Davao Doctors College, Inc.

General Malvar St., Davao

City Nursing Program

NURSING CARE PLAN

Name of Patient: Deo, Zara Date of Admission: 01/15/2023 Room#: 401a

Age: 42-year-old Sex: Female Chief Complaint: Irregular labor contraction with lower back pain
Religion: N/A Attending Physician: Dr. Ran

PROBLEM NURSING GOALS/OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS S CRITERIA INTERVENTIONS

INDEPENDENT:
January 15, 2023 Risk for maternal injury After 15 hours of my . January 15, 2023
@ 8 AM related to changes in nursing intervention, 1. Evaluate the patient Changes in the circulatory
diabetic control secondary @ 11 PM
the patient will be able for vaginal system related to diabetes
OBJECTIVES: to gestational diabetes. bleeding and may bring the patient at
to: “GOAL MET”
. abdominal risk for placental abruption.
 Mother presents tenderness. After 15 hours of my
having SCIENTIFIC BASIS: nursing interventions,
a. Maintain stable
Gestational 2. Identify the natureThe presence of glucose in the patient was able to:
Gestational Diabetes vital signs. of any vaginalthe urine may develop a
Diabetes
Mellitus (GDM) is discharge. fungal infection called
 The Px is glucose intolerance with b. Maintain a monilial vulvovaginitis, by A. Exhibit stable vital
diagnosed as onset during pregnancy. normal blood the causative agent Candida signs.
having primary Women with sugar level. albicans. This more likely
infertility. gestational diabetes are at lead to oral thrush among
an increased risk of newborn. B. Show normal blood
VS: complications during glucose level with 122
pregnancy and delivery. c. The patient will mg/dl.
 Temp – 35.8- be free of signs
degree Celsius
In diabetes mellitus, cells 3. Evaluate for anyPatients with diabetes are at
essentially starve because and symptoms signs and higher risk of developing C. Deliver a baby boy
 RR – 23
they cannot obtain of maternal symptoms of UTIs since increased blood vaginally and without
 BP: 130/80 glucose. This puts the urinary tract sugar level gives a
mmHg injury related to complications.
mother risk for gestational infection. favorable environment for
 Weight – 170 hyperglycemia, bacterial growth.
lbs diabetes.
Gestational hypertension,
 Height – 5’5 cesarean birth, preterm
 WBC – 11.5 birth.
4. Check and monitorA person with diabetes is
 RBC – 4.07
for signs of edema. also prone to developing
 Hemoglobin – excess fluid retention and
11.1 REFERENCES: pregnancy-induced
Curran. Rn, A. B. (2022, hypertension. This is
May 16). Gestational because of changes in
Diabetes Nursing vascularity.
Diagnosis and Nursing
Care Plans. 5. Find out for thePregnant diabetic patients
NurseStudy.Net. fundal height; are at risk of developing
Examine for edemaHydramnios, by 6% to
of extremities and25%. Excessive amniotic
difficulty fluid can be related to the
breathing. increased fetal contribution
because hyperglycemia
rises fetal urine output.

6. Check for episodesTo achieve a normal blood

of hyperglycemia. sugar level, a proper diet
and regulated insulin level
are necessary, especially
during the second and third
trimesters.

It provides greater accuracy

7. Guide the patient inrather than urine testing
learning bloodbecause during pregnancy
glucose monitoringthe renal threshold for
at home. It can beglucose is much lower. A
done a minimum ofblood glucose test makes it
4 times a day. easier to control sugar
levels.

The presence of ketones in

8. Check for urineurine implies a starvation
ketones daily. state, which may have
negative effects on the
development of the fetus.
9. Check for a urineEarly detection may
test. If vaginalprevent kidney infection.
discharge is
present, obtain
urine culture.

10. Check HbA1cIt provides more exact

usually every 2 to 4results to assess glucose
weeks, or ascontrol for the past 2
ordered by themonths.
physician.

11. Provide health Assess their understanding

teaching amongof Gestational diabetes and
family members explain to them its effects
on the mother and fetus.
They can help in
monitoring the patient and
assist with the client’s
needs. They can also
support the client by
motivating them to be
compliant with the
treatment.