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Women’s Health Clinic

In order to protect the client’s privacy, she will be named as Mrs. Z and all other names will be represented by a respective letter to maintain confidentiality. This encounter happened at the Jewish General Hospital’s Women’s Health Clinic. Mrs. Z is a 34 year old female from a Filipino ethnic background. She works as a housekeeper. Mrs. Z is pregnant with her 2nd child and her estimated date of confinement is November 21st 2015. The fetus is active at home. She currently has gestational diabetes (GD) which is being treated for by diet control and insulin, both Humulin R and Humulin N. Otherwise, no thyroid or blood pressure health issues have been reported. Her past medical history includes a history of hepatitis B positive in 2012.

She does not smoke nor drink alcohol. Her first pregnancy did not include GD, the delivery was a spontaneous vaginal delivery with a moderate amount of blood loss. Her current situation is that she is married to Mr. X. They live together but having , within the past few days, been victim of spousal violence, police was involved and a restraining order has been placed against her husband.

Genogram and Ecomap (see appendix page 7) Strengths One of her strengths is her internal locus of control. She believes that she can actually change things. She stated that she could be able to maintain her GD under control if she took care of what she ate and took her medications properly from then onwards. This is consistent with the fact that her internal locus could help her engage in more health-promoting behaviors. (Norman, Bennett, Smith, & Murphy, 1998) Another strength is her ability to voice the spousal violence.

If she did not mention it to the police, the social service wouldn’t have been involved, the restraining order wouldn’t be in place and the violence could have continued. Talking about it with the nurses also allows a continuous monitoring of her situation during prenatal visits. Deficits Her value which is family unity is also one of her deficits. She said “I feel safe, I don’t want a restraining order. I want my family to be together. ” Considering the situation of spousal violence, if she does go according to her wishes another case of violence could occur; potentially injuring herself, her 3 year old child as well as her unborn child.

One deficit is that a few factors, such as her age which is above 30 years old and her family history of diabetes, put her at an increased risk for GD. (Cianni et al. , 2003) These prevalence factors are which contributed to the situation she in right now. Risks As a victim of spousal violence, she could be at an increased risk for depression. (Al-Modallal, 2015) This could have negative impacts on her caring regarding her child, the fetus as well as her own health. She is also at risk for poor management of GD.

Previously, during her verbal and physical fights with her husband, she stated not taking the insulin correctly and her glucose levels were relatively high at the next reading. This shows poor management of the health issue. If he were to live with her again, this might occur again and complications may arise from the lack of management. Resources Both her sisters act as a resource as they were the ones she turned to when the first case of spousal violence occurred. She found refuge in their homes with her 3 year old child and was kept away from the abusive husband.

On the other hand, another resource is the social services, at the CLSC, that monitor her familial situation and are kept up to date about the spousal relationship. They allow both the mother, and the children to be safe. Health Issue The main health issue that will be focused on, in the next pages to come, is her poorly controlled gestational diabetes. It has recently been poorly controlled as it was indicated by several high values of her capillary blood glucose monitoring (CBGM) testing that is done 4 times every day. Moreover, she has also omitted to take her insulin injections several times within the span of a week.

Nursing Hypotheses Uncontrolled gestational diabetes, indicated by values of CBGM that were above the normal which are 4. 0-5. 2 in the morning and 5. 0-7. 7 the rest of the day, could have possible negative outcomes not only on the mother but also on the fetus. A women with diabetes during pregnancy has an increased chance of developing diabetes mellitus (DM) type II 5 to 10 years after the pregnancy. (Lewis et al. , 2014). This could affect her health on the long term continuum, therefore, managing GD, the best possible, could act as a method of prevention against DM type II.

GD increases, as well, the risks for a cesarean and could be associated to pre-eclampsia and eclampsia which are hypertensive disorders that could also impact both mother and fetus. (Lindsay, 2009) On the other hand, an infant born to a mother with gestational diabetes is more at risk for jaundice, hypocalcemia and macrosomia,. Higher birth weight is associated with increased risk of a higher body mass index (BMI) in adulthood. In other words, higher chances for obesity which could lead to further complications (Oken & Gillman, 2012).

Moreover, other possible complications include jaundice and respiratory distress syndrome at birth which could put the life of the infant at risk. (Lindsay, 2009) Therefore, this health issue could possibly lead to long-term negative effects on the offspring, impacting the family as a whole. The baby, once born, could require more time at the hospital. This could represent a possible source of stress on the mother as she would then have to care for both her 3 year old and her newborn baby which would be at the hospital. This is yet another indication why GD should be under good control. Negotiated Goal of Client/Family

The negotiated goal with the client would be to try various interventions in order to maintain her CGBM levels and her GD under control. This would be indicated by values of CBGM within the norms and regular insulin injections. Nursing Interventions One of the main interventions was patient education on the issue of gestational diabetes and its consequences. Patient education remains one essential role for nurses. Reminding her what uncontrolled gestational diabetes could have as impacts on both the baby and herself could increase her awareness to the issue and motivate her to manage it more efficiently.

According to the behavior change theory, different techniques could be used to modify someone’s behavior and support progress towards healthy behavior. Consciousness raising, in other words, increasing the available information and environment reevaluation which is noticing the effect of your action on others around you could promote someone to opt towards increased healthy behaviors. In her case, the latter would be more adherence to the medical treatment and management of GD. (Bastable, 2014) Another nursing intervention was to promote exercise, which in other words is promotion of healthy lifestyle.

Exercise is known to lower blood glucose levels by increasing its uptake by the body cells and increasing insulin sensitivity. Therefore, the recommendation was to walk 15 to 30 minutes four times or more per week given the fact that she is pregnant. (Perry et al. , 2013) Moreover, this supports the patient’s own finding that, during one episode, her CBGM was lower after light exercise. This also increases the patient’s self-efficacy as she could seem to have more control over her health rather simply relying on medical management. (Gottlieb, 2013).

Given that her diet was fairly well controlled but that the issue was more about missing her insulin injections, the next nursing intervention was to provide insulin teaching. First off, assessment of her previous knowledge about insulin was taken into account and additional information was afterwards provided to increase her resources. A possible cause to her not taking her insulin properly could also be caused by the lack of knowledge on the subject. Moreover, assessment of the specific reasons of her irregular insulin taking was also done.

There after, insulin teaching was offered. The difference between long acting and short acting insulin was also taught as well as the importance of taking the medication carefully. It has been shown that insulin injection techniques should also be reviewed often, even with long-term users of insulin. (Lewis et al. , 2014) It was also reminded to her that, even though we acknowledge the fact that her family situation is complicated and could represent a source of stress at this moment, it was very important to take the insulin injections.

Finally, teach-back method was also an intervention used to assess the client’s understanding of the information that was provided to her. (Bastable, 2014) As health care professionals, we often tend to provide increased number of information during one teaching session which overwhelms the patient. The teach-back technique could allow you to verify that all the information has been grasped and could be put into practice by the client. (Bastable, 2014) Outcomes The client was receptive to the teaching, demonstrated proper acquisition of knowledge as she repeated the information provided and was optimist towards controlling her GD.

I have not had a chance to meet the patient again after the first encounter. However, in the next appointment, I will take a look at the CGBM monitoring sheet that was provided to her. It will allow me to see with the patient if the interventions have worked and to see if she is able to maintain her GD under control. The sheet also indicates whether she took her insulin dose regularly or not. Given that she was truthful in her results and omissions the previous visit, it is fair to believe that the results indicated on paper could be reliable. Follow-up

As a patient attending the clinic and being 35 weeks pregnant, she needs to attend the Women’s Health Clinic weekly. During those appointments, we could follow-up on her gestational diabetes and if the goals have been met. In this follow-up, nurses, doctors and the dietician can be involved. The follow-up would consist of an assessment of the insulin taking, of whether the GD is under control and whether modifications need to be made to the diet or the units of insulin that is taken. An inter-professional approach is needed to accomplish the latter elements. A more precise TNP is attached on page 9.

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