Assessment

Nursing DX/

Clinical Problem

Client Goals/

Desired Outcomes

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

∙ Husband’s “income is variable dependent on work”

∙ Client has gestational diabetes

Objective

∙ 1 Hour GTT: 145

∙ 3 Hour GTT: Fasting- 100    1 Hour- 195     2 Hour- 165 3 Hour- 170

Problem

Risk for unstable blood glucose

Long Term:

Client will maintain fasting blood glucose level 105 mg/dL, 1-hour after the meal (pc) level 155 mg/dL, and 2-hour pc level 130 mg/dL until the EDD (xxxxx) (Ackley & Ladwig, 2008).

∙ Monitor blood glucose before meals and at bedtime. (Self-monitoring of blood glucose is an easy, less intensive way to help reach blood glucose goals) (Ackley & Ladwig, 2008).

∙ Monitor for signs and symptoms of hyperglycemia, such as polydipsia, polyuria, and polyphagia. (Being aware of blood glucose levels outside of normal allows for early detection and treatment before progressing to ketoacidosis or other more serious conditions) (Ackley & Ladwig, 2008).

A goal would be met if the client’s blood glucose levels are between or below the targeted levels. A goal that is not successfully met would be shown by glucose levels being above the targeted levels.

∙ If the client verbalizes self-monitoring blood glucose levels before meals and at bedtime then the intervention has been successfully carried out. If the client does not monitor blood glucose levels before meals and at bedtime the intervention is not successfully

∙ If the client can verbalize several signs and symptoms of hyperglycemia the intervention would be successfully carried out. If the client can not, the intervention is not successfully met.

Risk Factors

Pregnancy, stress (Ackley & Ladwig, 2008).

Short Term:

Client will verbalize self-care actions to take if blood glucose is too high or too low a week from the date of care, xxxxx (Ackley & Ladwig, 2008).

∙ Teach client to maintain a blood glucose diary. (Keeping a diary can help clients realize what symptoms are related to blood glucose readings, as well as guide diabetes treatment) (Ackley & Ladwig, 2008).

∙ Teach clients who are treated with insulin that they may need to eat extra carbohydrates before exercise, depending on how exercise affects their blood glucose levels. (Taking glucose before exercise can help prevent hypoglycemia) (Ackley & Ladwig, 2008).

∙ Teach client that stopping insulin therapy can lead to hyperglycemic crisis (ketoacidosis or hyperosmolar hyperglycemia). Ensure client has resources to purchase insulin. (Diabetes can be a particularly expensive disease to cope with, but it is important to continue therapy) (Ackley & Ladwig, 2008).

The goal would be successfully met if the client can verbalize 5 self-care actions to take if blood glucose is too high or too low on xxxxxx. If the client can not verbalize 5 self-care actions the goal would not be successfully met.

∙ If the client either verbalize having kept a blood glucose diary, or can present a blood glucose diary this intervention would be successful. If not, the intervention would be unsuccessful.

∙ The intervention would be successful if the client verbalizes having consumed extra carbs or glucose before exercising. If the client can not do this the intervention is not successful.

∙ The intervention would be successful if the client verbalizes continuing insulin therapy. If the client can not do this the intervention is not successful.