Princess Levie Ceniza BSN 2A Case study 119

SCENARIO

You are working as an RN in a large women’ s clinic. Y.L., a 28 years old Asian
woman, arrives for her regularly scheduled obstetric appointment. She is in her 26th
week of pregnancy and is primigravida. After examining the patient, the nurse -
midwife tells you to schedule Y.L for a glucose challenge test. You review Y.L.’s
chart and note she is 5 feet, 3 inches and weighs 143 pounds; her pregnancy body
mass index ( BMI ) is 25. Her father has type 2 diabetes mellitus , and both paternal
grandparents had type 2 DM. You enter the room to talk to Y.L.

1. What is the purpose of a glucose challenge test ?

The glucose challenge test is done during pregnancy to screen for gestational diabetes
that develops during pregnancy. The glucose challenge test is done in two steps. First
you drink a sugary solution. One hour later, your blood sugar level is measured. An
oral glucose tolerance test can be used as the initial test if a women is at high risk for
GDM,but the test is more likely to be used for diagnosis following abnormally high
GCT results
Gestational diabetes mellitus (GDM) 

2. When is the glucose challenge performed ?

Between 24 and 28 weeks gestation

This test checks for gestational diabetes. Most pregnant women have a glucose
screening test between 24 and 28 weeks of pregnancy. The test may be done earlier if
you have a high glucose level in your urine during your routine prenatal visits, or if
you have a high risk for diabetes.

3. What instructions would you provide Y.L. regarding the test ?

You have to fast from midnight on the day of the test. Tho, fasting is not necessary for
a glucose challenge test, but if the concentration is really high then you do have to fast
to do a oral glucose tolerance test.
When you receive a glucose tolerance test, a phlebotomist will draw a sample of
your blood through a needle from a vein in your arm after you have fasted for at
least eight hours, typically overnight. Then you will drink a sweet drink, and the
technician will take more blood samples over the next two to three hours.
A phlebotomist is a trained medical professional specializing in safely extracting
blood from patients and performing routine blood and urine tests. Phlebotomy
schools are institutions that instruct individuals on how to be phlebotomists. ... The
most common place this is done is at a hospital or during a blood drive.
CHART VIEW

Laboratory test results

Time of test Value Normal range

0730 109 mg/dL under 95 mg/dL
0830 213 mg/dL under 180 mg/dL
0930 162 mg/dL under 153 mg/dL

4. Interpret the results of Y.L’s test.

It shows that Lucy does had gestational diabetes.Her results are all higher than normal
which also shows that she is at higher risk for gestational diabetes

5. Y.L. is diagnosed with gestational diabetes mellitus ( GDM ). What is GDM ?

During pregnancy, your placenta makes hormones that cause glucose to build up in
your blood. Usually, your pancreas can send out enough insulin to handle it. But if
your body can't make enough insulin or stops using insulin like it should, your blood
sugar levels rise, and you get gestational diabetes.

6. List five risk factors for DGM. Place a star or asterisk next to those risk factors that
Y.L. has.

●Overweight and obesity.

Maternal obesity and gestational diabetes are the most common metabolic
complications of pregnancy related to fetal overgrowth and more specifically
adiposity. Women with gestational diabetes have increased insulin resistance and
inadequate insulin response compared with weight-matched controls.

●A lack of physical activity.

When you have gestational diabetes, your blood glucose levels run higher than they
normally would. One way to lower blood glucose levels is to exercise. When we
exercise, our muscles take in more glucose. When this effect wears off, our muscles
remain more sensitive to insulin for some time.
●Previous gestational diabetes or prediabetes.
Gestational diabetes arises in certain women who cannot overcome the insulin
resistance that develops during pregnancy. In most cases, the condition goes away
after the baby is delivered. However, women who have gestational diabetes have
increased risks of developing Type 2 diabetes later in life.
●Polycystic ovary syndrome.
This is because this condition is associated with high blood sugar and insulin
resistance. Because of this risk, pregnant women with PCOS may be tested for
gestational diabetes earlier than at the routine 24-28 weeks.
●Diabetes in an immediate family member.
Your chances of developing gestational diabetes (GD) are higher if a close relative,
like your mum, or your sister, have had it. That's because diabetes can run in families.
Your chances of developing GD are also increased if: You have a BMI above 30.
●Previously delivering a baby weighing more than 9 pounds (4.1 kilograms).
Diabetes in the mother is the most common cause of babies who are large for
gestational age. When a pregnant woman has high blood sugar, she can pass that
along to her baby. In response, the baby's body makes insulin. All the extra sugar
and the extra insulin that is made can lead to fast growth and deposits of fat.

CASE STUDY PROGRESS

Medical nutrition therapy is the primary treatment for the management of GDM.
Because treatment must begin immediately, you call the dietitian to come see Y.L. to
meet with other members of the DM management later in the week.

7. What is the goal of medical nutrition therapy ?

Focused on the management of disease through individualized nutrition assessment

and education. The goal of this is to influence/counsel a patient on behavioral and
lifestyle change required to positively affect long term health. This can not only
manage disease, but can reduce risk of any complication associated with the disease,
also.They include:

●managing weight
When a person with diabetes reach and maintain a healthy weight, they feel better
and have more energy. Their diabetes symptoms decrease and their blood sugar
levels are better controlled. They also may be less likely to develop complications
from diabetes, like heart disease.

●managing blood glucose levels

Take your insulin or pills when you're supposed to. Follow your meal plan. Get
regular exercise. Check your blood sugar levels often and make changes with the
help of your diabetes health care team.
Take your insulin or pills when you're supposed to. Follow your meal plan. Get
regular exercise. Check your blood sugar levels often and make changes with the
help of your diabetes health care team.
●managing blood lipid levels
Target LDL cholesterol levels for adults with diabetes are <100 mg/dl (2.60 mmol/l);
HDL cholesterol levels are >40 mg/dl (1.02 mmol/l); and triglyceride levels are <150
mg/dl (1.7 mmol/l). In women, who tend to have higher HDL cholesterol levels than
men, an HDL goal 10 mg/dl higher may be appropriate.

Insulin resistance and type 2 diabetes are associated with a clustering of interrelated
plasma lipid and lipoprotein abnormalities, which include reduced HDL
cholesterol, a predominance of small dense LDL particles, and elevated triglyceride
levels.
●reducing the chances that you’ll need additional medications

8. Describe the usual diet used in treating GDM.

●Plenty of fruits/vegetables (about 3 to 5 servings/day)

●Moderate amounts of lean protein and healthy fats (about 2 to 3 servings/day)
●Moderate amounts of whole grain (about 6 or more servings/day) eat more complex
carbs rather than simple
●Fewer foods with a lot of sugar

9. Why is medical nutrition therapy for a woman with GDM higher in fat and
protein ?

●Protein is crucial because it can assist in the building of the heart and brain of the
baby.
Protein and iron, especially, are found in meat. There is a higher percentage of iron in
red meat, specifically. The pregnant woman must ingest a higher caloric intake daily
than a woman who is not pregnant in order to gain weight, and maintain her and the
baby's health.
●A pregnant woman should maintain a diet that is high in calcium, folic acid, iron,
and protein. Calcium will help build the baby's bone structure and teeth. Folic acid
can help prevent any birth defect in the baby's brain and spinal cord. Iron is necessary
to produce more blood to supply the baby with adequate oxygen.

10. Women with GDM cannot metabolize concentrated simle sugars without a sharp
rise in blood glucose. Name five examples of simple sugars you would teach Y.L. to
limit ?

●regular soda, milk

Milk is a healthy food and an important source of calcium. However, milk is a liquid
form of carbohydrate and drinking too much at one time can raise your blood
sugar. Fruit is a healthy food, but it is high in natural sugars. You may eat one to
three portions of fruit per day, but only eat one at a time.
Researchers have found for the first time that drinking more than 5 servings of
sugar- sweetened cola a week prior to pregnancy appears to significantly elevate
the risk of developing diabetes during pregnancy.
●Candy, cake, cookies-alls desserts in general

People with diabetes either do not produce enough insulin or their cells do not
respond to the hormone appropriately. This causes blood glucose levels to become
too high. Simple sugars tend to raise blood glucose levels faster and higher than
complex carbohydrates, such as whole wheat and oatmeal.
●Whole-wheat pasta, beans, sweet potatoes, jams or jellies, syrup
●Glucose, honey, fructose, corn syrup, molasses, sucrose
●fruit, fruit juice

11. Complex carbohydrates do not cause a rapid rise in blood glucose when eaten in
small amounts. Identify five foods from this group.

●Whole oats
The pros of adding oatmeal to your diabetes eating plan include: It can help regulate
blood sugar, thanks to the moderate to high fiber content and lower glycemic index.
It's heart-healthy due to its soluble fiber content and the fact it can lower cholesterol.
●Apples
An apple a day keeps the doctor away! Apart from being great for your overall health,
the natural-sugar in the fruit has a relatively low impact on the insulin and blood sugar
levels in the body. Diabetics can opt for carrots in their daily diet despite its sweet
flavour as it can help manage blood glucose levels.
● Cashews
Over 75 percent of the fat in cashews is oleic acid, which is also known to be a heart-
healthy mono-unsaturated fat. Moreover, cashews are responsible for lowering
blood sugar levels.

CASE STUDY PROGRESS

During the meeting with the dietitian, Y.L. gives a diet history that is high in noodles
and rice with little protein. She informs the dietitian she is lactose intolerance but can
have dairy products occasionally in small portions.
12. It is important that Y.L take a calcium supplement along with her prenatal
vitamins ?

Calcium during pregnancy are necessary to calcify fetal bones and teeth. Women of
Y.L.'s age normally need 1000 mg/day of dietary calcium intake. Calcium can also
help with her lactose intolerance and it can also help with the Ca+ loss in
ketoacidosis.

13. Y.L is instructed to monitor her fasting blood glucose first thing in the morning
and 2 hours after every meal. What are the purposes of this request ?

The purpose of this request is to make sure that her sugar is under control and isn’t
too low in the AM and isn’t too high after meals. Keeping track and notifying the
HCP over any elevation or decreases in blood glucose is important.

14. Y.L is instructed to complete ketone testing using the first voided urine in the
morning. What is the rationale of this request ?

Because of the long overnight fast, blood sugar can drop too low in the night, and the
body would have to turn to other sources of energy like the fat stores, thus giving off
or 'spilling' ketones.

15. Y.L asks whether having gestational diabetes will hurt her baby. How would you
respond ?

Gestational diabetes affects the mother in late pregnancy, after the baby's body has
been formed, but while the baby is busy growing. Because of this, gestational diabetes
does not cause the kinds of birth defects sometimes seen in babies whose mothers had
diabetes before pregnancy.
However, untreated or poorly controlled gestational diabetes can hurt your baby.
When you have gestational diabetes, your pancreas works overtime to produce
insulin, but the insulin does not lower your blood glucose levels. Although insulin
does not cross the placenta, glucose and other nutrients do. So extra blood glucose
goes through the placenta, giving the baby high blood glucose levels. This causes the
baby's pancreas to make extra insulin to get rid of the blood glucose. Since the baby is
getting more energy than it needs to grow and develop, the extra energy is stored as
fat.
16. At the conclusion of the visit, you need to evaluate your teaching. Which
statement made by Y.L indicates the clarification is necessary ?

A. “ I will stay on the diabetic diet described by the dietitian.”

B. “ I will monitor mu glucose levels at least four times each day.”
C. “ I need to stop exercising because I will need more carbohydrates.”
D. “ I should immediately report any ketones in my urine.”

-Answer: C. “I need to stop exercising because I will need more carbohydrates.”

As far as controlling your diabetes is concerned, your goal is to balance the insulin
in your body and the exercise you do with the carbs you eat. Balancing insulin,
physical activity, and carb intake keeps your blood sugar levels in a healthy range.