Case Study of Lisa Lawrence: Gestational Diabetes

Case Study of Lisa Lawrence: Gestational Diabetes
            The case analysis involves the primipara patient Lisa Lawrence, and the health care provider that shall administer the needs of Mrs. Lawrence. The following are the queries imposed in the overall case, which are answered by basing in the subjective and objective cues presented, as well the principles of the disease.
Set A:

How would the nurse respond to Lisa?
Guided by the therapeutic form of communication and ethical considerations of beneficence and veracity, the best response of the nurse to initiate is, “As of now, I cannot answer that yet since in our initial exam, it is evident you are having an increased blood sugar; however, it is still too early to conclude on anything. Do not worry, I will prepare for your glucose challenge test or GTT to determine how quickly sugar is cleared from your body. It will take 3-hours for me to prepare, and after which, I can assure to provide the results to you. Meanwhile, I need you to relax, and not to worry about the condition.” According to the ethical considerations, we should not mention something to the patient without having further basis. In this scenario, the best intervention is to have the patient as comfortable and relax as possible while waiting for the results.
How would the nurse prepare Lisa for the 3-hour GTT?
GTT is utilized in order to test for diabetes, insulin resistance, and sometimes reactive hypoglycemia through an oral test or OGTT. Prior to the tests, the nurse should explain first the purpose, and method involved in the process of GTT, and after which, let the patient verbalize any feeling of concern, questions, etc. Explain to the patient that a small needle will be inserted into an arm vein for blood sampling, and the needle will have to stay in place until the whole exam is completed. The patient will be given 300 ml of glucose to drink, which is very sweet, but it is essential that the patient drink it all over the 5 minutes, so that the results of the test can be interpreted correctly. Validate if the patient has taken high carbohydrates meals for the three days before the test, and then, asked the patient if she has taken something to eat or drink, except water, for the past 13 hours prior to admission. Lastly, ask the patient if she had taken a smoke for the past 1 hour prior to the test procedure. The test should be performed in the morning; since, this is the best time especially if 12-hour-food fasting is required. Have the patient on the most relaxing and comfortable status while waiting for three hours.
Set B:
How should the nurse explain Lisa’s insulin needs throughout her pregnancy and postpartum?
“Hi Mrs. Lawrence. About your concern regarding the doctor’s orders, I understand that this is very much new to you. However, the sole purpose of these instructions is reduce possible complications resulted by having increased blood sugar, such as increased of blood pressure during pregnancy, and over-increased on your baby’s size. By having this maintenance treatment, we can promote the status of your pregnancy that is why we would need your outmost participation regarding this matter.”
Explain how the nurse will teach Lisa to administer two types of insulin (NPH 15u. and regular 5u.) together?
In mixing NPH and regular insulin, it is essential for the nurse to assess and evaluate the patient’s understanding before and after the teaching procedures. It is also essential that the nurse provide clear and accurate teaching for the patient. When it is necessary to mix insulin, there are five important guidelines that you must teach to the patient: (1) Do not contaminate the contents of one vial with the contents of the other vial, (2) Always draw up Regular insulin first, (3) Always draw up the NPH insulin last because chemically it has a protein substance in it that Regular insulin does not have. Drawing up the NPH insulin last helps prevent contamination of the Regular insulin, (4) Choose a Lo-Dose insulin syringe (U-30 or U-50) to measure low dosages; use a U-100 syringe for insulin combinations, and lastly, (5) Always add air into each vial equal to the amount of the required dose. Air prevents a vacuum from occurring. Emphasize that it is important to inject air into the NPH vial first.
What kinds of insulin have been ordered? How are they different and why are they both ordered?
Regular and Humulin NPH insulins are the prescribed insulin medication for the case of Mrs. Lawrence. Regular insulin has a quick onset and peak, and a short duration of therapy. The physician prescribed low dose regular insulin due to it pharmacokinetic features, which can be administered multiple times a day, usually before meals and at bedtime. This feature provides urgent preparation for intermittent blood sugar increase. On the other hand, Intermediate-acting Insulin (NPH), ha a slower onset with a peak effect longer than those of regular insulin. The combination of both regular and NPH insulins provide current and long-term maintenance of blood sugar. Regular insulin aims to provide a reversal shot in case blood sugar surges up, while NPH provides maintenance dose for gestational diabetes.
When during her pregnancy will Lisa be most prone to hypoglycemia and hyperglycemia?
Human placental Lactogen, which is the primary contributor of gestational diabetes, reaches its peak late in pregnancy; during the third trimester, insulin requirements rise. Such occurrence causes Lisa to be prone to hyperglycemia. On the other hand, hypoglycemia may be present on first contact or may be iatrogenic, which connotes the result of an extended stay in the acute care setting during which ongoing glucose testing and meals are disrupted.
Explain the signs of hypoglycemia and hyperglycemia and how each are treated.
The signs of hypoglycemia involve perspiration, confusion, anxiety, mood changes (argumentive, agitated, and anxious), lethargy, tachycardia, hunger, nausea, and adverse events can lead to hypotension, unconsciousness, seizure, and hypothermia. Hypoglycemia can be treated by simple ingestion or administration of glucose, such as at least 4tsp table sugar, or 2-3 hard candies. On the other hand, the signs of hyperglycemia involve fruity breath odor (indication of ketoacidosis), complain of extreme thirst (polydipsia), urge to urinate frequently (polyuria), feeling of hungriness (polyphagia), nausea and/or vomiting, and loss of consciousness. Insulin treatment is the most common management for hyperglycemia; however, in case of severe cases emergency medical services and treatment for shock are necessary.
What other complications are possible for Lisa to encounter because of her diabetes?
The complications that usually rise during maternal complications of diabetes during pregnancy are the following: Preeclampsia, miscarriage, infection, postpartum hemorrhage, increased risk for cesarian section, hypoglycemia, ketoacidosis, diabetic coma, macrosomia (fetal enlargement as manifested by more than normal fetal weight), peripheral neuropathy, gastrointestinal disturbances, and other fetal complications.
Set C:
How would the nurse explain to Lisa why her baby weighed 12 lbs.?
In accordance to ethical considerations and role of the nurse as an educator, it is essential to provide necessary awareness in accordance to occurring problem. The nurse needs to explain that the enlargement is due to gestational diabetic complications, macrosomia, while other complications, such as shoulder dystocia and twitching of the arms and legs are also part of the diabetic complications. The nurse needs to consider therapeutic communication, and provide empathic conversation that initiates the patient’s expression of her feelings towards the incident.
If Lisa had been a diabetic for 10 years, what could the baby be expected to be like in contrast to the gestational diabetic’s baby?
Women with gestational diabetes have a lessened risk of congenital abnormalities compared to women with overt diabetes because gestational diabetes generally does not occur until the 24th week of gestation. The risk of congenital abnormalities is three times greater in pregnant overt diabetes than in the non-diabetic population. In addition, infants of mothers who have diabetes are at increased risk for RDS because of physiologic pulmonary immaturity. This risk is taken into account in the determination of planned deliveries and care is taken to avoid delivery of a premature infant. Infants of mothers who have diabetes also may develop significant hypocalcemia in the first few days of life.
What assessments of Lisa should the nurse make to monitor for potential complications after delivery and why?
The nurse should monitor the risk for infection at the delivery site due to the forth degree laceration that has occurred. Infection may predispose the patient’s post partum condition; since, the condition of the wound site is open, and easily transmitted with microorganism due to excretal function. If this if not monitored properly by the nurse, severe complications of the postpartum may progress.
What complications does Lisa’s baby have and what additional complications might the nurse anticipate? How might the nurse intervene?
The complications present in Lisa’s baby involve fetal macrosomia or enlargement more than the standard body weight, and shoulder and shoulder dystocia, which are the primary complications of gestational diabetes. Other complications that the nurse should expect are infection due to diminished immunologic immunologic function of the child due to macrosomial manifestations, episodes of hyperglycemia and hypoglycemia, and probable pulmonary complications.
How will the nurse encourage maternal infant bonding?
The nurse should encourage breast feeding if no contraindications are present. According to various studies, breast feeding is the best possible initiator of bonding between mother and child; hence, it is beneficial if the mother provides such care concept towards her infant.
Reflective Writing:
            Lisa says to the nurse. “I’m sure glad this all over and I won’t have to deal with having diabetes anymore.” How would you respond?
            “I understand how you feel after recent delivery. Gestational diabetes usually ends 2-10 days after delivery; however, this may still progress and carry a lot of complications. It is essential that you monitor still your conditions. If in case, signs and symptoms such as fruity breath odor, increased thirst, increased  frequency of urination, and feelings of hunger progress, it is important that you have an urgent monitoring of your blood sugar. If in case, high level of blood sugar has been monitored, please have your health care provider immediately. In order to prevent such occurrence, have plenty of exercise after you healed from your condition, and rightful diet, particularly with vegetables.”

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