A 34 years old patient Rowena, who is a multiparous pregnant woman came to the hospital who

appeared to be pale, tired, and sleepy in general with a total weight of 170lbs, 5.5 ft,and a BMI of 27.5
(Overweight). Upon verbalization, the patient is not sure about her condition but she verbalized feeling
of dizziness. During the interview, the patient verbalized that she has a normal BP of 120/90mmHg but
had a family history of Diabetes and Hypertension, she also had a history of miscarriage. She had her
urinary examination and upon the result, it shows +3 glycosuria (presence of sugar in urine which is not
normally seen in urine).

Upon the doctor’s medication order, it can be concluded that the patient is diagnosed of having a Type 2
Gestational Diabetes Mellitus, this is due possible evidence of the medications order made by the
physician which is the Insulin (Lispro & Levimir) that is commonly administered to a diabetic patient with
type 2 dm to help lower their blood sugar level.

Gestational diabetes Mellitus 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,
GDM is often complicated by hypertension which could lead to unusual feeling of dizziness that is felt by
the patient, Rowena.

Patient’s Profile

Biographic Data

Name: Rowena Alejandro

Age: 34 years old

Sex: Female

Birthday: January 1, 1987

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Height: 5 feet and 5 inches

Weight: 170 lbs

Educational Status: High School Graduate

Occupation: Works in a textile company

LMP: Aug. 29, 2020

EDC: June, 05, 2021
Clinical Data
CBC With Differential Platelet (April 21, 2021 @ 9:00AM)
WBC: 11.5 (Normal)
RBC: 4.07 (Low)
Hemoglobin: 11.1 (Normal)
Hematocrit: 45.5 (Normal)
MCV: 112 (High)
MCH: 38.8 (High)
MCHC: 34.3 (Normal)
RDW: 14.2 (Normal)
Platelets: 256 (Normal)
Neutrophils: 57 (Normal)
Lymphs: 32 (Normal)
Monocytes: 8 (Normal)
Eos: 2 (Normal)
Basos: 1 (Normal)
Neutrophils (Absolute): 3.7 (Normal)
Lymphs (Absolute): 2.1 (Normal)
Monocytes (Absolute): 0.5 (Normal)
Eos (Absolute): 0.1 (Normal)
Basos (Absolute): 0.0 (Normal)
Immature Granulocytes: 0 (Normal)
Immature Grans (Abs): 0.0 (Normal)
PROCEDURE PURPOSE NORMAL RESULT NURSING
RANGE MANAGEMENT
CBC With The complete WBC - Reduce
Differential blood count physical or
Platelet (April (CBC) is a emotional
21, 2021 @ group of tests stress, drink
9:00AM) that evaluate more water and
WBC the cells that 3.4 - 10.8 11.5 High avoid eating
 RBC circulate in 4.14 – 5.80 4.07 Low street foods,
Hemoglobin blood, 13.0 – 17.7 11.1 Low have a checkup
Hematocrit including red 37.5 – 51.0 45.5 for possible
MCV blood cells 79 – 97 112 High infections.
MCH (RBCs), white 26.6 – 33.0 38.3 High RBC – Increase
MCHC blood cells 31.5 – 35.7 34.3 folic acid intake,
RDW (WBCs), and 12.3 – 15.4 14.2 vitamin b12, b6
Platelets platelets 150 – 379 256 Hemoglobin –
Neutrophils (PLTs). The Not estab. 57 Increase folic
Lymphs CBC can Not estab. 32 acid, vitamin C
Monocytes evaluate your Not estab. 8213 and B12
Eos overall health Not estab. .7 MCV & MCH –
Basos and detect a Not estab. 2.1 Increase folic
Neutrophils variety of 1.4 – 7.0 0.5 acid, vitamin C
(Abs) diseases and 0.7 – 3.1 0.1 and B12
Lymph (Abs) conditions, 0.1 – 0.09 0.0
Monocyte such as 0.0 – 0.4 00
(Abs) infections, 0.0 – 0.02 .0
Eos (Abs) anemia and Not estab.
Baso (Abs) leukemia 0.0 – 0.1
Immature
Granuo
Immature
Grans (Abs)

Urinalysis with Micro rflx Cult (April 21, 2021 @ 9:00AM)

Color: Yellow
Appearance: Cloudy
Specific Gravity: 1.010 (Normal)
pH: 6.0 (Normal)
Glucose: Negative
Bilirubin: Negative
Ketone: Negative
Occult Blood: 2+
Protein: 3+
Nitrite: Negative
Leukocyte Esterase: 1+
WBC: 20-40
RBC: 10-20
Squamous Epithelial: 6-10
Bacteria: Many
Crystals: Not Seen
Casts: Not Seen
Yeasts: Not Seen
PROCEDURE PURPOSE NORMAL RESULT NURSING
RANGE MANAGEMENT
Urinalysis A urinalysis is Appearance –
with Micro rflx used to detect Drink more
Cult (April 21, and manage a water, cloudy
2021 @ wide range of appearance
9:00AM) disorders, such CLEAR CLOUDY may be result to
Appearance as urinary tract 1.001 – 1.035 1.010 high content of
Specific infections, 5.0 – 8.0 6.0 solute
Gravity kidney disease NEGATIVE NEGATIV Occult blood –
pH and diabetes. NEGATIVE E Drink more
Glucose A urinalysis NEGATIVE NEGATIV water, refer to
Bilirubin involves NEGATIVE E physician for
Ketone checking the NEGATIVE NEGATIV treatment of
Occult Blood appearance, NEGATIVE E possible urinary
Protein concentration NEGATIVE 2+ tract infections
Nitrits and content of <=5 WBC/HPF 3+ Protein – Drink
Leukocytes urine. <=2 RBC/HPF NEGATIV more water,
Est. <=5 HPF E refer to
WBC NONE SEEN +1 physician for
RBC HPF 20-40 treatment of
Squamous epi. NONE SEEN 10-20 possible kidney
Bacteria HPF 6-10 disease
Crystals NONE SEEN NONE Nitrits – Drink
Casts HPF SEEN more water,
Yeast NONE SEEN NONE refer to
HPF SEEN physician for
NONE treatment of
SEEN possible
NONE bacterial
SEEN infection.

OGTT & FBS (February 8, 2021 @ 10:00AM)

OGTT: Fasting: 120mg/dL
1 hour post-prandial: 190 mg/dL
2 hours post-prandial: 165 mg/dL
FBS: 6.9 mmol/L
PROCEDURE PURPOSE NORMAL RESULT NURSING
RANGE MANAGEMENT
OGTT & FBS Your blood Promoting self-
(February 8, sugar level care:
2021 @ can give your - support the patient
10:00AM) doctor and help them
OGTT important Fasting: develop their own
clues about 120 self-care with
your health, mg/dL guidance from a
and an oral 1hr registered nurse
glucose postprandia observe and report
tolerance test l: any
(OGTT) shows 10mg/dL concerns that you
how well your 2hours may
body handles postprandia have about a
sugar from l: patient that
FBS foods. It can 165 would affect their
tell whether mg/dL ability
you are at risk to self-care
for diabetes or 6.9 mmol/L
if you already Screening,
have it. A prevention
shorter version and early
of an OGTT detection of
checks for type 2 diabetes
diabetes describe the risk
during factors
pregnancy. for type 2 diabetes
- Explain the
Blood samples importance of
are generally prevention or delay
used to screen of onset of type 2
for diabetes. diabetes in
Your doctor individuals at risk
will order a Explain the role that
fasting blood exercise plays in
sugar (FBS) the
test. This test prevention of, or
measures your delay in
blood sugar progression to, type
levels, or a 2
glycosylated diabetes
hemoglobin, - Explain the
also called a importance of
hemoglobin weight
A1C test. The control and the role
results of this that diet plays in the
test reflect prevention of, or
your blood delay in
sugar levels progression
over the to, type 2 diabetes.
previous 90
days. Blood glucose
monitoring
- Perform the test
according to
manufacturers’
instructions and
local
guidelines
- Perform the test
unsupervised, at
the
request of a
registered nurse
- Document and
report
the result according
to local guidelines
and procedures
- Recognize and
follow
local quality
assurance
procedure,
including
disposal of sharps
- Recognize
hypoglycemia and
be
able to administer
glucose
- Understand the
normal range of
glycaemia and
report
any readings
 outside
this range to the
appropriate person.

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

Name: Rowena Alejandro Age: 34 years old Sex: Female
LMP: Aug. 29, 2020
Exam Date: April 22, 2021 Placental location: Left Biometry:
General Survey: Posterolateral BPD: 8.51 cm
No. Of Fetus: Single (1) Placenta Grade: 2 HC: 30.2 cm
Presentation: CEPHALIC AC: 28.7 cm
FHT: 138 bpm
Amniotic Fluid Index: 2.87
Ave.
Ultrasonic Age: 33W 5D
Ultrasonic EDC: 06/05/21
Estimated Fetal Weight:
2845
grams
Gender: Female
Impression: With good cardiac and somatic activity, female, cephalic, 33 weeks & 5
days, by biometry with adequate fluid, BPP=8/8, grade 2 left posterolateral placenta (2.0
cms from the internal os). Estimated fetal weight is large for gestational age.
PROCEDURE PURPOSE RANGE NURSING
MANAGEMENT
Biophysical A biophysical No. of fetus: Baby is
Scoring: profile (BPP) Single (1) considered Large
February 8, test measures Presentation for gestational
2021: 2:00PM the health of : age.
your baby CEPHALIC There is no
(fetus) during FHT: 138 specific treatment
pregnancy. A bpm for LGA.
BPP test may Amniotic Respiratory
include a Fluid distress and
nonstress test index: 2.87 meconium
with electronic Average aspiration are
fetal heart Ultrasonic treated with
monitoring and age: supplemental
a fetal 33W 5D oxygen or other
ultrasound. Ultrasonic supportive devices
The BPP EDC: such as
measures your 06/05/21 continuous
baby's heart Estimated positive airway
rate, muscle Fetal pressure (CPAP—
 tone, weight: 2845 a technique allows
movement, grams newborns to
breathing, and Gender: breathe on their
the amount of Female own while being
amniotic fluid Placental given slightly
around your location: pressurized
baby. Left oxygen) or a
Posterolater mechanical
al ventilator,
Placenta depending on the
Grade: 2 severity of the
Biometry: problem.
BPD: 8.51
cm
HC: 30.2 cm
AC : 28.7
cm

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

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

MISCELLANEOUS
VDRL Non-Reactive

Past Health History

There were no other diseases found aside from the patient’s having allergy to shrimp
which she was only taking Cetirizine 10mg whenever needed as per her doctor’s order.
Aside from that the patient reported that she undergone surgery that her gallbladder
was removed because of gallstones way back in 2013. And she claimed that she was
able to finished all her immunization and received tetanus toxoid in this pregnancy.
Present Health History
The patient is currently being seen for prenatal care at 33rd weeks gestation, however,
she felt dizzy on her way to the nearest primary hospital and decided to admit herself.
She never felt that way before her previous pregnancies. She reported that she ate
before she goes and reported the food she consumed which were half rice, sunny side
up, and she also drank coffee. She does not have an idea why that happened to her.
And the patient was eager to know how’s her current condition and she stated that she
was afraid if abortion or miscarriage will happen again.
The patient vital signs are 130/80 mmHg, 35.8 degrees Celsius, 99bpm, and 23cpm
which signifies that she is hypothermic and tachycardic. In regards to her weight which
is 170 lbs and her height is 5 feet and 5 inches it implies that the patient is overweight
with a BMI of 28.3. As for her laboratory results came, it shows that her WBC is 11.5,
Hemoglobin is 11.1g/dL, MCV is 112, and MCH is 38.3 which implies greater than the
normal range.
Upon inspection, the patient has fair-colored skin complexion, with a head of rounded,
normocephalic and symmetrical. Pallor is noted. There is a visible neck veins, and there
is no enlargement found. The nose has no signs of flaring and no presence of discharge
found. The neck muscles are equally in size, and no palpable nodules was found. The
abdomen is globular and a faint linea nigra and stretch marks are still visibly noted.
Breasts are symmetric, no dimpling and discoloration noted, nipples and areolas are
dark in color, according to the patient her breast seems to appear larger and firmer. The
chest is symmetrical. She reported that once in a while, difficulty of breathing is
experienced especially when she is lying flat on bed and doing household activity.
Lower extremities were checked, and no edema was noted. On musculoskeletal, no
pelvic girdle pain or back pain was noted. Extremities have a good range of motion,
sometimes felt leg pain due to prolong standing at work and some varicosities were
noted. Palmar erythema noted. Capillary refill actively returns to its normal color in less
than 2 seconds. And during auscultation, lungs have normal breath sounds without
dyspnea, in auscultation to all lobes it is clear. Cardiac rate of patient is 99 beats per
minute and no signs of crackles, wheezing, stridor. And there is audible bowel sounds in
patient’s abdomen.
Family History
Rowena is married to Jon for almost 10 years now. She works at a textile factory and a
high school graduate. They live in a single unit house, and the husband’s source of
income is a Foreman in a construction company near their community. Her family
history reveals that her mother has type 2 diabetes mellitus and on her paternal side is
hypertension.
Health Assessment
GENERAL Looks Pale, Tired, and Sleepy
SKIN Fair-colored complexion Hypothermic (35.8
No lesions, no degree C)
inflammation, no swelling
Mask of pregnancy is
visible.
Abdomen is globular, and
a faint linea nigra and
stretch marks are visibly
noted.
Palmar erythema noted.
HEAD, EYES, EARS Head is round,
NOSE, AND THROAT normocephalic, and
symmetrical.
Pupils are black and equal
in size.
Nose doesn’t have
presence of discharges or
flaring.
No ear discharges and
odor.
No sore throat.
NECK Neck veins are visible.
No enlargement noted.
Neck muscles are equal in
size.
No palpable nodules.
BREAST Symmetric, no dimpling, no
discoloration.
Nipples and areola are
dark in color.
Larger and firmer
RESPIRATORY Chest is symmetrical.
Difficulty sometimes in
breathing especially when
lying down flat and doing
household chores.
Lungs have normal breath
sounds without dyspnea.
23cpm
CARDIOVASCULAR No other cardiac Tachycardic (99 bpm)
abnormalities.
130/80 mmHg
GASTROINTESTINAL Able to digest food. Constipated, hemorrhoids
Has audible bowel sounds. present.
URINARY No infections.
GENITAL No lesions, no
inflammation.
PERIPHERAL/VASCULAR No edema in lower Some varicosities are
extremities. noted.
Capillary refill in less than
2 seconds.
MUSKULOSKELETAL No pelvic girdle pain or
back pain.
NEUROLOGIC Coherent, Alert.
No seizures.
HEMATOLOGIC Normal amounts of WBC, RBC is low.
 Hemoglobin, and MCV is high.
Hematocrit. MCH is high.
ENDOCRINE High in levels of Estrogen
and Progesterone.
PSYCHIATRIC Calm Stressed

PHYSICAL ASSESSMENT
System Assessed: [ ] Integument [ / ] Head & Neck [ / ] Eyes & Ears [ ] Cardiopulmonary
[ ] Preliminaries [ / ] Gastrointestinal [ / ] Genitourinary/OB [ / ] Musculoskeletal [ ]
Neurologic
Inspection
The patient has fair-colored complexion. There is pallor noted. Mask of pregnancy is
visible on the face. The head is rounded, normocephalic and symmetrical. The pupils of
the eyes are black and equal in size. The nose has no presence of discharge or flaring
and it is clear. The neck veins are visible and no enlargement is noted. The muscles in
neck are equal in size.
The chest is symmetrical. The breasts are symmetric, no dimpling and discoloration
noted. The nipples and areolas are dark in color and breasts seems to appear larger
and firmer according to patient. The abdomen is globular and a faint linea nigra and
stretch marks are still visibly noted. Patient reported that once in a while, difficulty of
breathing is experienced especially when lying flat on bed and doing household activity.
There is no edema on lower extremities noted. On musculoskeletal, no pelvic girdle pain
or back pain was noted. Extremities have a good range of motion but sometimes felt leg
pain due to prolong standing at work and some varicosities were noted. Palmar
erythema noted. Capillary refill actively returns to its normal color in less than 2
seconds.
The patient is constipated, hemorrhoids are present and the urine dipstick result shows
3+ glycosuria and negative ketones.
Palpation
Neck muscles has no palpable nodules. Cardiac rate of 99 beats per minute.
Percussion
N/A
Auscultation
Lungs have normal breath sounds without dyspnea and it is clear to auscultation in all
lobes. There are no signs of crackles, wheezing and stridor. Abdomen has audible
bowel sounds.
Other significant findings:
The patient felt dizzy on her way to the nearest primary hospital and decided to admit
herself. She never felt that way before her previous pregnancies. And her laboratory
results in CBC shows that her WBC is 11.5, Hemoglobin is 11.1g/dL, MCV is 112, and
MCH is 38.3 which implies greater than the normal range.

Drugs
1. Regular Insulin – Humulin
2. Insulin Lispro - Humalog
3. Paracetamol – Biogesic
4. Miconazole Oral (buccal) – Oravig
5. Ascorbic Acid – Vitamin C
6. Calciferol – Vitamin D
7. Ferrous Sulfate + Folic Acid – Renatal Vit – Ferrous & Sulfat – FA Tablets
8. Tetanous Toxoid and reduced diptheriatoxoid vaccine absorbed (Tdap) - Bcostrix
9. Metoclopramide – Reglan Apo-Metoclop