Nursing Goal and
Cue(s) Nursing Diagnosis Scientific Rationale
16-week AOG Risk for During pregnancy, other
overweight: fetal: women may get a type of
r/t excessive diabetes which is called
FBS: 150 mg/dL glucose uptake aeb the gestational diabetes,
- DIABETIC diabetic mother as pregnancy can change
with fbs of 150 how a woman’s body uses
mg/dL glucose.
Throughout pregnancy, a
fetus of a diabetic mother
may be exposed to high
blood glucose levels as
well as high levels of
other nutrients. If diabetes
is not well-controlled, this
can result in them being
larger than other
newborns, making vaginal
birth more difficult and
increasing the risk of
nerve damage and other
birth trauma. Cesarean
births are also more
common. (MedlinePlus,
2022)
Nursing Interventions Rationale Evaluation
Objectives
After nursing intervention, A. Independent After nursing intervention,
the: the:
 Pt will learn the  Establish rapport  A trusting relationship  Pt learned the effects
effects of high blood facilitates cooperation of high blood glucose
glucose to her and the with plan of care to her and the fetus’
fetus’ health  Educate the pt about  Helps client to make health
 Pt will maintain possible effects of informed decisions  Pt maintained balance
balance between diabetes on fetal growth about managing between insulin and
insulin and glucose and development regimen and may glucose throughout
throughout pregnancy increase cooperation pregnancy
 Pt will verbalize and  Educate pt with  Helpful in avoiding  Pt verbalized and
demonstrate selection appropriate food foods that may trigger demonstrated
of foods that will selection to help high blood glucose selection of foods that
achieve normal blood maintain normal blood level will achieve normal
glucose level glucose blood glucose level
 Pt will be able to  Educate pt with the  Helps meet daily  Pt was able to
demonstrate the importance of taking 3 nutritional needs demonstrate the
accurate way of meals and 3 snacks- accurate way of
testing blood glucose including bedtime testing blood glucose
 Pt will be able to snacks which needs to  Pt was able to identify
identify self-care have protein & self-care actions to
actions to take to complex CHO take to maintain target
maintain target  Tell pt the importance  Regular exercise is glucose levels
glucose levels of self-care such as beneficial to overall  Pt was able to
 Pt will be able to having regular physical health and may help demonstrate the
demonstrate the activity such as walking improve glucose correct administration
correct administration and swimming metabolism of prescribed
of prescribed  Determine pt’s diabetic  Strict control before medications, given
medications, if given control before conception helps  Pt normally gave birth
 Pt will give birth to a conception reduce the risk of fetal to a healthy newborn
healthy newborn mortality and
congenital
abnormalities
 Monitor fundal height  Useful in identifying
 each visit abnormal growth
pattern
 Provide information  Frequent monitoring is
and reinforce procedure vital in maintaining the
for home blood glucose normal range of blood
monitoring and diabetic glucose, in order to
management reduce the incidence of
overweight or obese
fetus
 Instruct pt with  Aids in making
accurate recording of accurate interventions
blood glucose level
 Assess fetal movement  Fetal movement and
and fetal heart rate each fetal heart rate may be
visit. Encourage pt to negatively affected
periodically record fetal when placental
movements beginning insufficiency and
about 18 weeks’ maternal ketosis occur
gestation, then daily
from 34 weeks’
gestation on

B. Dependent
 Conduct ultrasound at  Helps determine
18 and 28 weeks whether the fetus is
average, larger or
smaller in size for its
gestational age
 Insulin prescription, if  To keep blood sugar
needed level in a normal range
 Prepare for  Close monitoring is
hospitalization if blood important to evaluate
glucose level keeps on the mother and fetus’
rising condition

Cue(s) Nursing Diagnosis Scientific Rationale
16-week AOG Risk for delivery of A mother’s high blood
macrosomic infant glucose level gives extra
FBS: 150 mg/dL and impaired tissue glucose to the fetus causing
- DIABETIC integrity r/t extra weight and making
gestational diabetes the fetus larger in size or
aeb fbs of 150 what we called as
mg/dL macrosomia.
According to North
American Nursing
Diagnosis Association
(NANDA), impaired tissue
integrity is a state in which
an individual has damage to
a mucous membrane,
corneal, or subcutaneous
tissue.
During vaginal delivery, the
mother’s perineum
stretches tremendously
while pushing the baby out,
causing perineal
tear/laceration.
If the mother is giving birth
to a baby that is larger than
normal,
episiotomy is needed in
order to prevent laceration.
This is done by cutting
through the area between
the vaginal opening and the
anus, making the vaginal
opening larger (John
Hopkins Medicine, 2022).
Nursing Goal and
Nursing Interventions
Objectives
After nursing A. Independent
intervention, the:  Establish rapport
 Pt will verbalize the
importance of
maintaining normal  Educate pt about the
blood glucose level importance of glucose
 Pt will learn the control
effects of delivering
macrosomic fetus if
blood glucose level  Educate pt about dietary
is not controlled regulation
 Pt will learn ways on
how to monitor and
maintain blood  Instruct pt to do regular
glucose level physical activity such as
 Pt will maintain a walking and swimming
normal blood
glucose level
 Educate pt the effects of
high blood glucose level
to the size of the fetus
and her delivery
 Every visit, monitor for
signs and symptoms of
pre term labor.
Hydramnios may
predispose the pt to early
labor
 Assist pt in learning
accurate home
monitoring of blood
glucose
Rationale Evaluation
After nursing intervention,
 A trusting relationship the:
facilitates cooperation  Pt verbalized the
with plan of care importance of
 Helps client to make maintaining normal
informed decisions blood glucose level
about managing  Pt learned the effects
regimen and may of delivering
increase cooperation macrosomic fetus if
 Accurate food group blood glucose level is
choices helps control not controlled
and maintain blood  Pt learned ways on
glucose level how to maintain
 Regular exercise is blood glucose level
beneficial to overall  Pt maintained a
health and may help normal blood glucose
improve glucose level
metabolism
 Macrosomic fetus
might cause
complications both to
the mother and fetus
and affect delivery
 Overdistention of the
uterus caused by
macrosomia
 For accurate record
and tighter control of
glucose levels
 Either the tear happened
naturally due to stretches or
the cut is done surgically, B. Dependent
the tissue is still damaged.  Prepare pt for
After an episiotomy is ultrasonography at 18,
performed, the doctor or 26, and 36-38 weeks of
midwife will stitch the gestation as indicated
perineum (R.E Weiss, PhD,
MPH). And the tissue
remain wounded.
 Insulin prescription, if
needed
 Prepare for
hospitalization if blood
glucose level keeps on
rising
 To determine fetal size
using biparietal
diameter, femur
length, and estimated
fetal weight. The pt
would be at risk for
CPD and dystocia due
to macrosomia
 To keep blood sugar
level in a normal range
 Close monitoring is
important to evaluate
the mother and fetus’
condition

Nursing Nursing Goal and

Cue(s) Scientific Rationale Nursing Interventions Rationale Evaluation
Diagnosis Objectives
16-week OAG Risk for infection The body produces more After nursing A. Independent After nursing
r/t hyperglycemia hormones and undergoes other intervention, the: intervention, the:
aeb fbs of 150 changes during pregnancy, such  Pt will learn that  Establish rapport  A trusting  Pt learned that high
FBS: 150 mg/dL mg/dL as weight gain. Insulin resistance high blood glucose relationship facilitates blood glucose level
- DIABETIC is a condition in which the body's level can lead to cooperation with plan can lead to infection
cells utilize insulin less infection of care  Pt verbalized and
effectively as a result of these  Pt will verbalize and  Educate pt about the  Helps client to make demonstrated proper
changes. Insulin resistance raises demonstrate proper possibility of informed decisions ways to prevent or
the body's insulin requirement ways to prevent or occurrence of about managing reduce the risk of
(Centers for Disease Control and reduce the risk of infection due to high regimen and may infection
Prevention, 2021). infection blood glucose level increase cooperation  Pt was free from
 Pt will be free from  Educate the pt on how  In order for the pt to infection
Because insulin resistance infection to recognize signs of seek medical help
develops with gestational age, infection early and avoid
diabetic pregnant women's complications
vulnerability to infections may
increase with the duration of
pregnancy and poor glycemic
control.
Pregnant women with diabetes
have a high risk
of Candida infection because the
elevated sugar level in the blood
provides food for yeast and
encourages Candida colonization
. (Ahmed et al., 2016).
This infection causes irritation,
discharge and intense itchiness of
the vagina and the vulva — the
tissues at the vaginal opening (S.
Pruthi, M.D)
 Teach and promote  Helps reduce the risk
proper hand hygiene of infection
 Tell pt to avoid self-  To prevent serious
medication with OTC risk of complications
vaginal creams  Helps prevents stasis
 Encourage pt to and aids in reducing
increase fluid intake bacterial growth,
maintaining urine
acidity, and flushing
organisms out of the
system
 Tell the pt to clean her  To minimize the risk
perineal from front to of UTI
back
C. Dependent
 Obtain culture of  A helpful way to
vaginal discharge, if confirm the presence
needed of candida
 Obtain urinalysis and  In order to make
urine culture, as immediate treatment
needed if necessary and
reduce maternal and
fetal risk
 Administer antibiotic,  An antimicrobial
if needed therapy that will help
with the treatment of
infection