Diabetes Mellitus Prepregnancy/Gestational

This disorder of carbohydrate metabolism of variable severity may be preexisting (pregestational insulin-dependent diabetes mellitus [IDDM] or non–insulin-dependent diabetes mellitus [NIDDM]), or may develop duringpregnancy (gestational diabetes mellitus [GDM]).

(This plan of care is to be used in conjunction with the Trimesters and the High-Risk Pregnancy.)

CLIENT ASSESSMENT DATA BASECirculation

Pedal pulse and capillary refill of extremities may be diminished or slowed (with diabetes of long duration).Edema, elevated BP (PIH).

EliminationMay have history of pyelonephritis, recurrent UTI, nephropathyPolyuria

Food/FluidPolydipsia, polyphagia.Nausea and vomiting.Obesity; excessive or inadequate weight gain (client with GDM is usually obese; client with IDDM is not usually obese

before pregnancy).Abdominal tenderness.May report episodes of hypoglycemia, glycosuria.

Safety

Skin integrity/sensation of arms, thighs, buttocks, and abdomen may be altered from frequent injections of insulin.Visual impairment/retinopathy may be present.History of symptoms of infection and/or positive cultures for infection, especially urinary or vaginal.

Sexuality

Fundal height may be higher or lower than normal for gestational age (hydramnios, inappropriate fetal growth).History of large for gestational age (LGA) neonate, hydramnios, congenital anomalies, unexplained stillbirth.

Social Interaction

Socioeconomic concerns/factors can increase risk of complications.Inadequate or lack of committed support system (may adversely affect diabetic control).

Teaching/Learning

Client’s own birth weight may have been 9 lb or more.May report recent problems/change in stability of diabetic control.Family history of diabetes, GDM, PIH, infertility problem; LGA infant, history of neonatal death(s), stillbirth,

congenital anomalies, spontaneous abortion, hydramnios, macrosomia (greater than 4000 g or 9 lb at birth).

DIAGNOSTIC STUDIES

Glucose Tolerance Test (GTT): Elevated above 140 mg/dL at 24–28 weeks’ gestation. Clients with specific riskfactors are screened at first prenatal visit. (If screening result is positive,3-hr glucose challenge or oral glucose tolerance test [OGTT] test done to make diagnosis.)

Glycosylated Hemoglobin (HbA1c): Reveals glucose control over previous 4–8 wk. Levels greater than 8.5%,especially before pregnancy, puts the fetus at risk for congenital anomalies.

Random Serum Glucose Level: Determines immediate diabetic control.

Urine Ketone Levels: Determines nutritional state.Glycosylated Albumin: Reflects glucose control over last several days as possible screening test for GDM.Urine Culture: Identifies asymptomatic UTI.Vaginal Culture: May be positive for Candida albicans (Monilia infection).Protein and Creatinine Clearance (24 hr): Verify level of kidney function, especially in diabetes of long duration.Thyroid Function Tests: Establish baseline and/or identify coexisting hypothyroidism or hyperthryoidism.Hemoglobin (Hb)/Hematocrit (Hct): May reveal anemia.Triglycerides and Cholesterol Levels: May be elevated.Estriol Level: Indicates level of placental function.Electrocardiogram (ECG): May reveal altered cardiovascular function in diabetes of long duration.Nonstress Test (NST): May demonstrate reduced fetal response to maternal activity.Serial Ultrasonography: Determines presence of macrosomia or IUGR.Contraction Stress Test (CST), Oxytocin Challenge Test (OCT): Positive results indicate placental insufficiency.Amniocentesis: Ascertains fetal lung maturity using lecithin to sphingomyelin (L/S) ratio or presence of

phosphatidylglycerol (PG).BPP Criteria: Assesses fetal well-being/maturity.

NURSING PRIORITIES

1. Determine immediate and previous 8-wk diabetic control.2. Evaluate ongoing client/fetal well-being.3. Achieve and maintain normoglycemia (euglycemia).4. Provide client/couple with appropriate information.

NURSING DIAGNOSIS: Nutrition: altered, risk for less than body requirements

Risk Factors May Include: Inability to ingest/utilize nutrients appropriately

Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actualdiagnosis]

DESIRED OUTCOMES/EVALUATION Gain 24–30 lb prenatally, or as appropriate forCRITERIA—CLIENT WILL: prepregnancy weight.

Maintain fasting serum glucose levels between 60–100 mg/dL and 1 hrpostprandial no higher than 140 mg/dL.

Be free of signs/symptoms of ketoacidosis.

Verbalize understanding of individual treatment regimen and need forfrequent self-monitoring.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Weigh client each prenatal visit. Encourage client Weight gain is the key index for deciding caloricto periodically monitor weight at home between adjustments.visits.

Assess caloric intake and dietary pattern using Aids in evaluating client’s understanding of24-hr recall. and/or adherence to dietary regimen.

Review/provide information regarding any Metabolism and fetal/maternal needs changerequired changes in diabetic management; greatly during gestation, requiring closee.g., switch from oral agents to insulin, use monitoring and adaptation. Research suggestsof Humulin insulin only, self-monitoring of antibodies against insulin may cross the placenta,serum glucose levels at least 4 times/day causing inappropriate fetal weight gain. The use of(e.g., before breakfast and 2 hr after each meal), human insulin decreases the development of theseand reducing/changing time for ingesting antibodies. Reducing carbohydrates to less thancarbohydrates. 40% of the calories ingested decreases the degree of

the postprandial glucose peak of hyperglycemia.Because pregnancy produces severe morningcarbohydrate intolerance, the first meal of the dayshould be small, with minimal carbohydrates.

Review importance of regularity of meals and Small, frequent meals avoid postprandialsnacks (e.g., 3 meals/3 or 4 snacks) when taking hyperglycemia and fasting/starvation ketosis.insulin. Note: Bedtime snack should contain both protein and

complex carbohydrates to prevent nighttimehypoglycemia.

Note presence of nausea and vomiting, especially Nausea and vomiting may result in carbohydratein first trimester. deficiency, which may lead to metabolism of fats and

development of ketosis.

Assess understanding of the effect of stress on Stress can elevate serum glucose levels, creatingdiabetes. Provide information about stress fluctuations in insulin needs.management and relaxation. (Refer to CP: TheHigh-Risk Pregnancy.)

Teach client finger-stick method for self-monitoring Insulin needs for the day can be adjusted based onof glucose. Have client demonstrate procedure. periodic serum glucose readings. Note: Values

obtained by reflectance meters may be 10%–15%lower/higher than plasma values.

Recommend monitoring urine for ketones on Insufficient caloric intake is reflected by ketonuria,awakening and when a planned meal or indicating need for an increase of carbohydrates orsnack is delayed. addition of an extra snack in the dietary plan (e.g.,

recurrent presence of ketonuria on awakening maybe eliminated by a 3 AM glass of milk). Presence ofketones during second half of pregnancy may reflect“accelerated starvation” as diminished effectivenessof insulin results in a catabolic state during fastingperiods (e.g., skipping meals), causing maternalmetabolism of fat. Adjustment of insulinfrequency/dosage/type must then be considered.

Review/discuss signs and symptoms and Hypoglycemia may be more sudden or severe insignificance of hypoglycemia or hyperglycemia. first trimester, owing to increased usage of glucose

and glycogen by client and developing fetus, as well aslow levels of the insulin antagonist human placentallactogen (HPL). Ketoacidosis occurs more frequentlyin second and third trimesters because of the increasedresistance to insulin and elevated HPL levels.Sustained or intermittent pulses of hyperglycemia aremutagenic and teratogenic for the fetus during the firsttrimester; may also cause fetal hyperinsulinemia,macrosomia, inhibition of lung maturity, cardiacdysrhythmias, neonatal hypoglycemia, and risk ofpermanent neurological damage. Maternal effects ofhyperglycemia can include hydramnios, UTI and/orvaginal infections, hypertension, and spontaneoustermination of pregnancy.

Instruct client to treat symptomatic hypoglycemia, Using large amounts of simple carbohydrates toif it occurs, with an 8-oz glass of milk and to repeat treat hypoglycemia causes serum glucose values toin 15 min if serum glucose levels remains overshoot. A combination of complexbelow 70 mg/dL. carbohydrates and protein maintains normoglycemia

longer and helps maintain stability of serum glucosethroughout the day.

CollaborativeParticipate in/coordinate multispecialty care Provides opportunity to review management ofconference as appropriate. both pregnancy and diabetic condition, and to plan

for special needs during intrapartum and postpartumperiods.

Discuss dosage, schedule, and type of insulin Division of insulin dosage considers maternal(e.g., usually 4 times/day: 7:30 AM—NPH; basal needs and mealtime insulin-to-food ratio,10 AM—regular; 4 PM—NPH; 6 PM—regular). and allows more freedom in meal scheduling.

Total daily dosage is based on gestational age,current maternal body weight, and serum glucoselevels. A mix of NPH and regular human insulinhelps mimic the normal insulin release pattern of thepancreas, minimizing “peak/valley” effect of serumglucose level. Note: Although some providers maychoose to manage clients with GDM with oral agents,insulin is still the drug of choice.

Adjust diet or insulin regimen to meet Prenatal metabolic needs change throughout theindividual needs. trimesters, and adjustment is determined by weight

gain and laboratory test results. Insulin needs in thefirst trimester are 0.7 unit/kg of body weight.Between 18 and 24 weeks’ gestation, it increases to0.8 unit/kg; at 34 weeks’ gestation, 0.9 unit/kg, and1.0 unit/kg by 36 weeks’ gestation.

Refer to registered dietitian to individualize diet Diet specific to the individual is necessary toand counsel regarding dietary questions. maintain normoglycemia and to obtain desired

weight gain. In-depth teaching promotesunderstanding of own needs and clarifiesmisconceptions, especially for client with GDM.Note: New recommendations (Peterson & Peterson,1992) set dietary needs at 25 kcal/kg dependent onthe client’s current pregnant weight.

Monitor serum glucose levels (FBS, preprandial, Incidence of fetal and newborn abnormalities is1 and 2 hr postprandial) on initial visit, then as decreased when FBS levels range between 60 andindicated by client’s condition. 100 mg/dL, preprandial levels between 60 and 105

mg/dL, 1-hr postprandial remains below 140 mg/dL,and 2-hr postprandial is less than 120 mg/dL.

Ascertain results of HbA1c every 2–4 wk. Provides accurate picture of average serum glucosecontrol during the preceding 60 days. Serum glucosecontrol takes 6 wk to stabilize.

Prepare for hospitalization if diabetes is not controlled. Infant morbidity is linked to maternalhyperglycemia-induced fetal hyperinsulinemia.

NURSING DIAGNOSIS: Injury, risk for fetal

Risk Factors May Include: Elevated maternal serum glucose levels, changes in circulation

Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actualdiagnosis]

DESIRED OUTCOMES/EVALUATION Display normally reactive NST and negative OCTCRITERIA—FETUS WILL: and/or CST.

Be full-term, with size appropriate for gestational age.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Determine White’s classification for diabetes; Fetus is at less risk if White’s classification is A, B,explain classification and significance to or C. The client with classification D, E, or F whoclient/couple. develops kidney or acidotic problems or PIH is at

high risk. As a means of determining prognosis forperinatal outcome, White’s classification has been usedin conjunction with (1) evaluation of diabetic controlor lack of control and (2) presence or absence ofPederson’s prognostically bad signs of pregnancy(PBSP), which include acidosis, mild/severe toxemia,and pyelonephritis. The National Diabetes Data GroupClassification, which includes diabetes mellitus (type I,insulin-dependent; type II, non–insulin-dependent),impaired glucose tolerance, and gestational diabetesmellitus, has not yet had prognostic significance inpredicting perinatal outcomes.

Note client’s diabetic control before conception. Strict control (normal HbA1c levels) before conceptionhelps reduce the risk of fetal mortality and congenitalanomalies.

Assess fetal movement and FHR each visit Fetal movement and FHR may be negativelyas indicated. (Refer to CP: Third Trimester, affected when placental insufficiency and maternalND: Injury, risk for fetal.) Encourage client to ketosis occur.

periodically count/record fetal movementsbeginning about 18 weeks’ gestation, thendaily from 34 weeks’ gestation on.

Monitor fundal height each visit. Useful in identifying abnormal growth pattern(macrosomia or IUGR, small or large for gestationalage [SGA/LGA]).

Monitor urine for ketones. Note fruity breath. Irreparable CNS damage or fetal death can occur asresult of maternal ketonemia, especially in the thirdtrimester.

Provide information and reinforce procedure Decreased fetal/newborn mortality and morbidityfor home blood glucose monitoring and complications and congenital anomalies are associateddiabetic management. (Refer to NDs: Knowledge with optimal FBS levels between 70 and 96 mg/dL,Deficit [Learning Need]; Nutrition: altered, and 2-hr postprandial glucose level of less thanrisk for less than body requirements.) 120 mg/dL. Frequent monitoring is necessary to

maintain this tight range and to reduce incidenceof fetal hypoglycemia or hyperglycemia.

Monitor for signs of PIH (edema, proteinuria, About 12%–13% of diabetic individuals developincreased blood pressure). hypertensive disorders owing to cardiovascular

changes associated with diabetes. These disordersnegatively affect placental perfusion and fetal status.

Provide information about possible effect of diabetes Helps client to make informed decisions abouton fetal growth and development. managing regimen and may increase cooperation.

Review procedure and rationale for periodic NSTs Fetal activity and movement are good predictors(e.g., weekly NST after 30 weeks’ gestation, twice- of fetal wellness. Activity level decreases beforeweekly NST after 36 weeks’ gestation). alterations in FHR occur.

Discuss rationale/procedure for carrying out CST assesses placental perfusion of oxygen andperiodic OCT/CST beginning at 30–32 weeks’ nutrients to fetus. Positive results indicategestation, depending on diagnosis of IDDM or GDM. placental insufficiency, in which case fetus may(Refer to CP: Third Trimester; ND: Injury, need to be delivered surgically.risk for fetal.)

Review procedure and rationale for amniocentesis When maternal/placental functioning is impairedusing L/S ratio and presence of PG. (Refer to CP: before term, fetal lung maturity is criterion used toSecond Trimester; ND: Injury, risk for fetal.) determine whether survival is possible. Hyper-

insulinemia inhibits and interferes with surfactantproduction; therefore, in the diabetic client, testing forpresence of PG is more accurate than using L/S ratio.

Collaborative

Assess HbA1c every 2–4 wk, as indicated. Incidence of congenitally malformed infants isincreased in women with high HbA1c level (greaterthan 8.5%) early in pregnancy or before conception.Note: HbA1c is not sensitive enough as a screeningtool for GDM.

Assess glycolysated albumin level at 24–28 weeks’ Serum test for glycolysated albumin reflectsgestation, especially for client in high-risk category glycemia over several days and may gain(history of macrosomic infants, previous GDM, acceptance as screening tool for GDM because itor positive family history of GDM). Follow with does not involve potentially harmful glucoseOGTT if test results are positive. loading as does OGTT.

Verify AFP levels are obtained at 14–16 weeks’ Although AFP screen is recommended for allgestation. clients, it is especially important in this population

because the incidence of neural tube defects is greaterin diabetic clients than in nondiabetic clients,particularly if poor control existed before pregnancy.

Prepare for ultrasonography at 8, 12, 18, 28, and Ultrasonography is useful in confirming gestation36–38 weeks’ gestation, as indicated. date and helps to evaluate IUGR.

Perform NST and OCT/CST, as appropriate. Assesses fetal well-being and adequacy of placentalperfusion.

Review periodic creatinine clearance levels. There is a slight parallel between renal vasculardamage and impaired uterine blood flow.

Obtain sequential serum or 24-hr urinary specimen Although estriol levels are not used as often now,for estriol levels after 30 weeks’ gestation. falling levels may indicate decreased placental

functioning, leading to possibility of IUGR andstillbirth.

Assist as necessary with BPP assessment. Provides a score to assess fetal well-being/risk. Thecriteria include NST results, fetal breathingmovements, amniotic fluid volume, fetal tone, andfetal body movements. For each criterion met, a scoreof 2 is given. A total score of 8–10 is reassuring, ascore of 4–7 indicates need for further evaluation andretesting, and a score of 0–3 is ominous.

Assist with preparation for delivery of fetus Helps ensure positive outcome for neonate.vaginally or surgically if test results indicate Incidence of stillbirths increases significantly withplacental aging and insufficiency. gestation more than 36 wk. Macrosomia often causes

dystocia with cephalopelvic disproportion (CPD).

NURSING DIAGNOSIS: Injury, risk for maternal

Risk Factors May Include: Changes in diabetic control, abnormal blood profile/anemia, tissuehypoxia, altered immune response

Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes in actualdiagnosis]

DESIRED OUTCOMES/EVALUATION Remain normotensive.CRITERIA—CLIENT WILL: Maintain normoglycemia, free of signs/symptoms of ketoacidosis.

Be free of complications (e.g., infection, placental separation).

ACTIONS/INTERVENTIONS RATIONALE

Independent

Note White’s classification for diabetes. Assess Client classified as D, E, or F is at higher risk fordegree of diabetic control (Pederson’s criteria). complications, as is client with PBSP.(Refer to ND: Injury, risk for fetal.)

Assess client for vaginal bleeding and Vascular changes associated with diabetes placeabdominal tenderness. client at risk for abruptio placentae.

Monitor for signs and symptoms of preterm labor. Overdistension of uterus caused by macrosomia or hydramnios maypredispose client to early labor.

Assist client in learning home monitoring of Allows greater accuracy than urine testing becauseblood glucose, to be done a minimum of renal threshold for glucose is lowered during4 times/day. (Refer to NDs: Nutrition: altered, pregnancy. Facilitates tighter control of serumrisk for less than body requirements; Knowledge glucose levels.deficit [Learning Need].)

Request that client check urine for ketones daily. Ketonuria indicates presence of starvation state,which may negatively affect the developing fetus.

Identify for hypoglycemic episodes occurring at home. Hypoglycemic episodes occur most frequently in thefirst trimester, owing to continuous fetal drain onserum glucose and amino acids, and to low levels ofHPL. In the presence of hypoglycemia, vomiting maylead to ketosis.

Identify for episodes of hyperglycemia. Diet/insulin regulation is necessary fornormoglycemia, especially in second and thirdtrimesters, when insulin requirements often double(may quadruple in third trimester).

Assess for and/or monitor presence of edema. Because of vascular changes, the diabetic client is(Refer to CP: Pregnancy-Induced Hypertension; prone to excess fluid retention and PIH. TheND: Fluid Volume deficit.) severity of the vascular changes before pregnancy

influences the extent and time of onset of PIH.

Determine fundal height; check for edema of Hydramnios occurs in 6%–25% of pregnantextremities and dyspnea. diabetic clients; may possibly be associated with

increased fetal contribution to amniotic fluid, becausehyperglycemia increases fetal urine output.

Assess for, and review with client, signs and Early detection of UTI may prevent pyelonephritis,symptoms if UTI. which is thought to contribute to premature labor.

Determine nature of any vaginal discharge. If glycosuria is present, client is more likely to developmonilial vulvovaginitis, which is caused by Candidaalbicans and may result in oral thrush in newborn.

Monitor client closely if tocolytic drugs are Tocolytic drugs may elevate serum glucose andused to arrest labor. insulin levels.

Collaborative

Monitor serum glucose levels each visit. Detects impending ketoacidosis; helps determinetimes of day during which client is prone tohypoglycemia.

Obtain HbA1c every 2–4 wk, as indicated. Allows accurate assessment of glucose control forpast 60 days.

Assess Hb/Hct on initial visit, then during second Anemia may be present in client with vasculartrimester and at term. involvement.

Instruct in insulin administration, as required. Insulin requirements are decreased in firstEnsure that client is adept at self-administration, trimester, then double and may even quadruple aseither subcutaneously (SC) or with pump, the pregnancy progresses. Highly motivated anddepending on client’s needs or care setting. capable clients may do well with a continuous

subcutaneous insulin infusion pump to morenaturally meet insulin needs.

Obtain urinalysis and urine culture; administer Helps prevent or treat pyelonephritis. Note: Someantibiotic as indicated. antibiotics might be contraindicated because of

danger of teratogenic effects.

Obtain culture of vaginal discharge, if present. Candida vulvovaginitis can cause oral thrush in thenewborn.

Collect specimens for total protein excretion, Progressive vascular changes may impair renalcreatinine clearance, BUN, and uric acid levels. function in clients with severe or long-standing

diabetes.

Schedule ophthalmologic examination during Owing to severe vascular involvement,first trimester for all clients, and in second and background retinopathy may progress duringthird trimesters if client is class D, E, F. pregnancy. Laser coagulation therapy may improve

client’s condition and reduce optic fibrosis.

Prepare client for ultrasonography at 8, 12, 18, 26, Determines fetal size using biparietal diameter,and 36–38 weeks’ gestation as indicated. femur length, and estimated fetal weight. Client is at

increased risk for CPD and dystocia due tomacrosomia.

Start IV therapy with 5% dextrose; administer Glucagon is a naturally occurring substance thatglucagon SC if client is hospitalized with insulin acts on liver glycogen and converts it to glucose,shock and is unconscious. Follow with protein- which corrects hypoglycemic state. (Note:containing fluids/foods, e.g., 8 oz skim milk Hypertonic glucose [D50] administered IV maywhen client is able to swallow. have negative effects on fetal brain tissue because of

its hypertonic action.) Protein helps sustainnormoglycemia over a longer period of time.

NURSING DIAGNOSIS: Knowledge deficit [Learning Need], regarding diabeticcondition, prognosis, and self care treatment needs

May Be Related To: Lack of exposure to information, misinformation, lack of recall,unfamiliarity with information resources

Possibly Evidenced By: Questions, statement of misconception, inaccurate follow-through ofinstructions, development of preventable complications

DESIRED OUTCOMES/EVALUATION Participate in the management of diabetes duringCRITERIA—CLIENT WILL: pregnancy.

Verbalize understanding of the procedures, laboratory tests, andactivities involved in controlling diabetes.

Demonstrate proficiency in self-monitoring and insulinadministration.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Assess client’s/couple’s knowledge of disease Clients with either preexisting diabetes or GDMprocess and treatment, including relationships are at risk for ineffective glucose uptake within thebetween diet, exercise, illness, stress, and cells, excess utilization of fats/proteins for energy,insulin requirements. and cellular dehydration as water is drawn from the

cell by a hypertonic concentration of glucose withinthe serum. Pregnancy alters insulin requirementsdrastically and necessitates more intense control,requiring the client/couple to take a very active role.Informed decisions can be made only when there is aclear understanding of both the disease process andthe rationale for management.

Discuss importance of home serum glucose Frequent blood glucose measurements allow clientmonitoring using reflectance meter, and the need to recognize the impact of her diet and exercise onfor frequent readings (at least 4 times/day), serum glucose levels and promote tighter controlas indicated. Demonstrate procedure, then of glucose levels.observe return demonstration by the client.

Review reasons why oral hypoglycemic medications Although insulin does not cross the placenta, oralshould be avoided, even though they may have hypoglycemic agents do and are potentiallybeen used by the class A client, to control diabetes harmful to the fetus, necessitating a change inbefore pregnancy. diabetic management. Although some clinical sources report use of

oral agents in clients with GDM, this is not recommended duringpregnancy.

Provide information about action and adverse Prenatal metabolic changes cause insulineffects of insulin. Assist client to learn administration requirements to change. In the first trimester,by injection, insulin pump, or nasal spray insulin requirements are lower, but they double(experimental technique) as indicated. and then may quadruple during second and third

trimesters.

Explain normal weight gain to client. Encourage Total gain in the first trimester should be 2.5–home monitoring between visits. 4.5 lb, then 0.8–0.9 lb/wk thereafter. Caloric

restriction with resulting ketonemia may cause fetaldamage and inhibit optimal protein utilization. (Referto ND: Injury, risk for fetal.)

Provide information about need for regular daily Regular exercise may decrease insulinmild exercise program (regularly, 20 min after requirements, while radical fluctuations inmeals). Warn against exercising if glucose physical activity can adversely affect glucoseexceeds 300 mg/dL. control. Client should exercise after meals to help

prevent hypoglycemia and to stabilize glucoseexcursion, unless excessive elevation of glucose ispresent, in which case exercise promotesketoacidosis.

Provide information regarding the impact of Increased knowledge may decrease fear of thepregnancy on the diabetic condition and unknown, may increase likelihood offuture expectations. participation, and may help reduce fetal/maternal

complications. About 70% of clients diagnosed withGDM will develop NIDDM within 15 yr.

Discuss how client can recognize signs of infection. Important to seek medical help early to avoidCaution client not to treat self with OTC complications. Choice of self-treatment may bevaginal creams. inappropriate/mask infection.

Recommend client maintain a diary of home When reviewed by healthcare practitioner(s),assessment of serum glucose levels, insulin client’s diary can assist with evaluation anddosage, diet, exercise, reactions, general feelings alteration of therapy.of well-being, and any other pertinent thoughts.

Provide contact numbers for health team members. Client needs to be assured that questions will beanswered and problems dealt with immediately on a24-hr–day basis.

Review Hb/Hct levels. Provide dietary information Anemias are of greater concern in clients with pre-about sources of iron and the need for existing diabetes because elevated glucose levelsiron supplements. replace oxygen in the Hb molecule, resulting in

reduced oxygen-carrying capacity.

Assist client/family to learn glucagon administration. Presence of symptoms of hypoglycemiaInstruct client to follow with protein source, such (diaphoresis, tingling sensation, palpitations) withas 8 oz of milk, then recheck glucose level in 15 min. a serum glucose level under 70 mg/dL requires

prompt intervention. Use of glucagon in combinationwith milk can increase the serum glucose levelwithout the risk of rebound hyperglycemia.Glucagon is also useful during periods of morningsickness/vomiting when food intake is curtailed andserum glucose levels fall.