menstruation. Progesterone aids in preparing the uterus during pregnancy to avoid miscarriage and prepares the breasts for lactose formation. PLACENTA The placenta is not a permanent organ; it is only formed during gestation and serves as the fetus’ system for respiration, excretory, and nutrition delivery. It also induces proteins and steroid hormones that aid in pregnancy and preparation for delivery. Gestational diabetes mellitus (GDM) is a complication in which the placenta's hormone stops the body from taking insulin efficiently. Glucose ends up in the blood instead of being ingested by the cells. Dissimilar from type 1 diabetes, gestational diabetes is not caused by insulin deficiency but by other hormones released during conception that can cause insulin to be less effective- a condition termed insulin resistance. Gestational diabetes can be diagnosed during the second trimester- around 24 to 28 weeks. Gestational diabetes is essentially similar to diabetes mellitus type 2, in which hyperglycemia and insulin problems can be experienced. The pancreas plays a vital role in discussing gestational diabetes mellitus since it is the gland responsible for producing insulin. During pregnancy, there is what we call Beta-cell hyperplasia. B-cell is present in the pancreas, which is mainly the cell that produces insulin. And Bcell hyperplasia means an increase in the number of b-cells. When a pregnant woman takes in food, her blood glucose level increases- this is called hyperglycemia. Hyperglycemia stimulates the bcells found in the pancreas to release insulin into the circulation. The released insulin will circulate the body while targeting cells; as this happens, the cells take up the glucose found in the bloodstream to Page 16 of 59reduce blood glucose levels present in the maternal tissue. This process aside, there is still enough glucose left to aid the fetus’ growth and development in the womb. During pregnancy, insulin sensitivity decreases- effects of insulin in maternal tissue are reduced, resulting in more glucose in the blood. Due to a decrease in insulin sensitivity in the maternal tissue, b-cell hyperplasia occurs, resulting from the fetal hormones signaling the maternal body to feed it. In gestational diabetes, instead of having a slight decrease in insulin sensitivity in the maternal tissue, there is a lot of insulin sensitivity decrease, thus resulting in insulin resistance. Blood glucose is not taken up by the maternal tissue as efficiently, resulting in hyperglycemia- which also travels to the fetal circulation. Hyperglycemia in the fetal tissue results in an increase in fetal blood glucose level. Which then triggers the fetal pancreas to produce its insulin. As a result, the fetal tissue will take up more available insulin, causing the fetus to increase in size, leading to macrosomia. Maternal hyperglycemia causes the maternal tissue to experience and show symptoms of diabetes. Often, these symptoms are called the 3 P’s: (1) Polyuria- which is the frequent passage of large urine volumes. (2) Polyphagia- extreme hunger, and (3) Polydipsia- excessive thirst. A significant decrease in insulin sensitivity and the development of insulin resistance in gestational diabetes is thought to be caused by the placental hormones being produced during pregnancy. These hormones are the growth hormones, corticotropin-releasing hormones (CRH), and placental lactogen. Placental hormones cause a decrease in insulin sensitivity to signal the mother to feed the fetus with more glucose. Page 17 of 59Page 18 of 59Concept Map (Etiology, Pathophysiology, Symptomatology & Prognosis) A. Schematic Diagram Page 19 of 59 Biographical Data Pt. Julia is a 40-year-old patient G3 P1 30 weeks AOG Etiology The glomerular filtration of glucose is increased, and the glomerular excretion threshold is lowered, causing slight glycosuria. The rate of insulin secretion is increased and the fasting blood sugar level is lowered Predisposing Factors Age Family History of Diabetes Mellitus Ethnicity Hypertension in current pregnancy Insulin-resistant conditions History of stillbirth or spontaneous abortion Fetal anomalies in previous pregnancy Precipitating Factors Obesity Sedentary Lifestyle Diet Glycosuria High risk for pregnancy induced glucose tolerance Pancreatic beta cells work overtime to keep up with the increasing insulin demands Normal metabolic changes during pregnancy Symptomatology Obesity and Polyphagia Diagnostic Test BMI CalculationPage 20 of 59 Pancreatic beta cells “tire out” and are unable to keep up with insulin demands High fetal demands after 15 weeks gestation Placenta releases hormones that are diabetogenic (Growth hormone, human placental lactogen, progesterone, corticotropin releasing hormone) Increase in carbohydrate intake Increase in insulin requirements High insulin resistance Symptomatology Obesity and Polyphagia Diagnostic Test BMI Calculation Plasma glucose rises Medical Management Diet Exercise Lifestyle changes Nursing Diagnosis Obesity related to high frequency of restaurant or fried food Gestational Diabetes Mellitus Symptomatolo gy Fatigue Diagnostic Test None Medical Management Advise client to rest Pharmacological Management Oral antihyperglycemic agents such as metformin and glyburide Nursing Diagnosis Fatigue r/t decreased metabolic energy production PrognosisB. Narrative Discussion a. ETIOLOGY Julia is a 40-year-old pregnant woman. Gravida 3, preterm 1 and is at 30th-week gestation. She is diagnosed with Gestational Diabetes Mellitus (GDM). GDM is a disease in which the placenta produces a hormone that prevents the body from efficiently utilizing insulin. Instead of being consumed by the cells, glucose builds up in the blood. It is a serious pregnancy complication, in which women without previously diagnosed diabetes develop chronic hyperglycemia during gestation. In most cases, this hyperglycemia is the result of impaired glucose tolerance due to pancreatic β-cell dysfunction on a background of chronic insulin resistance. The glomerular filtration of glucose is elevated, and the glomerular excretion threshold is lowered that causes slight glycosuria. Glycosuria defines the presence of reducing sugars in the urine, such as glucose, galactose, lactose, fructose, etc. This is typically caused by an underlying condition that affects your blood sugar level, such as diabetes. The rate of insulin secretion is increased, and the fasting blood sugar level is lowered. The predisposing factors are composed of the patient’s age, Family History of Diabetes Mellitus, Ethnicity, Hypertension in the current pregnancy, Insulin-resistant conditions, and obesity. Nevertheless, the precipitating factors are composed of the patient’s Obesity, Sedentary lifestyle, Diet, and Glycosuria. Predisposing Factors Prese nt Abse nt Implication Age / Pregnant women over the age of 25 are more likely to develop gestational diabetes than younger women. Family History of Diabetes Mellitus / People with a moderate to high family risk of diabetes were more likely than those with a low risk to confirm a diabetes diagnosis. Ethnicity / Asian and Filipina women had a prevalence of GDM of 9.9 and 8.5%. It was relatively high than other ethnic groups. Hypertension in current pregnancy / Gestational diabetes increases the risk of high blood pressure and preeclampsia, a severe pregnancy complication that causes high blood pressure and other Page 21 of 59 Symptomatolo gy Fatigue Diagnostic Test None Symptomatolo gy Polydipsia, Polyuria, and Glycosuria, Diagnostic Test Urinalysis Symptomatolo gy Vaginal yeast infection Diagnostic Test Urinalysis Medical Management Advise client to rest Pharmacological Management Oral antihyperglycemic agents such as metformin and glyburide Nursing Diagnosis Fatigue r/t decreased metabolic energy production Pharmacological Management Treatment with antifungal medications (e.g. miconazole) Nursing Diagnosis Risk for infection r/t yeast colonization in the vagina Pharmacological Management Initiation of insulin Nursing Diagnosis Deficient fluid volume related to compromised endocrine regulatory mechanism 00 If Treated: Normoglycemia will usually occur after birth and mother is at risk of nongestational diabetes within 5 to 16 years after the index pregnancy. However, a study by Langer, et. al revealed that 18% of those with treated GDM still had adverse neonatal outcome such as stillbirth, neonatal macrosomia/LGA, neonatal hypoglycemia, erythrocytosis, and hyperbilirubinemia. If left untreated: Mother will have increased incidence of Caesarean section and gestational hypertension. Study by Langer, et. al revealed that 58% of the respondents with untreated GDM had a higher risk of adverse neonatal outcome such as stillbirth, neonatal macrosomia/LGA, neonatal hypoglycemia, erythrocytosis, and hyperbilirubinemia.symptoms that can endanger both the mother and the baby's lives. Insulin-resistant conditions (Polycistic Ovary Syndrome or PCOS) / This was not seen in the patient. Women with PCOS have a higher risk of gestational diabetes mellitus than women without PCOS. Both gestational diabetes mellitus and polycystic ovary syndrome have negative effects on pregnant women. Preeclampsia, pregnancy-induced hypertension, and neonatal hypoglycemia are all linked to each other, increasing the risk of preeclampsia, pregnancy-induced hypertension, and neonatal hypoglycemia. Fetal anomalies in previous pregnancy / The patient experienced fetal anomalies in her first pregnancy. There is about a 50 percent risk of gestational diabetes coming back for a second pregnancy. In women who had it in a prior pregnancy, we want to screen them earlier than usual because of the higher risk. Precipitating Factors Prese nt Abse nt Implication Obesity / Obese women are even more likely to develop the'metabolic syndrome of pregnancy.' They are more likely to develop glucose sensitivity (GDM). Sedentary lifestyle / Lack of physical activity raises the risk of preterm birth and low birth weight the weight of the baby at birth. In addition, exercising is one way to reduce blood glucose levels. Our muscles take in more glucose as we exercise. When this effect wears off, our muscles stay insulin-sensitive for a while longer. Diet / In gestational diabetes it is important to keep your blood sugar levels in check, you will need to keep track of your carbohydrate intake. This will involve limiting the sugary food consumption in your diet. Glycosuria / Glucose can be found in the urine of up to half of pregnant women at some stage. Glucose in the Page 22 of 59urine could indicate that a woman is suffering from gestational diabetes. b. PATHOPHYSIOLOGY Controlling the balance between insulin and blood glucose levels to avoid hyperglycemia or hypoglycemia is the primary concern for any woman with these disorders. Both conditions are risky during pregnancy, not just because of the long-term impact on the woman's health, but also because normal fetal development is jeopardized. Babies born to mothers who have uncontrolled diabetes are five times more likely to be born big for gestational age or with birth defects. Previously, gestational diabetes mellitus (GDM) was defined as any degree of glucose intolerance that begins or is first recognized during pregnancy. Imprecision hampered the definition. Type diabetes has been diagnosed in women diagnosed with diabetes in the first trimester. GDM is a type of diabetes that is diagnosed in the second or third trimester of pregnancy but is not overt. Insulin requirements rise during pregnancy due to the presence of insulin antagonists like human placental lactogen or chorionic somatomammotropin, as well as cortisol, which promotes lipolysis and lowers glucose consumption. GDM is becoming more popular all over the world. Chronic insulin resistance and B-cell dysfunction are two major metabolic disorders currently linked to the pathogenesis of GDM, but the cellular mechanisms involved are unknown. B-cells' main job is to store and secrete insulin in response to a glucose load. B-cell dysfunction occurs when -cells lose their ability to properly sense blood glucose concentrations or release enough insulin in response. Long-term, excessive insulin output in response to chronic fuel excess is thought to trigger B-cell dysfunction. The exact mechanisms underlying -cell dysfunction, on the other hand, can be varied and complex. Effects can occur at any point in the process, including proinsulin synthesis, post-translational modifications, granule storage, Page 23 of 59blood glucose sensing, and the complex machinery that underpins granule exocytosis. Insulin sensitivity is an essential metabolic adaptation. Insulin sensitivity changes during pregnancy, depending on the needs of the mother. Insulin sensitivity rises during early pregnancy, encouraging glucose absorption into adipose stores in preparation for the energy demands of later pregnancy. However, as the pregnancy progresses, a release of local and placental hormones, such as estrogen, progesterone, leptin, cortisol, placental lactogen, and placental growth hormone, trigger insulin resistance. As a result, blood glucose levels rise slightly, and this glucose is quickly transferred across the placenta to fuel the fetus's development. This mild state of insulin resistance also encourages the development of endogenous glucose and the breakdown of fat stores, leading to a rise in blood glucose and free fatty acid (FFA) levels. Even prenatally, excessive fetal insulin production can stress developing pancreatic -cells, resulting in -cell dysfunction and insulin resistance. Macrosomia is often linked to shoulder dystocia, which is a form of obstructed labor. As a result, babies born to women with GDM are usually delivered via cesarean section. Glucose cannot be used by body cells if a woman's insulin output is inadequate. The liver rapidly transforms stored glycogen into glucose to raise the serum glucose level after the cells detect a need for glucose. However, since insulin is still unavailable, the body cells are unable to use the glucose, causing the serum glucose level to increase. In an attempt to reduce the level, the kidneys begin to excrete large amounts of glucose in the urine (glycosuria). Huge amounts of urine are excreted with urine. Page 24 of 59As dehydration progresses, the blood serum becomes more concentrated, and the total blood volume decreases as blood flow is reduced. Because cells don't get enough oxygen, anaerobic metabolic reactions cause lactic acid to leak out of muscles and into the bloodstream. Fat is mobilized from fat stores and metabolized for energy to replace needed glucose, releasing large amounts of acidic ketone bodies into the bloodstream. c. SYMPTOMATOLOGY I. Discussion of the symptomatology of the disease. Gestational diabetes is a form of diabetes that develops during pregnancy when the body's ability to produce or react to insulin is compromised. Because many of the changes that occur during pregnancy are similar to those that occur during gestational diabetes, there may be no obvious signs or symptoms. When the body fails to react to insulin properly, high levels of sugar build up in the bloodstream, resulting in diabetes symptoms. Furthermore, these dangers to your wellbeing include fatigue, vaginal yeast infection, polydipsia, polyuria, glycosuria, obesity, and polyphagia. Some pregnant women are aware of the early warning signs of gestational diabetes. The signs and symptoms are close to those of other diabetes types. However, since they are common signs in all pregnant women, they are easy to overlook as a warning sign that something is wrong. Both the pregnant woman and the fetus are at risk if the mother has gestational diabetes. Signs and Symptoms Prese nt Abse nt Implication Fatigue / The client was showing signs of exhaustion. Fatigue is normal in pregnant women, particularly in the first 12 weeks, due to hormonal changes; however, it is also one of the positive signs of GDM. Sugar remains in the bloodstream rather than entering cells to provide nutrition, causing fatigue. Vaginal Yeast Infection / This was seen in the client. Since a genital candida infection was discovered in the client. It is one of the signs of GDM is vaginal infection. An abnormally high blood sugar level can prevent white blood cells from reaching Page 25 of 59the infection site, leaving the individual vulnerable to infection. Polydipsia / This was not reported by the client. Polydipsia is excessive thirst or excess drinking. It is a nonspecific symptom in various medical disorders. Polyuria / This was not reported by the client. Polyuria is a condition where the body urinates more than usual and passes excessive or abnormally large amounts of urine each time you urinate. Polyuria is defined as the frequent passage of large volumes of urine – more than 3 litres a day compared to the normal daily urine output in adults of about 1 to 2 litres. Glycosuria / The patient is experiencing this one. Glycosuria is a term that defines the presence of reducing sugars in the urine, such as glucose, galactose, lactose, fructose, etc. Glucosuria connotes the presence of glucose in the urine and is the most frequent type of glycosuria and is the focus of this review. Obesity / There was an objective data reported to this. The client is weighing above the normal weight. Polyphagia / This was not reported by the client. Polyphagia is an excessive or extreme hunger. It is different than having an increased appetite after exercise or other physical activity. d. PROGNOSIS GDM (gestational diabetes mellitus) is linked to long-term maternal and fetal complications. GDM has been linked to an increased risk of long-term maternal cardiovascular disease, chronic kidney disease, and cancer, according to new research. If treated, the patient will experience normoglycemia. This usually occurs after birth and the mother is at risk of nongestational diabetes within 5 to 16 years after the index pregnancy. However, a study by Page 26 of 59Langer, et. al revealed that 18% of those with treated GDM still had adverse neonatal outcomes such as stillbirth, neonatal macrosomia/LGA, neonatal hypoglycemia, erythrocytosis, and hyperbilirubinemia. If left untreated the mother will have an increased incidence of Caesarean section and gestational hypertension. A study by Langer, et. al revealed that 58% of the respondents with untreated GDM had a higher risk of adverse neonatal outcomes such as stillbirth, neonatal macrosomia/LGA, neonatal hypoglycemia, erythrocytosis, and hyperbilirubinemia. Page 27 of 59Laboratory and Diagnostic Tests Laboratory & Diagnostic Procedure Indications & Purposes Results/ Interpretation Normal Values Nursing Responsibilities Complete Blood Count  a complete blood count (CBC) test is performed to determine whether the pregnant mother has developed any health problems. It helps to diagnose illnesses or infections in the expecting mother. Parameters  Explain the test procedures  Explain that slight discomfort maybe felt when skin is punctured  Apply manual pressure and dressing over puncture site  Explain the interpretation to the patient and patient’s family WBC Used to screen for a variety of diseases and conditions. Assist in the diagnosis of infections, inflammatory processes, and other diseases that affect the number of white blood cells (WBCs). 15.6/uL Within the normal range. 5.6 - 16.9/uL RBC The amount of red blood cells in the blood that can imply her ability to bring oxygen to the fetus through blood. Can be used to help diagnose blood-related conditions, such as iron deficiency anemia 4/uL Within the normal range. 2.72 - 4.43/uL Hemoglobin The test may be used to screen for, diagnose, or monitor a number of conditions and diseases that affect red blood cells (RBCs) and the amount of hemoglobin in blood. 11g/dL Hemoglobin is low, patient shows positive for anemia. 12.3 - 15.3 g/dL Page 28 of 59Hematocrit The test for hematocrit measures the volume of cells as a percentage of the total volume of cells and plasma in whole blood. 45 Hematocrit is high, patient shows risk for type 2 diabetes and could mean dehydration. 28 - 39 MCV This measures the average size of the red blood cells. 110fL MCV is high and can be suggestive of folate or B-12 vitamin deficiency 91-99 fL MCH MCH is the average weight of hemoglobin per red cell. 39pg MCH is high can be a sign for macrocytic anemia 27-32 pg MCHC MCHC is the average concentration of hemoglobin per erythrocyte. 33g/dL Within the normal range. 33-37 g/dL RDW A quantitative estimate of the uniformity of individual cell size. 14 Within the normal range. 11.4 - 16.6 Platelets The platelet count is a test that determines the number of platelets in your sample of blood. High or low platelet levels can be a sign of a severe condition. 275/uL Within the normal range. 146 - 429/uL Page 29 of 59Neutrophils Can provide the doctor with important clues about the health of the patient. Having a high percentage of neutrophils in the blood is called neutrophilia. This is a sign that the body has an infection. 4/uL Within the normal range. 3.9 - 13.1/uL Lymphocytes The levels of the main types of white blood cells in the body are measured. High lymphocyte blood levels indicate the body is dealing with an infection or other inflammatory condition. 3/uL Within the normal range. 1- 3.6/uL Monocytes Help in diagnosing infection. Low levels can indicate the existence of chronic infections or an autoimmune disease, while high levels can indicate the presence of chronic infections or a bone marrow issue. 8 Within the normal range. 2-8 Eos A blood test that counts the number of eosinophils, a form of white blood cell. 2 Within the normal range. 1–4 Basophil Tests to help diagnose certain health problems such as allergic reaction if the basophil level is low. 1 Within the normal range. 0.5-1 Urinalysis  Used to detect and manage a wide range of disorders, such as urinary tract infections, bladder infection, kidney disease and diabetes by measuring the levels of sugar, protein, bacteria, or other substances in the urine. Page 30 of 59Parameters Appearance Can help a doctor determine whether a person has certain health conditions. Cloudy The diagnosis of gestational diabetes mellitus may be the underlying cause of the cloudy appearance. Clear  Explain the need to increase the patient’s fluid intake to promote renal blood flow and to flush bacteria from the urinary tract.  Explain to the patient to avoid urinary irritants such as coffee, tea, colas, and alcohol.  Explain the interpretation to the patient and patient’s family Specific Gravity Urine specific gravity is a measure of urine concentration. This test simply indicates how concentrated the urine is. 1.010 Within normal range 1.005-1.025 pH The pH level indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or urinary tract disorder. 6.0 Within normal range 4.5-8 pH Glucose To check for abnormally high levels of glucose in your urine. Negative Normal Result 0-trace Bilirubin Helps indicate liver damage or disease. This test screens for bilirubin in the urine. Bilirubin is not present in the urine of normal, healthy individuals. Negative Normal Result 0-trace Ketone The test measures ketone levels in your urine. Negative Normal Result 0-trace Occult Blood To screen any presence of blood in the urine called hematuria. 2+ 0-3 RBC's Protein The protein test pad provides a 3+ 0-trace Page 31 of 59rough estimate of the amount of albumin in the urine . High amount of protein in the urine is considered as proteinuria may be due to infection. Protein in the urine with raised blood pressure indicates preeclampsia Leukocyte Esterase Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine. This may mean you have a urinary tract infection. 1+ Leukocyte esterase is positive, it could be a sign of a urinary tract infection (UTI) . 0-trace WBC When WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or kidneys. 30-50/HPF WBC is high making the leukocyte esterase positive it may indicate urinary tract infection (UTI). 2-5 /hpf or less per RBC The presence of RBC is usually a sign of an underlying health issue, such as an infection or irritation of the tissues of your urinary tract. 15-30/HPF RBC is high that can indicate urinary tract infection (UTI). 0-5/ HPF Squamous Epithelial To know if the sample is contaminated or not. If there are squamous epithelial cells in your urine, it may mean your sample was contaminated. 8-10 Squamous epithelial cells are present which means the sample was 0-2 hpf Page 32 of 59contaminated. Bacteria To know if there are any bacteria. TNTC Bacteria are detected and too many to count. This indicates infection 0-trace OGTT and FBS z  OGTT a test that is used to diagnose gestational diabetes which can develop during pregnancy. The test measures your body's ability to maintain a normal blood glucose (sugar) level 125mg/dL 1 hour postprandial: 200mg/dL 2 hours postprandial:170 mg/dl The results are higher than normal, the patient shows positive for gestational diabetes. Explain to the patient that managing her blood glucose level throughput the rest of her pregnancy is a must, to avoid any complications. FBS Fasting blood sugar (FBS) measures blood glucose after you have not eaten for at least 8 hours. It is often the first test done to check for prediabetes and diabetes. 7mmol/L The result is high; patient shows positive for diabetes. ≤ 5.6 mmol/L Biophysical Scoring Biophysical Scoring Test that measures the health of the fetus during pregnancy. A BPP test may include a non-stress test with electronic fetal heart monitoring FHR: 138 bpm Within normal range Score of 8-10  Explain the test procedures.  Explain the interpretation to the patient and patient’s Amniotic Fluid index: 2.87 Average Page 33 of 59and a fetal ultrasound. The BPP measures the fetus’ heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around the fetus. family.  Inform the patient that before the test, she might be asked to drink water or other liquids, especially if the patient is smoking. Estimated Fetal Weight: 2845 grams Fetus is large for gestational age Placenta Grade: 2 BPP = 8/8 Normal Result Page 34 of 59Pharmacologic Studies A. Pharmacotherapy, Intravenous Fluids & Nursing Responsibilities Drug Study: PLR Dr. Chua ordered: PLR 1L at 100mL/hour x 2 Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: PLR Lactated Ringer's is a sterile solution for fluid and electrolyte replenishment. It restores fluid and electrolyte balances, produces diuresis, and acts as alkalizing agent (reduces acidity). Lactated Ringer's is used for balancing fluid and electrolytes and as an alkalizing agent. Contraindicated in patients with liver dysfunction. Most of the lactate is metabolized in the liver, and any dysfunction there will be an accumulation of lactate. This can confuse interpretation of lactate levels, with cerebral edema requiring osmotic therapy should avoid all hypotonic or isotonic fluid. Side effects include chest pain, abnormal heart rate, decreased blood pressure, cough, sneezing, rash, itching Adverse effects include severe redness and itching, regional cellulitis. • Monitor patient’s electrolytes. • Monitor IV infusion site and access – check for signs of infiltration, redness, pain, swelling, and discomfort. • Be attentive to the amount of volume infused. • Advise patient to report any signs of side and adverse effects. Brand Name: N/A Classification: Intravenous Fluid Dose, Route & Timing: 100mL/hour x 2 Page 35 of 59Drug Study: METOCLOPRAMIDE Dr. Chua ordered: Metoclopramide 1 amp IVTT STAT then 1 amp IVTT PRN Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Metoclopramide Metoclopramide works by blocking a natural substance (dopamine) which can cause nausea and vomiting. It also speeds up stomach emptying and movement of the upper intestines. Indicated for active vomiting. Metoclopramid e injection is used to relieve symptoms caused by slow stomach emptying in people who have diabetes. Metoclopramide should not be used in those patients with hypersensitivity to the drug or its components. Chronic use (e.g., greater than 12 weeks) should be avoided due to the increased risk for the development of movement disorders such as tardive dyskinesia. Metoclopramide has been used off-label as an adjunct, based on risk-benefit ratios, for the treatment of severe nausea/vomiting of pregnancy (e.g., hyperemesis gravidarium) not responding to standard Side effects include drowsiness, weakness, headache, diarrhea, nausea, breast enlargemen t, frequent urination, foot tapping, difficulty to sleep, flushing, fever Adverse effects include depression or suicide, neuroleptic malignant syndrome, tardive dyskinesia, Parkinsonism, hyperprolactine mia, hallucinations, hypersensitivity reactions, blood disorders, galactorrhea, hypotension  Monitor blood pressure regularly  Monitor for extrapyramidal reactions, if present, notify the physician right away.  Inform patient to avoid use of alcohol, sleep remedies, and sedatives  Inform patient to report to the nurse immediately if involuntary movement of the face, eyes, or limbs, severe depression and diarrhea are experienced. Brand Name: Metozolv, Regans Classification: Prokinetic agent Dose, Route & Timing: Dose: 10 mg Route: Page 36 of 59Intravenously Timing: Once treatments. Drug Study: FERROUS SULFATE + FOLIC ACID Dr. Roa ordered: Ferrous sulfate + folic acid 1-tab PO daily Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Ferrous sulfate + folic acid Ferrous sulfate is a type of iron. Hemoglobin carries oxygen through your blood to tissues and organs. Myoglobin helps your muscle cells store oxygen. Folic acid helps your body produce and maintain new cells, and also helps prevent changes to DNA that may lead to This medication is an iron supplement used to treat or prevent low blood levels of iron (such as those caused by anemia or during pregnancy). Ascorbic acid (vitamin C) improves the absorption of iron from the Contraindicated to patients with hemolytic anemia, porphyria, and thalassemia. Side effects include constipation , diarrhea, and upset stomach Adverse effects include severe allergic reaction – rashes, itching, dizziness, difficulty in breathing • Inform patient to swallow the drug without crushing or chewing. • Inform patient that there are certain foods that may inhibit absorption, for example, milk, eggs, and caffeine. • Inform patient to notify the nurse once constipation or diarrhea has occurred. • Monitor patient’s bowel movement to identify constipation or diarrhea. Brand Name: N/A Classification: Vitamin Dose, Route & Timing: 1 tab PO daily Page 37 of 59cancer. stomach. Drug Study: TETANUS TOXOID Dr. Chua ordered: 1 vial single dose Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Tetanus Toxoid It is protective against effects from a grampositive bacillus, Clostridium tetani. This bacteria produces a neurotoxin called tetanospasmin, which blocks the release of an inhibitory neurotransmitter and leads to unopposed muscle contractions and spasms. The purpose of giving the vaccine to women of childbearing age and to pregnant women is to protect them from tetanus and to protect their newborn infants against NT and prevent newborn from whooping cough. Contraindicated for patients with hypersensitivity to any component of the vaccine including thimerosal or any history of systemic allergic reaction. Side effects include redness, warmth, edema, induration with or without tenderness as well as urticaria, and rash. Malaise, transient fever, pain, hypotension , nausea Adverse effects include anaphylaxis or anaphylactic shock, brachial neuritis, injury, cochlear lesion, paralysis of the radial nerve. • Inform the patient that pregnancy is not a contraindication of the vaccine. • Inform patient on how the vaccine works and what it is for. • Monitor the injection site – check for redness or swelling. • Inform patient to notify the nurse if any of the side and adverse effects has occurred. Brand Name: Bio-TT Classification: Vaccine Dose, Route & Timing: 1 vial, Intramuscularly, single dose Page 38 of 59and arthralgia may develop in some patients after the injection. Drug Study: VITAMIN C Dr. Roa ordered: Vitamin C 1-tab PO daily Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Vitamin C In humans, an exogenous source of ascorbic acid is required for collagen formation and tissue repair by acting as a cofactor in the post transitional formation of 4- hydroxyproline in – Xaa-Pro-Glysequences in collagens and other proteins. During pregnancy, vitamin C is vital for both mom and baby. It is needed for tissue repair and wound healing, and it helps the baby’s bones and teeth develop. Vitamin C also aids in the Contraindicated to patients with blood disorders- thalassemia, G6PD deficiency sickle cell disease, and hemochromatosis. Side effects include nausea, vomiting, diarrhea, heartburn, stomach cramps, bloating, headache. Adverse effects include acute hemolytic anemia, insomnia, urethritis, dysuria, hyperoxaluria, or hyperuricemia.  Return the medication ticket on the right box for the next timing.  Inform patient what the vitamin is for and that this vitamin increases the absorption of iron when taken with iron-rich foods.  Monitor patient for possible side and adverse effects.  Inform patient to report any side and adverse effects that has occurred. Brand Name: Poten-cee, Kirkland Classification: Vitamin Dose, Route & Timing: 1 tab PO daily Page 39 of 59Ascorbic acid is reversibly oxidized to dehydroascorbic acid in the body. body’s production of collagen, helps bolster immunity and, on top of it all, improves your ability to absorb iron. Drug Study: VITAMIN D Dr. Chua ordered: 1 cap PO daily Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Vitamin D Adequate nutritional vitamin D status during pregnancy is important for fetal skeletal development, tooth enamel formation, and perhaps general fetal growth and development. Vitamin D supplementatio n during pregnancy improves maternal vitamin D status and may reduce the risk of preeclampsia, low birthweight Contraindicated in patients with sarcoidosis, high amount of phosphate in blood, high amount of calcium in blood, kidney stones, decreased kidney function Side effects include nausea, vomiting, constipation , loss of appetite, thirst, unusual tiredness Adverse effects include serious allergic reactions, arrythmias, hypercalcemia, lethargy • Assess patient’s condition that may be contraindicated with the medication. • Determine baseline and periodic values for serum calcium, phosphorus, magnesium, and alkaline phosphatase. • Inform patient to notify the nurse if any of the side and adverse effects has Brand Name: Fern-D Classification: Vitamin Dose, Route & Timing: 1 cap PO daily Page 40 of 59There also is mounting evidence to suggest that vitamin D deficiency impacts on the immune function, not only of the mother, but also of the neonate and infant through the first year of life. and preterm birth. It needs for building and maintaining healthy bones and absorb calcium, the primary component of bone. occurred. • Monitor for hypercalcemia. Drug Study: MICONAZOLE Dr. Chua ordered: Miconazole 1-tab PO daily x 7 days Drug Mechanism of Action Indications or Purpose Contraindication s Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Miconazole Miconazole is an azole antifungal used to treat a variety of conditions, including those caused by Candida overgrowth. Unique among the Miconazole is indicated for the local treatment of oropharyngeal candidiasis in adult patients. It is indicated for the Contraindicated to hypersensitivity to miconazole and milk protein allergy. Side effects include diarrhea, nausea, headache, vomiting, upper Adverse effects include dysgeusia, pharyngeal pain, anemia, lymphopenia, fatigue, • Assess for any cautions and contraindications to prevent any untoward complications. • Monitor patient Brand Name: response to the drug. Page 41 of 59Oravig azoles, miconazole is thought to act through three main mechanisms. The primary mechanism of action is through inhibition of the CYP450 14α-lanosterol demethylase enzyme, which results in altered ergosterol production and impaired cell membrane composition and permeability, which in turn leads to cation, phosphate, and low molecular weight protein leakage. treatment of itchiness at genital area, vaginal reddening, and genital candida infection. abdominal pain pruritus • Instruct patient for correct method of administration, depending on route. • Monitor for any side and adverse effect and inform client to report any effects experienced. • Instruct patient to notify the prescriber if the condition worsen. Classification: Antifungal Dose, Route & Timing: Dose: 50 mg Route: Orally Timing: Daily for 7 days Drug Study: PNSS Dr. Chang ordered: 1L at 100mL/hr x 2 Drug Mechanism of Action Indications or Purpose Contraindication s Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Normal saline solution has an osmolality. Indicated for replacement of Contraindicated for patients with Side effects include Adverse effects include febrile • Obtain history of the patient’s fluid and Page 42 of 59Plain Normal Saline Solution Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF, does not cause red blood cells to shrink or swell. Isotonic fluids expand the ECF volume. extracellular fluid. heart failure, pulmonary edema, renal impairment, sodium retention hypotension . response, infection at IV site, venous thrombosis, extravasation, hypervolemia. electrolyte status before therapy. • Check the fluid for a safe administration. • Monitor patient frequently for any signs of infiltration, phlebitis, and condition of the skin • Inform patient to notify the nurse if any side and adverse effects has occurred. Brand Name: N/A Classification: Isotonic Intravenous Fluid Dose, Route & Timing: 100mL/hr x 2 Drug Study: INSULIN LISPRO Dr. Roa ordered: 10 units SQ TID pre-meals Drug Mechanism of Action Indications or Contraindication Side Effects Adverse Nursing Responsibilities Page 43 of 59Purpose s Reactions Generic Name: Insulin Lispro Insulins lower blood glucose by stimulating peripheral glucose uptake by skeletal muscle and fat, and by inhibiting hepatic glucose production. Insulins inhibit lipolysis and proteolysis, and enhance protein synthesis. Whether the pregnancy is classified as pregestational diabetes (occurring in women who have been diagnosed with type 1 or type 2 diabetes before pregnancy) or as gestational diabetes mellitus (GDM, occurring when a nondiabetic woman develops diabetes only during pregnancy), the goal of treatment is to maintain maternal glucose levels as near to normal as possible throughout the pregnancy. Insulin lispro use is contraindicated in patients during episodes of hypoglycemia. Side effects include headache, nausea, hunger, confusion, drowsiness, weakness, sweating, redness of the injection site, swelling or itching of the site Adverse effects include low blood sugar, lipodystrophy, pruritus, rash • Ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking. • Give maintenance doses subcutaneously, rotating injection sites regularly to decrease incidence of lipodystrophy • Carefully monitor patients being switched from one type of insulin to another • Monitor urine or serum glucose levels frequently to determine effectiveness of drug and dosage. • Advise patient to inform the nurse if any of the side and adverse effects has occurred. Brand Name: Humalog Classification: Human Insulin Dose, Route & Timing: 10 units, subcutaneously, TID pre-meals Drug Study: INSULIN LEVIMIR Page 44 of 59Dr. Roa ordered: 10 units SQ BID pre-meals Drug Mechanism of Action Indications or Purpose Contraindication s Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Insulin Detemir Insulin detemir, a long-acting insulin, exerts its action by binding to insulin receptors. Receptorbound insulin lowers blood glucose by facilitating cellular uptake of glucose into skeletal muscle and fat, and inhibiting the output of glucose from the liver. Insulin detemir is effective as a glucose-lowering agent, with glycemic control equivalent to that of NPH insulin. Contraindicated to insulin detemir or cresol, diabetic ketoacidosis, coma, hypoglycemia. Side effects include weight gain, swelling of hands and feet, thickening or hallowing of the injection site, dizziness, hunger, slurred speech, headache, shakiness Adverse effects include low blood sugar, low potassium levels, fluid retention • Follow order to administer before meals. • Monitor patient’s weight. • Notify the prescriber of any of the following: fever, infection, trauma, diarrhea, nausea, or vomiting. • Rotate injection sites and never inject into an area with redness, swelling, itching, or dimpling. • Inform patient not to take any other medication unless approved by physician. Brand Name: Levemir Classification: Human Insulin Dose, Route & Timing: 10 units, subcutaneously, BID pre-meals Page 45 of 59Drug Study: PARACETAMOL Dr. Roa ordered: Paracetamol 500mg/tab 1 tab q4 PRN Drug Mechanism of Action Indications or Purpose Contraindications Side Effects Adverse Reactions Nursing Responsibilities Generic Name: Paracetamol Decreases fever by a hypothalamic effect leading to sweating and vasodilation, inhibits pyrogen effect on the hypothalamicheat-regulating centers, inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin synthesis Indicated for fever and headache. Contraindications to the use of acetaminophen include hypersensitivity to acetaminophen, severe hepatic impairment, or severe active hepatic disease. Side effects include nausea, stomach pain, loss of appetite, itching, rash, headache, dark urine, drowsiness. Adverse effects include methemoglobin emia, hemolytic anemia, neutropenia, thrombocytope nia, leukopenia, jaundice.  Encourage patient to take it with food or drink to minimize GI upset.  Instruct patient to report if cyanosis, shortness of breath, and abdominal pain has occurred.  Inform patient to notify prescriber if paleness, weakness, jaundice, itchiness, and dark urine are present.  Monitor patient if pain persists for more than 3- 5 days.  Monitor patient’s response to the therapy. Brand Name: Biogesic, Tylenol Classification: Analgesic, Antipyretic Dose, Route & Timing: Dose: 500 mg Route: Orally Timing: q4 PRN Page 46 of 59B. Diet & Activity Management & Nursing Responsibilities Type of Diet/Activity General Description Indication or Purposes Restricted Foods/Activities Nursing Responsibilities Diabetes Diet Eating the healthiest foods in moderate amounts and sticking to regular mealtimes. A healthy-eating plan that's naturally rich in nutrients and low in fat and calories. Key elements are fruits, vegetables and whole grains. Manage the blood glucose levels. Achieve target blood lipid (fat) levels. Maintain a healthy blood pressure. Maintain a healthy body weight. • Fried foods and other foods high in saturated fat and trans fat • Foods high in salt, also called sodium • Sweets, such as baked goods, candy, and ice cream • Beverages with added sugars, such as juice, regular soda, and regular sports or energy drinks • Discuss glucose monitoring at home with the patient according to individual parameters to identify and manage glucose variations. • Explain to the client to identify foods and drinks with high sugar content. • Instruct the client to follow the nutritional plan and report any related problems • Instruct the client to measure and record the waist circumference, height and weight accurately. Page 47 of 59Diet as Tolerated (DAT) Usually orders given regarding dietary restrictions after a medical procedure. This means that a person should be careful of what they eat. This particular diet is given when client can now tolerate any food she desires that is nutritious, if this will not lead to any complications and if the client needs further monitoring for lab test. Foods that is intolerable to ingest by the patient like highly processed foods, trans fat, added sugar and salts refined grains and alcohol. • Discuss to the client the importance of following any restrictions of the food to avoid any complications. • Explain to the client to identify foods and drinks that is difficult to ingest, in order to avoid ingesting it. Page 48 of 59Summary of Medical Management A. Pharmacotherapeutics Date & Time Medication Classificatio n Dosage Route 02/20/202 1 – 8:00AM Metoclopramid e Prokinetic Agent 1 tab (10mg) Orally 02/20/202 1 Ferrous sulfate + folic acid Vitamin 1 tab Orally 02/20/202 1 Vitamin C Vitamin 1 tab (100mg) Orally 02/20/202 1 Vitamin D Vitamin 1 cap (5000IU) Orally 02/20/202 1 Tetanus Toxoid Vaccine 1 vial Intramuscularl y 02/20/202 1 – 12:00NN Miconazole Antifungal 1 tab (50mg) Orally 02/21/202 1 – 5:30AM Insulin Lispro Human Insulin 10 units Subcutaneous ly 02/21/202 0 Insulin Detemir Human Insulin 10 units Subcutaneous ly 02/21/202 0 – 5:00PM Paracetamol Antipyretic, analgesic 1 tab (500mg) Orally B. Intravenous Fluids Date & Time Bottle No. Type of IV Fluid & Volume Rate Incorporatio n 02/20/2021 – 8:00AM Lactated Ringer’s Solution (PRN) 25 gtts/min. None 02/20/2021 – 4:00PM Plain Normal Saline Solution 25 gtts/min. None Page 49 of 59Nursing Care Plan A. Problem List (Summary) Cues Nursing Diagnosis Definition Patient stated “magpaprenatal raman unta ko pero nikalit lng og lain akong paminaw, nalipong ko og kalit.” Hypothermia related to decrease metabolic rate as evidenced by cold clammy skin and temperature. Core body temperature below the normal diurnal range due to failure of thermoregulation. “Ok ra kaha ko maam? Ang baby nako ok ra kaha cya? mahadlok ko nga mahitabo sa ako utro ang nahitabo sa ako sauna katong permiro nako nga pag buntis…” As verbalized by the patient. Anxiety related to threat to current status as evidenced by fear, increase in wariness, high blood pressure, increase in heart rate, and increase in respiratory rate. Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipationof danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with that threat. Client says she is able to digest food but likely to consume fried chicken from known food chain and seldom eats green-leafy vegetables. Obesity related to high frequency of restaurant or fried food as evidence by moreover optimum body weight and excessive fat. A condition in which an individual accumulates excessive fat for age and gender that exceeds overweight. Page 50 of 59Nursing Care Plan Patient’s Code: JS Age: 40-year-old Sex: Female Civil Status: Married Religion: Roman Catholic Date & Time of Admission: 02/21/2021 8:00 am Room: 144 Attending Physician: Dr. Chua Chief Complaints: Dizziness Nursing Diagnosis (PES): Actual – Hypothermia related to decrease metabolic rate as evidenced by cold clammy skin and temperature Definition: Core body temperature below the normal diurnal range due to failure of thermoregulation. Assessment/ Cues (Subjective/ Objective) Planning (Goals and Objectives) Interventions Rationale Evaluation Subjective Data • Patient stated “magpaprenatal raman unta ko pero nikalit lng og lain akong paminaw, nalipong ko og kalit.” Objective Data • Generally looks pale, hypothermic and tachycardic. • BP: 140/90mmHg • CR/PR: 102 bpm • T: 35.4°C • • Pallor is noted Short-term Goals: • Within 8hrs of nursing interventions, patient will maintain body temperature within the normal range. • Blood glucose will be controlled. Long-term Goals: • After 2 weeks of nursing intervention patient will be able to verbalize understanding specific intervention to Independent • Monitor vital signs • Monitor body temperature at regular intervals. • Regulate the environment temperature or relocate patient to a warmer setting. • Perform Capillary blood glucose testing. • Maintain bed rest • Serve as baseline data. • Regular temperature monitoring will identify adequate or inadequate thermoregulation. • Provide for a more gradual warming of the body. • To rapidly test blood glucose level before administering insulin in order to identify those at highest risk for hypo-and • Within 8 hours of nursing interventions the patient maintained body temperature within the normal range as manifested by body temperature of 35.4°C. • Patient verbalize and understand the specific intervention to prevent hypothermia. Page 51 of 59prevent hypothermia. Objectives: • Demonstrate behaviors to monitor and promote normothermia. Dependent • Administer insulin as indicated by the physician. Collaborative • Refer to physician for consultation. hyperglycemia. • To reduce metabolic demands/oxygen consumption. • To control blood sugar of patient. References: Eds. (2017). NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme. Page 52 of 59Nursing Care Plan Patient’s Code: JS Age: 40-year-old Sex: Female Civil Status: Married Religion: Roman Catholic Date & Time of Admission: February 20, 2021 @ 8:00 AM Room: 144 Attending Physician: Dr. Chua Chief Complaints: “ Ok ra kaha ko maam? Ang baby nako ok ra kaha cya? mahadlok ko nga mahitabo sa ako utro ang nahitabo sa ako sauna katong permiro nako nga pag buntis… ” Nursing Diagnosis (PES): Anxiety related to threat to current status as evidenced by fear, increase in wariness, high blood pressure, increase in heart rate, and increase in respiratory rate. Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with that threat. Assessment/ Cues (Subjective/ Objective) Planning (Goals and Objectives) Interventions Rationale Evaluation Subjective Data • “Ok ra kaha ko maam? Ang baby nako ok ra kaha cya? mahadlok ko nga mahitabo sa ako utro ang nahitabo sa ako sauna katong permiro nako nga pag buntis…” As verbalized by the patient. Objective Data • BP: 140/90 mmHg- high blood pressure Short-term Goals: • After 1-2 weeks of nursing intervention, the patient will be able to show/verbalize decrease of worry and concerns regarding the possible problems of her pregnancy. • After 1-2 weeks, Independent • Monitor the patient’s blood pressure, respiratory and heart rate. • Monitor fetal vital signs. • Explain to/educate the patient about her feeling of being anxious.  Monitoring vital signs help alleviate risks for further complications.  Fetal monitoring avoids fetal complications.  Making the patient understand her feelings promotes After 1-2 weeks of nursing intervention, the goals were met:  The patient was able to show/verbalize decrease of concerns and worry. The patient’s vital Page 53 of 59• PR: 102 bpm- tachycardic • RR: 25 cpm along with the patient’s wariness, the patient’s vital signs will be back to its normal range for pregnant women on their 3rd trimester. Long-term Goals: • The patient will be able to maintain having positive outlook regarding her pregnancy. • Recognize awareness of the patient’s anxiety. • Accept patient’s defenses; do not dare, argue, or debate. • Help patient determine precipitants of anxiety that may indicate interventions. Dependent  Refer to a psych consult for better anxiety management and for possible drugs to be used. Collaborative  Collaborate with patient and her family on ways to manage anxiety. better intervention.  Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings.  The patient may feel secure and protected enough to look at behavior.  Obtaining insight allows the patient to reevaluate the threat or identify new ways to deal with it.  Psych consults know best on how to manage anxiety.  Family collaboration is one factor of a signs were back to normal ranges for her current status.  Long-term goal was partially met:  Patient is still doing her maximum best to manage her outlook about her pregnancy. Page 54 of 59good patient care and intervention. References: Herdman, T.H. & Kamitsumu, S. (2018). NANDA International Inc. Nursing Diagnosis. 2018 NANDA International Nursing Care Plan Patient’s Code: Julia Salazar Age: 40 Sex: Female Civil Status: Married Religion: Roman Catholic Date & Time of Admission: February 21, 2021 ;8:00 AM Room: 144 Attending Physician: Dr. Chua Chief Complaints: Sudden dizziness and not feeling well. Nursing Diagnosis (PES): Obesity related to high frequency of restaurant or fried food as evidence by moreover optimum body weight and excessive fat. Definition: A condition in which an individual accumulates excessive fat for age and gender that exceeds overweight. Assessment/ Cues (Subjective/ Objective) Planning (Goals and Objectives) Interventions Rationale Evaluation Subjective Data  Client says she is able to digest food but likely to consume fried chicken from known food chain and seldom eats green-leafy vegetables. Short Term At the end of my 8 hours of nursing care, the patient will be able to:  Verbalize consequences related to eating friend food and not green leafy vegetables that resulted to obesity. a. Gestational diabetes, cesarean delivery and Independent  Assess weight and blood pressure every week.  Discuss to the client about the proper foods and meals to eat and teach her to keep a food dairy to tract and change her eating habits.  To monitor the weight and provides information about the effectiveness of the therapy  Provides opportunity to focus and internalize a The planned care was met as evidence by:  Verbalization of consequences about her eating habits and choices of foods.  Demonstration Page 55 of 59Objective Data  Weight: 200 lbs.  Height: 5 ft. and 5 inches preeclampsia.  Demonstrate appropriate selection of meals towards the goal of weight reduction.  Identify behavior modification strategy to avoid frequent eating of unhealthy foods like having a food diary.  Would be able to understand the importance of proper weight during pregnancy. Long Term  After 1 month of nursing intervention the patient would be able to:  Display weight loss with optimal maintenance of health, prevent further weight gain and a longterm weight maintenance.  Display lifestyle and behavior, modification strategies to promote successful weight loss and control like walking and eating healthy foods.  Displays improvement of  Discuss the importance of exercise like walking, lifestyle and behavior in maintaining optimal health for her pregnancy. Dependent  Administer medication as prescribed by the physician. Collaborative  Consult to a dietician to determine caloric and nutrients required for the client’s weight loss.  Formulate an eating plan with a dietician that corresponds to the client’s condition and realistic picture of the amount of food and kinds of food to be ingested.  Engaging into exercise helps the client’s loss weight and a lifestyle and behavior has a big factor for the goals and plans to be realistic and achieved.  To help the client improve her overall metabolic health and reduce the risk of any known adverse pregnancy outcomes.  A dietician is more knowledgeable regarding diet plan appropriate for the client.  To help the client of appropriate selection of meals and foods.  Identification of behavior modification strategy to avoid eating unhealthy foods.  Demonstrate changes in lifestyle and behavior. Some planned care was partially met as evidence by:  Weight loss but not yet ideal for her high and condition. Page 56 of 59bad eating habits and wrong eating habits situation. about what food should and should not be ingested. References: Heather, H., & Shigemi, K. (n.d.). NANDA International, Inc. Nursing Diagnoses (2018-2020 Eleventh ed.). New York, NY 10001 USA +1 800 782 3488,: Thieme New York. Page 57 of 59References Biophysical profile: About this test. Retrieved from https://myhealth.alberta.ca/Health/aftercareinformation/pages/condition s.a spx?hwid=abq186. Buchanan, T. A., & Xiang, A. H. (2005). Gestational diabetes mellitus. Journal of Clinical Investigation, 115(3), 485–491. doi:10.1172/jci24531. DerSarkissian, C. (June 14, 2020). Diabetes and anemia: Know your risks and the warning signs. Retrieved from https://www.webmd.com/diabetes/diabetes- and-anemia. Edgar V Lerma, M. (2020, December 05). Urinalysis: Reference Range, INTERPRETATION, collection and panels. Retrieved March 17, 2021, from https://emedicine.medscape.com/article/2074001-overview. (Eds.). (2017). NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme. Epstein, J. (2017, July 8). RBC Indices. Retrieved from https://www.healthline.com/health/rbc-indices. Gestational Diabetes Mellitus. (2003). Diabetes Care, 27(Supplement 1), S88–S90. doi:10.2337/diacare.27. 2007.s88. Herdman, T.H. & Kamitsumu, S. (2018). NANDA International Inc. Nursing Diagnosis. 2018 NANDA International. Heather, H., & Shigemi, K. (n.d.). NANDA International, Inc. Nursing Diagnoses (2018-2020 Eleventh ed.). New York, NY 10001 USA +1 800 782 3488: Thieme New York. Hu L, Zhang Y, Wang X, et al. Maternal vitamin D status and risk of gestational diabetes: A meta-analysis. Cell Physiol Biochem. 2018;45(1):291-300. PMID: 29402818. https://doi.org/10.1159/000486810. JIMÉNEZ‐MOLEÓN, J. J., BUENO‐CAVANILLAS, A. U. R. O. R. A., LUNA‐DEL‐ CASTILLO, J. D., LARDELLI‐ CLARET, P. A. B. L. O., GARCÍA‐ MARTÍN, M. I. G. U. E. L., & GÁLVEZ‐VARGAS, R. A. M. Ó. N. (2000). Predictive value of a screen for gestational diabetes mellitus: influence of associated risk factors. Acta Obstetricia et Gynecologica Scandinavica: ORIGINAL ARTICLE, 79(11), 991-998. Johns, K., Olynik, C., Mase, R., Kreisman, S., & Tildesley, H. (2006). Gestational Diabetes Mellitus Outcome in 394 Patients. Journal of Obstetrics and Gynaecology Canada, 28(2), 122–127. doi:10.1016/s1701-2163(16)32068-0. Keshavarz, M., Cheung, N. W., Babaee, G. R., Moghadam, H. K., Ajami, M. E., & Shariati, M. (2005). Gestational diabetes in Iran: incidence, risk factors and pregnancy outcomes. Diabetes research and clinical practice, 69(3), 279- 286. Kjos, S. L., & Buchanan, T. A. (1999). Gestational Diabetes Mellitus. New England Journal of Medicine, 341(23), 1749–1756. doi:10.1056/nejm199912023412307. Laboratory tests interpretation. Retrieved https://www.nurseslearning.com/courses/nrp/labtest/course/section5/ind ex .htm. Page 58 of 59Langer, O., Yogev, Y., Most, O., & Xenakis, E. M. J. (2005). Gestational diabetes: The consequences of not treating. American Journal of Obstetrics and Gynecology, 192(4), 989–997. doi: 10.1016/j.ajog.2004.11.039. Learning, B. (2021, January 08). Interpreting the complete blood count and differential. Retrieved March 17, 2021, from https://www.elitecme.com/resource-center/laboratory/interpretingthe- complete-blood-count-and-differential. Litonjua AD, Boedisantoso R, Serirat S, et al. AFES Study Group on diabetes in pregnancy: Preliminary data on prevalence. Philipp J Int Med. 1996;34(2):67-68. Litonjua, A. D., Waspadji, S., & Pheng, C. S. (1996). AFES Study Group on Diabetes in Pregnancy: Preliminary data on prevalence. Phil J Internal Medicine, 34, 67-68. Mahak, A. (2020, May 13). CBC test during PREGNANCY: Importance & tests results. Retrieved from https://parenting.firstcry.com/articles/cbc-complete-blood- counttest-in-pregnancy-why-you-need-it/. Naranjo, Diana, and Korey Hood. "Psychological challenges for children living with diabetes." Diabetes Voice 58.1 (2013): 38-40. Perinatology.com. (n.d.). Retrieved from http://perinatology.com/Reference/Reference %20Ranges/Reference%20for%20Serum.htm Plows, J., Stanley, J., Baker, P., Reynolds, C., & Vickers, M. (2018). The Pathophysiology of Gestational Diabetes Mellitus. International Journal of Molecular Sciences, 19(11), 3342. doi:10.3390/ijms19113342. The Society of Obstetricians and Gynaecologists of Canada. Journal of Obstetrics and Gynaecology Canada Vol. 42 Issue 10. Elsevier Inc. Unite for Diabetes Philippines. Philippine practice guidelines on the diagnosis and management of diabetes. Retrieved from ttp://endo- society.org.ph/v5/wp-content/uploads/2013/06/DiabetesUnited-for- Diabetes-Phil.pdf. Urinalysis. Retrieved from https://labtestsonline.org/tests/urinalysis. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. Int J Gynaecol Obstet. 2001; 75:221–8. Page 59 of 5 [Show More]

Last updated: 1 year ago

Preview 1 out of 59 pages