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NSG 314 GDM and Hispanics

by: Emely Bolston, Katelyn Harper, Tina Mishalaine, and Ramil Relucio
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on 16 December 2015

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Transcript of NSG 314 GDM and Hispanics

References
scan
pro f
Antepartum Considerations:
Intrapartum Considerations:
Maternal
Nursing
Considerations

Questions???
GDM
Gestational Diabetes Mellitus (GDM)
and Hispanics

A presentation by:
Emely Bolston, Katelyn Harper,
Tina Mishalaine, and Ramil Relucio

NSG 314
GDM

Demographics:
Roughly 54 million Hispanics are living in the US, representing 17% of the US population. Hispanics are the nation's largest ethnic or race minority (CDC, 2015).
The state with the largest hispanic population is California with 14.7 million.
There are 1,010,784 individuals of Hispanic origin in San Diego county which accounts for 32.4% of the county's population (CDC, 2015).
Case File No.
GDM Pathophysiology:
Nursing Diagnosis (Physiologic)
Alteration in metabolic status r/t hyperglycemia aeb glocuse screening level > 140 mg/dL three hours after drinking glucose solution.
Patient will be able to verbalize understanding signs and symptoms of hypoglycemia.
Short-term Goal
Postpartum Considerations
Cuarentena (40 days) - Dietary and activity restrictions are followed during the 40 days postpartum to promote bonding and prevent future illnesses (Maldonado, et. al., 2012).
Cold foods are not consumed during postpartum period. These promote the emptying of the uterus which is considered to be "hot" or "warm" (Maldonado, et. al., 2012).
During the postpartum period women avoid spicy and acidic foods believing this will cause cramps and increased bleeding (Maldonado, et. al., 2012).
Newborn
Nursing
Consideration
Newborn Considerations:
Inspector:
Professor Kala Crobarger
A post term or prolonged pregnancy is defined as a pregna...by AMBERDAY. (n.d.)
Retrieved December 12, 2015 from http://www.thinglink.com/scene/
57105067423878490
Long-term Goal
Patient will be able to maintain glucose levels within normal range by end of shift.
Nursing Interventions
1. Monitor patient for hyper/hypoglycemia before meals daily.
Rationale:
To identify blood sugar levels that are too high or low. This will give insight into identifying if life style modifications are working (Lowdermilk, 2012).
2. Request for a dietary consult for patient.
Rationale:
This will provide the patient individualized plan to help control glucose (Lowdermilk, 2012).
3. Teach the patient the effects of breastfeeding on glucose levels and how to prevent hypoglycemia.
Rationale:

Hypoglycemia can be life threatening, making the patient aware that glucose levels can drop 15-30 points while breastfeeding and ways to prevent low serum glucose levels will prevent serious complications (Lowdermilk, 2012).
4. Monitor vital signs every 8 hours.
Rationale:
Monitoring vital signs i another way to monitor for hypoglycemia or any other metabolic issues. Early detection is necessary to prevent complications (Lowdermilk, 2012)

5. Teach patient about diabetes prevention programs available for access by all persons including low socioeconomical levels as well as Hispanics.
Rationale:
Prevention programs significantly help improve lipid levels, blood pressure, physical activity, dietary fat intake, and fatalistic and cultural diabetes beliefs (Preventing Diabetes, 2015).
GDM is characterized by having diabetes during pregnancy. Increased pregnancy-related hormones during early stage of pregnancy lower glucose level, as gestation progresses postprandial glucose levels increase as insulin sensitivity decreases. GDM occurs when there is insufficient insulin secretion to counteract the pregnancy-related decrease in insulin sensitivity (Lowdermilk, 2012).
Adverse neonatal outcomes reduced with a nurse-ledmodel of care for diabetes.
Nursing Standard
, 18-19.
American Diabetes Association. (n.d.). Retrieved December 12, 2015, from http://
www.diabetes.org/
Braun, P., Huebschmann, A., Kim, C., Lezotte, D., Shupe, A., & Dabelea, D. (n.d.).
Effect of Material Birthplace on Gstational Diabetes Prevalence in Colorado Hispanics. Journal of Immigrant and Minority Health, 426-433.
Chasan-Taber, L., Marcus, B., Rosal, M., Tucker, K., Hartman, S., Pekow, P.,...
Markenson, G. (n.d.). Estudio Parto: Postpartum diabetes prevention program for hispanic women with abnormal glucose tolerance in pregnancy: A ramdomised controlled trial - study protocol. BMC Pregnancy Childbirth 100
Deglin, J., & Vallerand, A. (2009).
Davis's drug guide for nurses (11th ed.)
. Philadelphia, Penn.: F.A
Davis.
German baby Jasleen born 13.5 pounds without C-section. (n.d.). Retrieved December 12, 2015,
from http://www.cbsnews.com/news/german-baby-jasleen-born-135-pounds-without-c-section/
Gestational diabetes. (n.d.) Retrieved December 12, 2015, from http://www.mayoclinic.org/
diseases-conditions/gestational-diabetes/basics/definition/CON-20014854
Hurst, H. (n.d.). Insulin Revisited.
Nursing for Women's Health
, 224-248.
Kim, S., England, L Sappenfield, W., Wilson, H., Bish, C., Salihu, H., & Sharma, A. (n.d.). Radical/
Ethnic Differences i the Percentage of Gestational Diabetes Mellitus Cases Attributed to Overweight and Obesity, Florida, 2004-2007.
Preventing Chronic Disease
.
Lowdermilk, D., Perry, S., Cashion, K., ALden, K., & Olshansky, E. (2016). Maternity & women's
health care (11th ed.). St. Louis, MO: Elsevier.
Macrosomia. (n.d.). Retrieved December 12, 2015, from http://emedicine.medscape.com/article/
262679-overview.
NICUniversity - Free News and Education for Neonatology Home. (n.d.) Retrieved December 12, 2015,
from http://www.nicuniversity.org/
Sommer, S., Johnson, J., Roberts, K., Redding, S., & Churchill, L. (2013). RN Maternal
Newborn Nursing Review Module (9th ed.). Assessment Technologies Institute, LLC.
Top 11 Doctor Insights on getational diabetes risk to fetus - Health Tap. (n.d.). Retrieved
December 12, 2015, from hhtps://www.healthtap.com/topics/gestational-diabetes-risk-to-fetus
Women's Health Care Physicians. (n.d.). Retrieved Dcember 12, 2015, from http://
www.acog.org/
Nursing journal articles:
http://web.a.ebscohost.comezproxy.nu.edu/ehost/pdfviewer/pdfviewer?sid=31ee96d5-e8e8-4ce0-9af8-522e717dbc01%40sessionmgr4003&vid=8&hid=4214
http://web.a.ebscohst.com.ezproxy.nu.edu/ehost/pdfviewer/pdfviewer?sid=31ee96d5-e8e8-4ec0-9af8-522e717dbc01%40sessionmgr4003&vid=13&hid=4214
Infant of Diabetes Mother (IDM)
Pathophysiology
Newborn Considerations
Long-term exposure to unregulated hyperglycemia leads to fetal adaptation. The fetal pancreas compensates for the hyperglycemia by increasing the number of insulin producing beta cells. Insulin acts to decrease blood sugar by stimulating uptake of glucose into fetal myocytes and lipocytes. At birth the constant supply of hyperglycemic blood is removed while the hyperinsulinism remains and hypoglycemia ensues (Statham, 2011)
Umbilical cord stump: It was believed that babies could take in air through their belly button so it was kept covered with a kind of gauze/fabric called ombligueras (Maldonado, et. al., 2012).
Sunken fontanel (caida de mollera): According to tradition, the fontanel becomes sunken when a baby is withdrawn from the nipple too suddenly or if someone give the baby the evil eye (Maldonado, et. al., 2012).
Traditional Latinos believe that babies felt cold more than adults and therefore need to be bundled up (Maldonado, et. al., 2012).
Undressing the baby without permission may make the parents fear that the baby will become ill as a result of the cold air. Aire is cured with herbal medicines or potions, or with "moxibustion" (Maldonado, et. al., 2012)
Evil Eye (mal de ojo): A baby who is the victim of the evil eye can run a fever, cry nonstop or show other symptoms. To protect the baby, they are given a red or pink bracelet to wear around the wrist or neck (Maldonado, et. al., 2012)
GDM disproportionately affects pregnant Latinas. Latinas have a greater predisposition to all types of diabetes, 1 in 4 has some form of GDM, and a 52.5% risk of developing diabetes in their lifetime (CDC, 2015).
The genetic predisposition for diabetes puts Latinas at higher risk of developing GDM. In many cases, Latinas don't even know they have diabetes when they get pregnant (CDC, 2015).
Patient Centered Care /
Health Promotion
Instruct the patient to perform daily kick counts (Sommer, et. al., 2013).
Educate the patient about the proper diet and exercise (Sommer, et. al., 2013).
Instruct the patient about self-administration of insulin (Sommer, et. al., 2013).
Educate the patient on the importance of postpartum laboratoy testing to include OGTT and blood glucose levels (Sommer, et. al., 2013).
Referral and Support Groups
Online Forums: women can post questions and get answers, advise and support from mothers who have GDM or had GDM in one of their previous pregnancies.
1. Baby Center
2. American Diabetes Association
3. Everyday Health
4. Social Networking Sites
Antojos (cravings) - infants may have characteristics of certain foods if cravings are not satisfied during pregnancy (e.g. strawberry birth mark) (Maldonado, et. al., 2012).
"Hot" and "Cold" diet. Her diet has to consist of "hot foods" based on the food's inherent properties vice the actual temperature. Chicken is considered "hot" and many fruits are "cold" (Maldonado, et. al., 2012).
Temazcal Baths (Vapor baths) - a pregnant woman may periodically exposed to one of these baths to eliminate toxic products through sweating (Maldonado, et. al., 2012).
Ser sobada (to have a massage) - Practiced by a curandero (traditional healer). The woman has a massage with her abdomen manipulated to help prepare baby for delivery (Maldonado, et. al., 2012).
Maldonado-Duran, J., Manguia-Wellman, M., Lubin, S., & Lartigue, T. (2012). Latino Families
Perinatal Period: Cultural Issues in Dealing with the Health-Care Systems. Great plains Research: A Journal of Natural and Social Sciences, 12(1). Retrieved from http://digitalcommons.unl.edu/cgi/viewcontent.cgi
article=1602&context=plainsresearch
Co-sleeping - In most Latino families, the baby will sleep at least with the mother, or with both parents in their bed (Maldonado, et. al., 2012).
Breastfeeding - traditional expectation and belief is that the baby naturally should be breastfed on demand. Breast are considered predominantly as nurturing organs and not sexual ones. Thus, a woman may find it very natural to breastfeed in public places (Maldonado, et. al., 2012).
A woman would have to deliver her baby with the assistance of other women, like female relatives. The delivery is mostly an affair of women (Maldonado, et. al., 2012).
The placenta is buried near the house. Also, the stump of ombligo (umbilical cord) is buried nearby. It is thought that the place where the umbilical cord was buried is the root of the person where he/she belongs forever (Maldonado, et. al., 2012).
Short-term Goal
Nursing Interventions
Poor maternal glucose control during the first trimester can result in congenital birth defects (Lowdermilk, et. al., 2016):
Most common heart defects : VSD and TGA
CNS malformation are 16x more likely with IDM.
Ear
GI: Duodenal or anorectal artesia, small left colon syndrome
Renal: hydronephrosis, renal agenesis, ureteral duplication
Infant of Diabetic Mother (IDM)
LGA infants should be routinely screened for hypoglycemia.
High rate of ceasarean delivery related to macrosomia (Lowdermilk, et. al., 2016)
Risk for shoulder dystocia
Potential brachial plexus injuries
C-section increases risk for TTN
IDM (Cont.)
Late gestation maternal hyperglycemia places IDMs at risk for:
Respiratory problems
NSG DX: Impaired gas exchange r/t hypoxemia/hypoxia secondary to respiratory distress syndrome (NANDA, 2016).
Growth abnormalities
NSG DX: Risk for imbalanced nutrition, less than body requirements r/t macrosomia and resulting increased metabolic demands (NANDA, 2016)
Polycythemia
NSG DX: Impaired gas exchange r/t hypoxemia/hypoxia secondary to respiratory distress syndrome and/or pulmonary hypertension (PPHN) (NANDA, 2016)
Cardiomegaly
NSG DX: Risk for ineffective tissue perfusion r/t weakly functioning myocardium secondary to cardiomegaly (NANDA, 2016)
Hypocalcemia or Hypomagnesemia
NSG DX: Risk for electrolyte imbalance r/t decreased serum calcium and/or magnesium levels (NANDA, 2016).
Hyperbilirubinemia (Jaundice)
NSG DX: Risk for neonatal jaundice r/t increased levels of unconjugated bilirubin secondary to polycythemia and/or immature liver (NANDA, 2016)
Iron deficiency
NSG DX1: Risk for ineffective breastfeeding r/t immature sucking patterns (NANDA, 2016).

NSG DX2: Infant feeding pattern, ineffective: impaired ability to suck or coordinate suck-swallow response resulting in inadequate oral nutrition for metabolic needs (NANDA, 2016).
Hypoglycemia
NSG DX: Risk for unstable blood glucose r/t increased fetal insulin development and subsequent neonatal hypersulinemia in response to increased intrauterine blood glucose supply (NANDA, 2016).
Maintain euglycemia (serum glucose level 40-60 mg/dL) after delivery and first 24 hours of life (Lowdermilk, et. al., 2016).
Long-term Goal
Maintain euglycemia (serum glucose level 50-90 mg/dL) beyond first 24 hours and until discharge (Lowdermilk, et. al., 2016)
1. Assess blood glucose level as soon as possible after birth.
Rationale:
Neonatal hypoglycemia must be treated or seizures may result (Lowdermilk, et. al., 2016).
2. Repeat assessment of blood glucose level at 30 minutes, 2, 4, 8, and 12 hours after birth.
Rationale:
Blood glucose levels can change rapidly and neonatal hypoglycemia must be treated or seizures may result (lowdermilk, et. al., 2016)
3. Assess blood glucose whenever jitteriness or other abnormal clinical signs are observed.
Rationale:
Jitteriness, irritability, apathy, poor feeding, high-pitched or weak cry, and hypotonia are all signs of hypoglycemia (Lowdermilk, et. al., 2016).
4. For blood glucose level less than 40 mg/dL or S&S of hypoglycemia, in the absence of respiratory distress, feed the infant.
Rationale:
Breast or bottle feeding will provide a source of glucose for the hypoglycemic newborn (Lowdermilk, et. al., 2016)
5. For infants in respiratory distress, infants unable to feed, infants whose blood glucose level does not increase with feeding, or for glucose level less than 20-25 mg/dL, IV dextrose should be administered as ordered by provider. This should include a bolus followed by continuous infusion for target of blood glucose level greater than 45 mg/dL.
Rationale:
Failure to provide continuous infusion of dextrose following a bolus may result in rebound hypoglycemia (Medscape, 2016).
6. When glucose levels have been stable for 12 hrs, IV glucose may be tapered by 1-2 mg/kg/min, as ordered to maintain BG lvls > 40 mg/dL. Resume or initiate PO feedings ASAP as ordered.
Rationale:
Enteral feedings hasten improvement in glucose control because of presence of protein & fat in breast milk or formula (Medscape, 2016).
7. Educate parents about infant's condition and treatment and encourage questions.
Rationale:
Understanding the infant's illness, treatment, and voicing concerns can help parents cope with anxiety regarding their infant (Lowdermilk, et. al., 2016).
8. Allow parents to hold skin-to-skin and participate in infant care as newborn's condition permits.
Rationale:
Skin-to-skin contact and participation in care help parents form attachment with their infant (Lowdermilk, et. al., 2016).
Expected Outcome:
To maintain euglycemia with PO feeding for discharge to home.
NANDA International (n.d.). Retrieved December 14, 2015, from http://www.nanda.org/
Medscape. (n.d.). Infant of Diabetic Mother. (2013). Retrieved December 14, 2015, from
CDC. (n.d.). Hispanic or Latino Populations. (2015). Retrieved December 10, 2015, from
http://www.cdc.gov/minorityhealth/populatins/REMP/hispanic.html
http://www.emedicine.medscape.com/article/97430-overview
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