Case Study 119

Name Class/Group Date Mary Joy S. Franco BSN 2D G-14

Group Members
INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to
the point. When
asked to provide several answers, list them in order of priority or significance. Do not assume
information that
is not provided. Please print or write clearly. If your response is not legible, it will be marked as?
and you will need to rewrite it
Scenario

You are working as an RN in a large women's clinic. Y.L., a 28-year-old Asian

woman, arrives for her regularly scheduled obstetric appointment. She is in her
26th week of pregnancy and is a primigravida. After examining the patient, the
nurse-midwife tells you to schedule Y.L. for a glucose challenge test. You review
Y.L.'s chart and note she is 5 feet, 3 inches and weighs 143 pounds; her
prepregnancy body mass index (BMI) is 25. Her father has type 2 diabetes mellitus
(DM), and both paternal grandparents had type
2 DM. You enter the room to talk to Y.L.

1. What is the purpose of a glucose challenge test?

-The glucose challenge test measures your body's response to sugar (glucose). The
glucose challenge test is done during pregnancy to screen for gestational diabetes -
diabetes that develops during pregnancy.

2. When is a glucose challenge test performed?

- the test is generally done between weeks 24 and 28 of pregnancy.

3. What instructions would you provide Y.L. regarding the test?

-The glucose challenge test measures your body's response to sugar (glucose).
The glucose challenge test is done during pregnancy to screen for gestational
diabetes - diabetes that develops during pregnancy. The glucose challenge test is
done in two steps, First you drink a sugary solution. One hour later, your blood
sugar level is measured. The results of the glucose challenge test indicate whether
you might have gestational diabetes.
Chart View
Laboratory Test Results
Time of Test Value Normal Range
0730 109 mg/dL under 95 mg/dL
0830 213 m g/dL under 180 mg/dL
0930 162 mg/dL under 153 mg/dL

4. Interpret the results of Y.L.'s test

-all results were suggestive of Gestational diabetes Mellitus (GDM)
5. Y.L. is diagnosed with gestational diabetes mellitus (GDM). What is GDM?
-Gestational diabetes mellitus (GDM) 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.
-Unlike type 1 diabetes, gestational diabetes is not caused by a lack of insulin, but
by other hormones produced during pregnancy that can make insulin less effective,
a condition referred to as insulin resistance. Gestational diabetic symptoms
disappear following delivery.
6. List five risk factors for GDM. Place a star or asterisk next to those risk factors
that Y.L. has.
1. Lack of exercise*
2. Overweight*
3. Unhealthy eating*
4. Family History
7. Ethnicity
5. Age (over 40 years old)
8. Lifestyle*
6. High Blood Pressure*
9. Gestational Diabetes*

CASE STUDY PROGRESS

Medical nutrition therapy is the primary treatment for the management of GDM.
Because treatment must begin immediately, you call the dietitian to come see Y.L.
You also schedule Y.L. to meet with other members of the DM management team
later in the week

7. What is the goal of medical nutrition therapy?

- The goals of medical nutrition therapy for gestational diabetes mellitus (GDM)
are to meet the maternal and fetal nutritional needs, as well as to achieve and
maintain optimal glycemic control
-Nutrition Requirements during pregnancy are similar for women with or without
GDM
8. Describe the usual diet used in treating GDM.
- Caloric intake recommendations should take into consideration the patient's
activity level, prepregnancy weight, and weight gain to date. The usual prescription
is 30 kcal/kg/dey, based on a normal preconception weight.
-For obese women, the usual prescription is up to 25 kcal/kg/day, which translates
into 1500 to 2000 kcal/day for most women.
To adequately control postprandial blood glucose levels, distribution of foods
should include approximately
CHO 35% to 40%
PROTEIN 20% to 25%, and
FAT 35% to 40%
- Moderate amount of whole grains such as bread cereal, pasta and rice plus starchy
vegetables such as corn and peas.
- Plenty of whole fruits and vegetables, Lean proteins ,Healthy fats
- Fewer foods that have a lot of sugar such as softdrinks, fruit juices and pastries
avoid
9. Why is medical nutrition therapy for a woman with GDM higher in fat and
protein?
- Medical Nutrition therapy for a GDM patient always consist of a higher amount
of FAT and PROTEIN
-The diet of the GDM patients consist fewer amounts of carbohydrate in order to
maintain the glycemic index Fats should be distributed as less than 33% from
saturated, less than 33% from polyunsaturated, and the balance from
monounsaturated sources.
-Fats provide the essential fatty acids needed for fetal brain development.
10. Women with GDM cannot metabolize concentrated simple sugars without a
sharp rise in blood glucose. Name five examples of simple sugars you would teach
Y.L. to limit.
1. Regular soda, milk
2. Candy, cake, cookies-alls desserts in general
3. Whole-wheat pasta, beans, sweet potatoes, jams or jellies, syrup
4. Glucose, honey, fructose, corn syrup, molasses, sucrose
5. fruit, fruit juice
11. Complex carbohydrates (CHO) do not cause a rapid rise in blood glucose when
eaten in small amounts. Identify five foods from this group.
1. Whole oats, kidney beans, black beans, wheat tortilla, lentils
2. Apples, oranges, carrots
3. Skim milk, cashews, peanuts,
4. Pearled barley, black beans, chickpeas, soy beans, peanuts
5. Grapefruit, pear, prunes
Case Study Progress
During the meeting with the dietitian, Y.L. gives a diet history that is high in
noodles and rice with little protein. She informs the dietitian she is lactose
intolerant but can have dairy products occasionally in small portions.
12. Is it important that Y.L. take a calcium supplement along with her prenatal
vitamins?
- Calcium for lactose intolerance to prevent Ca++ loss in ketoacidosis From 1,200
to 1,500 mg of calcium is recommended every day during pregnancy. If you are
lactose intolerant, you will need to look for other good sources of calcium, such as
legumes (starchy beans), dark green vegetables, tofu and canned salmon or
sardines.

13. Y.L. is instructed to monitor her fasting blood glucose first thing in the
morning and 2 hours after every meal. What are the purposes of this request?
- The purpose of this request is to make sure that her sugar is under control, not too
low in the morning and is not too high after meal
-A test to determine how much glucose sugar) is in a blood sample after an
overnight fast.
-The fasting blood glucose test is commonly used to detect diabetes mellitus. A
blood sample is taken in a lab, physician's office, or hospital. The test is done in the
morning, before the person has eaten.
-The normal range for blood glucose is 70 to 100 mg/dl. Levels between 100 and
126 mg/dl are referred to as impaired fasting glucose or pre-diabetes,
-Diabetes is typically diagnosed when fasting blood glucose levels are 126 mg/dl
or higher

14. Y.L. is instructed to complete ketone testing using the first-voided urine in the
morning.
What is the rationale for this request?
- The presence of urine ketones indicates nocturnal starvation because of
inadequate food intake as a bedtime snack but can also signify the need for
bedtime insulin.
- During pregnancy, there is an increased tendency to catabolize fat and, spare
amino acids and glucose for the developing fetus.
-There is evidence to suggest that elevated ketone levels might decrease
psychomotor skills and lower IQ scores in the fetus.
15. Y.L. asks whether having gestational diabetes will hurt her baby. How would
you respond?
- The higher blood sugar of the mother affects the baby too, since they gets
nutrients from the mother's blood. The baby stores that extra sugar as fat, which
can make them grow larger than normal. They're more likely to have certain
complications: Injuries during delivery because of their size Low blood sugar and
mineral levels when they're born Jaundice, a treatable condition that makes the skin
yellowish Pre-term birth Temporary breathing problems Later in life, the baby
might have a greater chance of obesity and diabetes. So help your child live a
healthy lifestyle -- it can lower their odds for these problems.
16. At the conclusion of the visit, you need to evaluate your teaching. Which
statement made by Y.L. indicates that clarification is necessary?
a. “I will stay on the diabetic diet described by the dietitian.”
b. “I will monitor my glucose levels at least four times each day.”
c. “I need to stop exercising because I will need more carbohydrates.”
d. “I should immediately report any ketones in my urine.”