19.17 Spotlight Application

This spotlight activity demonstrates how a nurse care for a high risk perinatal client.^[1]

Situation/Background

Ani and Elijah come in for a prenatal visit at 28 weeks. Ani is a G1P0 with the following medical, family, and social history.

Medical History

• No current prescribed medications.
• Allergic to penicillin.
• Not currently taking any over-the-counter medications or herbal preparations
• Negative history for STIs
• Denies any surgeries
• Denies any previous pregnancies
• Denies any history of medical conditions

Family History

Ani’s father has type 2 diabetes mellitus and her mother has hypertension.

Social History

Ani and Elijah live in a two-bedroom apartment on the second floor in a building with only a freight elevator. They have a small dog named Candy. Elijah works for a construction company and is 40 years old. Neither Ani nor Elijah smokes. Elijah does drink an occasional beer. Ani does not drink alcoholic beverages.

Prenatal Care History

Ani has received regular prenatal care. Information from the current 28-week visit is described in the following Table.

The nurse identifies the priority problem at this time as ________.        .

a. Knowledge deficit regarding gestational diabetes

b. Increased risk for infection

c. Knowledge deficit regarding labor and birth

          d. Risk for seizures due to elevated blood pressure

Answer: a

Rationale: The client is asking questions about the diagnosis. The nurse should provide teaching regarding gestational diabetes.

2. The nurse prepares to discuss the importance of glucose control and possible complications regarding gestational diabetes with Ani and Elijah. What topics should the nurse include in the discussion at this time? Select all that apply.

a. Nutrition

b. How to monitor her blood glucose

c. Relaxation techniques

d. Expected range of the 2-hour postprandial glucose reading

e. Importance of daily fetal movement counts (FMC)

f. Preparing for a planned cesarean birth

g. Increased risk for genetic anomalies

h. Increased risk for pregnancy-induced hypertension

i. Importance of exercise to regulate glucose

Answers: a, b, d, e, h, i

Rationale: Nutrition education is the first level of glycemic control. Education on how to monitor fasting and 2-hour postprandial blood glucose readings and the expected range provide a measure of glycemic control. Daily FMCs provide reassurance of fetal well-being. Gestational diabetes is associated with an increased incidence of pregnancy-induced hypertension. Exercise helps regulate blood glucose. Relaxation techniques are included in childbirth education. Gestational diabetes (GD) does not necessarily require a planned cesarean birth if blood glucose levels are adequately controlled. GD diagnosed in the third trimester is not associated with an increased risk for congenital anomalies.

3. The nurse develops a nursing care plan for this client. What additional assessment data should the nurse plan to collect?
To provide comprehensive nursing care for Ani, the nurse should gather the following additional data:

• Recent weight gain patterns
• Blood pressure readings
• Fundal height measurement
• Fetal heart rate and activity
• Signs of edema
• Nutritional assessment: 24-hour dietary recall, typical meal patterns, knowledge and understanding of gestational diabetes dietary requirements

4. What NANDA nursing diagnoses apply to Ani?

Examples of appropriate NANDA nursing diagnoses that apply to Ani include the following:

• Deficient knowledge related to lack of experience with gestational diabetes
• Imbalanced Nutrition: More than Body Requirements related to altered glucose metabolism as evidenced by elevated blood glucose levels and gestational diabetes diagnosis
• Risk for Unstable Blood Glucose Level related to hormonal changes during pregnancy affecting insulin resistance
• Risk for Fetal Injury related to uncontrolled maternal glucose levels

5. Provide an example of a SMART outcome criteria for this client.

An example of a SMART outcome criteria for the “Deficient Knowledge” nursing diagnosis is:

• Ani will verbalize three appropriate dietary changes related to managing gestational diabetes by the next prenatal visit the following week.

6. Provide sample nursing interventions that apply to the “Deficient Knowledge” nursing diagnosis.

• Provide written and verbal health teaching about gestational diabetes, associated risks, and recommended lifestyle changes.
• Involve the client’s partner in the health teaching session to support home care.
• Suggest the client keep a food journal of her dietary intake over the week to discuss at the next visit.

7. Give examples of how the nurse can evaluate the effectiveness of the nursing care plan.

To determine if the identified SMART outcome was met, partially met, or not met, the nurse asks Ani to explain gestational diabetes and describe how she’s managing her diet and glucose levels. The nurse may also ask the client to view her food journal to discuss  nutritional choices made during the week.

An example of the SMART outcome being “met” is  if Ani verbalizes understanding of gestational diabetes management and identifies three dietary changes made by the timeframe indicated.

An example of the SMART outcome being “partially met” is if Ani accurately verbalizes three dietary changes by the timeframe indicated but reports difficulty avoiding sugary snacks in the evening. The nurse modifies the interventions in the nursing care plan by adding a referral to a dietitian for additional support.

An example of the SMART outcome being “not met” is if Ani does not accurately verbalize understanding of gestational diabetes or does not make three dietary changes in the time frame indicated. The nurse modifies the interventions in the nursing care plan by reinforcing health teaching and adding a referral to a dietitian for additional support.