CASE PRESENTATION:

I. CASE INTRODUCTION
• Presenting the case of patient RA, 34 y/o G3P1 at 30 weeks in AOG by September 23, 2020
was brought to the hospital who presented a chief complaint of dizziness, unusual frequent
urination, hunger, extreme thirst for the past 2 days with the possible diagnosis of
Gestational Diabetes Mellitus.

II. PAST MEDICAL AND FAMILY HX

• In 2017, the patient had a miscarriage and undergone Dilation and Curettage.
• 2019 CS Delivery to a live baby boy by an OB-GYNE.
• She had experienced Gestational Diabetes Mellitus in her previous pregnancy.
• The patient is allergy to shrimp which she was only taking Cetirizine 10mg whenever
needed as per her doctor’s order.
• She was able to finished all her immunization and received tetanus toxoid in this
pregnancy.
Family History
• Her mother has Type II Diabetes Mellitus.

III. PERSONAL SOCIAL HX

• Patient is a non-smoker, not an alcoholic beverage drinker, and denies illicit drug use.
• High school graduate and currently living with her one child and her husband
• Work at a textile factory
• The patient had her first coitus was at age of 24 (+) post-coital bleeding with non-
promiscuous sexual partner.
• There is no history of OCP or IUD use and STDs.
• She experienced anxiety after abortion and divert herself by eating large amount of food in
a short period of time and became obese.
• The patient has average economic status

IV. MENSTRUAL HX
• The pt. had her menarche at age 13 with 27 days cycle, lasting for 7 days. Patient described
heavy amount on first 2 days associated with dysmenorrhea and light amount on the next
days until it last. Week before the expected menstrual period, patient verbalized molimina
symptoms such as breast tenderness, food cravings and headaches. Last menstrual period
was on Sept 23, 2020.

V. OBSTETRIC HX
• The pt. is a G3P1 T1P0A1L1M0. This is her 3rd pregnancy.
• The first of which was resulted in complete abortion at 16 weeks AOG last 2017. Dilatation
and curettage done in Saint Anthony Hospital.
 • The second pregnancy was via CS delivery by an OB-GYNE in Saint Anthony Hospital.
Live baby boy, 5.5 kg, LGA, w/o complications and diagnosed GDM.

VI. CLINICAL PRESENTATION

• The patient presented to the emergency room with chief complaint of unusual frequent
urination, hunger and extreme thirst for the past 3 days.
• The patient was conscious and weak. Exhausted facial expression was noted while
independently supporting her back with below average body build.
• Her non-pregnant weight was 160lbs, 5’5 feet high and has a 26.6 BMI which indicates
overweight.
• Signs noticed by the examiner – (+) restlessness (+) pallor
• During assessment, she weighs 197lbs and 5’5 feet high which indicates that the patient
was losing weight.

• Initial Assessment:
The patient verbalized dizziness, unusual frequent urination, hunger, excessive thirst, no history
of hypertension and symptoms of thyroid disease. Family history was remarkable since her
mother has Type II DM, unhealthy lifestyle, poor diet, BP 130/80 mmHg, PR 132 bpm, CR134
bpm, RR 20 bpm and temperature 37.2 degrees Celsius.
• Differential Diagnoses – Hyperthyroidism, Pre-eclampsia, Glomerulonephritis and Diabetic
Ketoacidosis
• Admitting Diagnosis – Gestational Diabetes Mellitus

VII. TEXTBOOK DISCUSSION

• Description
Gestational Diabetes Mellitus (GDM) is a condition in which a hormone made by the placenta
prevents the body from using insulin effectively. Glucose builds up in the blood instead of
being absorbed by the cells. Unlike type 1 diabetes, gestational diabetes is not caused by a
lack of insulin, but by other hormones produced during pregnancy that can make insulin less
effective, a condition referred to as insulin resistance. Gestational diabetic symptoms
disappear following delivery.

The primary cause is almost the same as the other types of diabetes. The inability of the
body to produce or synthesize a sufficient amount of insulin in response to glucose level (as
in type I DM), or the body’s rejection of insulin (as in type II DM) shows a significant
relationship on the development of any form of diabetes. The existence of either of these
problems, plus, the interaction of the protective mechanisms in pregnancy doubles the
occurrence of GDM.
 The incidence of Gestational Diabetes Mellitus is almost 3% in all pregnancies and 2% in all
women with diabetes before pregnancy. GDM causes a high incidence of fetal morbidity and
unwanted complications such as polyhydramnios and macrosomia in fetus.

• Risk Factors (Modifiable, Non-Modifiable)

Modifiable risk factors
• BMI
• Dietary pattern and level of physical activity
• Smoking has been identified as a potential risk factor
Non-modifiable risk factors for gestational diabetes
• Advanced maternal age (older than 35),
• A family history of Type 2 Diabetes
• A personal history of GDM.

• Signs and Symptoms

− Polyuria or frequent urination
− Polydipsia or excessive/extreme thirst
− Polyphagia/ hyperphagia or extreme hunger
− Weight loss
− Glycosuria or sugar in the urine
− Skin Infections

• Diagnostics
1. Random Blood Sugar (RBS) - Random blood glucose readings can help you identify hyperglycemia and
decrease the risk for some chronic complications. Normal value is below or equal 200 mg/dl.
2. Fasting blood sugar (FBS) - A test to determine how much glucose (sugar) is in a blood sample after an
overnight fast. The fasting blood glucose test is commonly used to detect diabetes mellitus. Normal value is
below or equal 126mg/dl.
3. Hemoglobin A1c (HbA1C) - An HbA1c test may be used to check for diabetes or prediabetes in adults.
Prediabetes means your blood sugar levels show you are at risk for getting diabetes. It can help monitor your
condition and glucose levels. Normal value is below or equal 6.5 %
4. Oral Glucose Tolerance Test (OGTT) - Glucose tolerance testing (GTT) is used to evaluate the ability to
regulate glucose metabolism and is indicated when random/fasting blood glucose testing alone is insufficient
in establishing or ruling out the diagnosis of diabetes mellitus. Normal Value is below 200 mg/dl after 2-3 hrs.
5. Postprandial glucose test (PPBS) - a glucose test done on the blood that helps determine the type of
sugar, also known as glucose after a certain meal. Carbohydrate foods are the main sources of glucose and
it is a primary source of energy present in the body. Normal value is 70-100mg/dl.
 • Medical Management
Pharmacologic therapy with metformin (Glucophage), glyburide, or insulin is appropriate for
women with GDM whose glucose values are above goal despite lifestyle modifications.
Women with GDM should be screened at six to 12 weeks postpartum, and every three years
thereafter, for abnormal glucose metabolism.

• Nursing Management
1. Establish an initial database, and maintain serial documentation of test results throughout the pregnancy.
2. Provide client and family teaching.
3. Arrange for the client to consult with a dietitian to discuss the prescribed diabetic diet and to ensure
adequate caloric intake
4. Address emotional and psychosocial needs. Intervene appropriately to allay anxiety regarding diabetes
and childbirth.
5. Prepare the client for intensive frequent intrapartum assessment,
6. Identify and make referral to support groups and resources available to the client and family.

VIII. PHYSICAL EXAM

 IX. SHORT TERM PLAN
Tests to be ordered:
Lab test Result Normal Interpretation
WBC 11.5 3.4 - 10.8 High

RBC 4.07 4.14 – 5.80 Low

Hemoglobin 11.1 13.0 – 17.7 Normal

Hematocrit 45.5 37.5 – 51.0 Normal

MCV 112 79 – 97 High

MCH 38.8 26.6 – 33.0 High

MCHC 34.3 31.5 – 35.7 Normal

RDW 14.2 12.3 – 15.4 Normal

Platelets 256 150 – 379 Normal

Neutrophils 57 30-75 Normal

Lymphocytes 32 20-45 Normal
Monocytes 8 2-8 Normal
Eosinophil 2 1-4 Normal
Basophil 1 0.5 - 1 Normal
Neutrophils (Absolute) 3.7 1.4 – 7.0 Normal

Lymphocytes (Absolute) 2.1 0.7 – 3.1 Normal

Monocytes (Absolute) 0.5 0.1 – 0.9 Normal

Eosinophil (Absolute 0.1 0.0 – 0.4 Normal

Basophil (Absolute) 0.0 0.0 – 0.02 Normal

Immature Granulocytes 0 1.5 – 8.5 Normal

Immature Grans 0.0 0.0 – 0.1 Normal
(Absolute)
T4 7 ug/dL 5.0-12.0 ug/dL Normal
T3 150 ug/dL 100-200 ug/dL Normal
TSH 1 mU/L 0.45-4.5 mU/L Normal
 ⎯ MCH levels is increased which is relative to sign of overactive thyroid in which is connected to the
pale, tired and sleepy appearance of the patient, and a tachycardic.
⎯ MCV levels is increased than the normal range in which is a sign of B12 deficiency, also supports to
the low levels of RBC in result and it is evident to the pale appearance of the patient.
⎯ WBC levels is high in which is a relative sign of UTI.
⎯ Hemoglobin level is low in which is a sign of anemia.

Urinalysis with Micro reflex Cult

Lab Test Result Normal Interpretation
Appearance CLOUDY CLEAR High concentration of
urine
Specific Gravity 1.010 1.001 – 1.035 Normal
pH 7.8 5.0 – 8.0 Normal
Glucose 2+ NEGATIVE Present
Bilirubin NEGATIVE NEGATIVE Normal
Ketone 1+ NEGATIVE Present
Occult Blood NEGATIVE NEGATIVE Normal
Protein NEGATIVE NEGATIVE Normal

Nitrites NEGATIVE NEGATIVE Normal

Leukocytes Esterase +1 NEGATIVE Present

WBC 3 <=5 WBC/HPF Normal

RBC 10-20 <=2 RBC/HPF High
Squamous Epithelial 6-10 <=5 HPF High
Bacteria NONE SEEN NONE SEEN HPF Normal
Crystals NONE SEEN NONE SEEN HPF Normal

Casts NONE SEEN NONE SEEN HPF Normal

Yeast NONE SEEN NONE SEEN HPF Normal

⎯ There is presence of Leukocytes Esterase and it may suggest that there is an infection.
⎯ Cloudy urine is present which could be a manifestation of the underlying illness associated with the
diabetes such as UTI. Also, it is indicating glucose in the urine.
⎯ Squamous Epithelial cells is present which could be an indication of possible UTI and liver or kidney
disease.
⎯ There is presence of RBC which could be an indication of possible gestational diabetes mellitus, pre-
eclampsia, and UTI.
⎯ There is presence of ketones which could be an indication of risk to Diabetic Ketoacidosis.
⎯ There is a presence of glucose in the urine which may be an indicate of glycosuria.
OGTT & FBS (February 8, 2021 @ 10:00AM)
Lab Test Result Normal Range Interpretation
RBS 190 mg/dl < 140 mg/dL Elevated
HbA1c 5.8% < 6.5% Normal
OGTT Fasting: 120 mg/dL < 92 mg/dL Elevated

1hrpostprandial: <180 mg/dL Elevated

190 mg/dL

2hours postprandial: <140 mg/dL Elevated

165 mg/dL

FBS 6.9 mmol/L 5.3 mmol/L Elevated

− Fasting Blood Sugar is elevated which could be an indication of possible Gestational diabetes
mellitus.
− OGTT is elevated which could be an indication of possible Gestational diabetes mellitus
− Random Blood Sugar is taken 1 hour test, the result is elevated which could be an indication of
possible Gestational diabetes mellitus.

Biophysical Scoring: (April 22, 2021 @ 2:00 PM)

Name: Rowena Alejandro Age: 34 years old Sex: Female
LMP: September 23, 2020
Exam Date: April 22, 2021 Placental location: Left Biometry:
Posterolateral BPD: 8.51 cm
General Survey: HC: 30.2 cm
No. Of Fetus: Single (1) Placenta Grade: 2 AC: 28.7 cm

Presentation: CEPHALIC

FHT: 138 bpm

Amniotic Fluid Index: 2.87 Ave.

Ultrasonic Age: 30W 5D

Ultrasonic EDC: 06/30/21

Estimated Fetal Weight: 2845

Grams

Gender: Female
 RESULTS RANGE
FHT: 138 bpm FHT: 110 – 160 bpm

Amniotic Fluid Index: 27cm Amniotic Fluid Index: 5-25cm

Estimated Fetal weight: 2845 grams Estimated Fetal Weight: 1918 grams

Placenta Grade: 2 Placenta Grade at 30 weeks: 2

Biometry: Biometry at 30 weeks:

BPD: 8.51 cm BPD: 8.3 cm
HC: 30.2 cm HC: 29.5 cm
AC : 28.7 cm AC: 28.38 cm

Labs done OPD: (April 20,2021 @ 12:00NN)

IMMUNOHEMATOLOGY
ABO and RH/ Blood Type A+
HBsAg (Qualitative) Non-Reactive

MISCELLANEOUS
VDRL Non-Reactive

DIFFERENTIALS DIAGNOSIS TO BE RULED OUT:

Hyperthyroidism – it was considered as one of the possible diagnosis due to the clinical presentation of
weight loss and the patient was tachycardic. However, it was ruled out because the result in CBC specifically
in T3, T4, and TSH were normal. And upon assessment there was no presence of enlarged thyroid gland, no
palpable nodule and neck muscles are equal in size base on the physical examination.
Pre-eclampsia - It was considered as one of the diagnosis because the patient complaint about dizziness
and have a blood pressure of 130/80. However, it was ruled out due to the test done which is the urinalysis
results that there was no presence of protein in the urine.
Glomerulonephritis - It was considered as one of the diagnosis because the patient came to the hospital
appeared pale, tired, sleepy and has blood pressure of 130/80. There is a presence of RBC and cloudy in
the urine. However, it was ruled out because based on the Occult Blood in the Urinalysis it was negative.
Also, there is no evident of edema, no fluid retention, and patient does not complain of loss appetite.
Diabetic Ketoacidosis – It was considered as one of the possible diagnosis due to the chief complaint of
unusual frequent urination, extreme thirst and presence of ketones. It was ruled out because the pH level is
not less than 7.3
STAT concern that needs treatment:
1. Dehydration
2. Nutrition
3. Knowledge Deficit

X. LONG TERM PLAN

MEDICAL MANAGEMENT:
The OGTT results revealed 120mg/dL which indicates that there is no indication for Overt DM wherein
the results are lower than the suspected range for Overt DM while the results for 1 hour post prandial
test is 190 mg/dL, 2 hours post-prandial test is 165 mg/dL, and FBS with 6.9 mmol/L or 129 mg/dL which
therefore aligns to the guidelines of POG in diagnosing Gestational Diabetes Mellitus.
Upon discussion with the patient and with her husband they were informed of her case, the treatment,
management and medications that are to be given including the benefits, efficacy and effects.
Miconazole Oral Buccal is given to the patient to enable the damage of the fungal cell wall which
increases the permeability and causes the leakage of nutrients. It is given orally with a dosage of 50 mg
1 tab daily good for 7 days.
Ascorbic Acid is given to the patient to increase the protection of the immune system against infections
and other pathogens and will also help and support wound healing. It is given orally with a dosage of 100
mg once a day.
Calciferol is given to the patient which promotes the absorption and utilization of calcium and phosphate
and helps in regulating calcium homeostasis. This is given orally with a dosage of 5000 IU/Cap, the
patient will intake 1 capsule daily.
Ferrous Sulfate + Folic acid is given to the patient which elevates the serum iron concentration to help
the formation of reticuloendothelial cells. This is given orally with a dosage of 200 + 400 mg wherein the
patient can take the medication at least 1 hour before meal or 2 hours after meals.
Insulin Lispro is given to the patient which stimulates the hepatic glycogen synthesis, synthesis of fatty
acids, and to stimulate lipoproteins to provide free fatty acids and most of all to improve the glycemic
control in adults with DM. This is given subcutaneously with a dosage of 10 units wherein the availability
100 units in 1 vial.
Metoclopramide is given to the patient which stimulates the motility of the upper GI tract and is a
symptomatic treatment of diabetic gastroparesis and gastroesophageal reflux. This is given intravenously
with a dosage of 10 mg per ampule if there is active vomiting another 1 ampule will be administered to
the patient.
Monitoring of blood sugar of the patient was still continued to identify if there are changes in the levels of
sugar while administration of medication is going on.
SURGICAL MANAGEMENT PRN:
A C-section is an operation to deliver the baby through the mother’s belly. A woman who has diabetes
that is not well controlled has a higher chance of needing a C-section to deliver the baby.

XI. NURSING CARE PLAN

Nursing Management
1. Patient R.A was assessed upon arrival in emergency room, she was asked about his condition and
vital signs were monitored.
2. Patient R.A was place on the bed comfortably with elevated feet and side rails up for safety
measures. After 15 minutes, vital signs were monitored. IVF: PLR 1L at 100 cc/hour was hooked
infusing well to her left metacarpal vein.
3. Patient R. A was initially diagnosed of suspected Gestational Diabetes Mellitus and ordered to admit
the patient, the consent was secured for laboratory like Urinalysis, CBC, CBG now then BID, OGTT
and FBS. The physician ordered a medication of Metoclopramide 10mg/amp, 1 ampule IVTT (STAT),
1 ampule IVTT PRN, Ferrous sulfate + Folic tab, 1 TAB PO daily, Vitamin C 100mg/tab 1 tab PO
daily, and Vitamin D 500IU/cap, 1 cap PO daily.
4. The Laboratory tests we’re explained to the patient and the section was informed about the stat
orders. Consent was secured.
5. The patient start giving Miconazole 50 mg/tab 1 tab PO daily x 7 days. Give insulin (Lispro) at 10
units daily.
6. Repeat CBG 60 mins post Insulin administration. Then facilitate patient’s pending Labs; NPO at
10:00pm for biophysical scoring and facilitate IVF: Shift PLR to PNSS 1l 100 mL/hr refer to
unusuality.
7. Continue meds IVF TF: PNSS 1L at 100mL/hr x 2.
8. Facilitate pending labs, refer results once in IVF TF: PNSS 1l at 100mL/hr x 2
9. Lispro 10 units SQ TID pre-meals was started giving and Levimir 10 units SQ BID pre-meals. Dietary
department was informed to change patient diet from DAT to Diabetic diet and continue other meds
10. Received the lab result for CBC, OGTT and Urinalysis
11. Upon the result of laboratory and diagnostic tests which showed and diagnosed GDM
12. Vital signs we’re monitored and further explain about the results.
Prioritization of Nursing Problems

Assessment Nursing Planning Intervention Evaluation

Diagnosis
Subjective Data: Deficient fluid After days of • Educate patient Goal met:
Patient verbalized volume related to intervention about possible After days of
cause and effect
frequent unusual polyuria as patient will of fluid losses or intervention
urination, thirst evidence by demonstrate decreased fluid patient able to
and dizziness decrease urine lifestyle changes intake demonstrate
output. to avoid • Monitor urine change of
Objective Data progression of output lifestyle that
• Encourage
Weight loss dehydration patient to drink
prevent the
BP: 130/80 prescribed progression of
mmHg amount of fluid dehydration
CR134 bpm • Collaborate with
the family to
encourage client
to drink bountiful
amount of water
• Insert prescribe
IVF for hydration
• Encourage
patient to avoid
causes
dehydration
such as coffee
and tea
• Provide
comfortable
environment
Assessment Nursing Planning Intervention Evaluation
Diagnosis
Subjective Data: Imbalanced After a week of • Educate patient along Goal met
Patient nutrition less than intervention with the family the After a week
verbalized body requirement patient will able to importance of of
unusual frequent related to inability demonstrate an regularity of meals intervention
urination, to utilize nutrients improved • Monitor client weight patient able
hunger, thirst appropriately as behavior and daily to
weight loss evidence by lifestyle and to • Advised the patient to demonstrate
weight loss regain weight eat well balanced an improved
Objective Data diet. It should be behavior
Weight: 170lbs highly nutritious and and lifestyle
Fbs: 120mg/dL easily digestible. and regain
1 hour post- • Take meals after 15 weight.
prandial: 190 minutes of insulin
mg/dL administration.
2 hours post • Collaborate with the
prandial: 165 dietician to change
mg/dl diet for overweight
RBC: 4.07 women is
recommended. High
protein diet.
• Instruct patient and
family to A avoid
foods containing
excess of
carbohydrate like
sweets, honey,
sugar, fried foods,
cold drinks.
• Avoid foods rich in
fats and calories
Assessment Nursing Planning Intervention Evaluation
Diagnosis
Subjective Data: Deficient After 1 hour of • Assess client’s Goal met After
“Ginhambalan ko knowledge related health teaching knowledge about the 1 hour of
sato sang nurse to lack of client will able to condition. health
nga magkaon exposure to verbalized • Tailor the information teaching client
damo nga information as understanding of according the patient’s verbalized
pagkaon kag akon evidence by GDM, procedures, ability to understand the understanding
cravings dabi verbalization of laboratory test and information of GDM,
hindi ko the patient. activities. • Educate client along procedures,
mapunggan” with the family about laboratory test
GDM, signs and and activities
Objective Data. symptoms.
Confused • Discuss how the client
Worried can recognize signs of
Stress infection.
• Teach client information
regarding the impact of
pregnancy on the
diabetic condition and
future expectations
• Discuss about the
importance of diet.
• Provide dietary
instructions on the
importance of intake
iron-rich foods along
with the family.
• Teach client along with
the family members
how to use insulin
• Explain the difference
between normal and
abnormal weight gain
during pregnancy.
• Educate patient to
prevent themselves to
do frequent exercises
Nursing Responsibility
Nursing Responsibilities of CBC
1. Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
2. Encourage to avoid stress if possible because altered physiologic status influences and changes
normal hematologic values.
3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of
lipidemia.
4. Instruct to resume normal activities and diet.

Nursing responsibilities of Urinalysis

1. Check the doctor’s order.
2. Inform the patient and the mother that urine specimen is needed. Explain the procedure and its
significance.
3. Explain to the patient and to the mother how to procedure is done.
4. Fill up request form properly.
5. Provide a clean container for collection of urine.
6. Instruct to collect a clean catch, mild-stream urine.
7. Send the specimen to the laboratory properly labeled together with laboratory slip.
8. Chart time of collection of urine.
9. Attach result to the chart as soon as they are available
10. Nursing responsibilities: All Drugs except for insulin
11. Verify Doctor’s order.
12. Remember the 10R’s of Drug Administration.
13. Verify patient’s identification.
14. Inform the patient with regards to drug administration.
15. Clean the IV port prior to administration of the drug.
16. Monitor patient for adverse effects.
17. Inform patient that easy bruising may occur.
18. Caution patient to stop taking drug abruptly without first consulting prescriber.

Nursing responsibilities for Insulin

1. New insulin must be kept on the door side of the fridge
2. Do not inject cold insulin
3. Rotate site to prevent Lipodystrophy

Health Education PRN

1. Teach patient about GDM, signs and symptoms
2. Teach the patient the importance of bed rest and diet to control the symptoms.
3. Encourage the support of family and friends to prevent patient to eat high glucose foods.
4. Provide information on tests and procedures to evaluate maternal-fetal status, such as laboratory
tests.
5. Include support of the neonatal team for discussion of fetal prognosis with the woman and her family.
6. Encourage patient to exercise regularly.