Nutrition is an extremely important aspect of everyone’s daily life. ‘ Nutrition is the process of taking in food and using it for growth, metabolism and repair’ (medicinenet.com). It is never as straight forward as we would like it to be. I did a two week placement in a maternity hospital and I looked after a patient with an altered nutritional status. She is 28 years of age and is having her first baby. The patient I was looking after has gestational diabetes and I choose this patient to do my case study on. I had never heard of gestational diabetes and I took a real interest into it. In my assignment I am going to tell you about my patient and how I cared for her during her altered Nutritional status, I will include, patient status, nutritional status, nutritional care plan analysis and finally recommendation’s. My patient was in the maternity hospital. It is a big hospital which includes seven birthing rooms, two operating theatres, a maternity emergency unit, two post-natal wards (27 bedded) and one antennal ward (29 beds). (HSE, 2019). The patient I was looking after was in the post-natal ward. “Gestational diabetes develops in women during pregnancy because the mother’s body is not able to produce enough insulin. Insulin is a hormone that enables the body to break down sugar (glucose) to be used as energy.”(Diabetes Ireland, 2019). It is hard for a pregnant woman to have this on top of being pregnant because there is a lot more nutritional planning involved. This patient is 28 years of age and is having her first baby. She was telling the Nurse that she was extremely tired and having excessive urination. It was decided to screen the patient for gestational Diabetes. GDM can be diagnosed by 2 different types of oral glucose tolerance tests (OGTT), a “one-step” 75gram OGGT and “two-step” approach with a 50-g (non- fasting) screen followed by a 100-g OGTT for those who screen positive.(ADA, 2016). This patient undertook the oral glucose tolarance test. A 75 gram oral glucose tolerance test (OGTT), involves drinking a glucose drink followed by measurement of blood sugar levels after one and two hours (ADA, 2016). The OGTT should be performed in the morning after an overnight fast of at least 8 hours (ADA, 2016). According to ADA (2016) diagnosis of GDM is made when any of the following plasma glucose values are exceeded:• Initial Fasting level: >92 mg/dL (5.1 mmol/L)• Fasting after 1 hour: >180 mg/dL (10.0 mmol/L)• Fasting after 2 hours: >153 mg/dL (8.5 mmol/L)Gestational diabetes can lead to other complications for the mother as well as the baby. This is why is it vatal that the patient does coherts with the dieticians advice. Women with gestational diabetes should be monitored for components of metabolic syndrome, suchas central obesity, dyslipidemia, and hypertension (ADA, 2016). Accordicing to the NICE guidelines, ‘Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia: fasting: 5.3 mmol/litre, 1 hour after meals: 7.8 mmol/litre or 2 hours after meals: 6.4 mmol/litre. (NICE, 2015). Blood sugars can change very quickly when pregnant therefore my patient needs to check her blood sugar regularly to avoid risk of complications.She was screened for gestational diabetes, and it came back positive. People are more likely to get gestational diabetes if they have family history of type 2 diabetes and my patients mother had type two diabetes. My patient has past medical history that includes, thyroid disease, hypothyroidism for the last eight years. She has also got migraines from previous surgeries and continues to get migraines on a regular basis. My patient has also undergone other surgery’s in the past, wisdom teeth exertion in 2002 under general anaesthetic. She had an appendectomy in 2010. This patient has been admitted to the Maternity hospital as she is having an elective caesarean section for her first baby. She was admitted through MEU and is now on the post-natal ward before being called for her surgery. The reason she is having a C section is because her baby is quite big weighing in at 9 pound 8 ounces. She has no known allergies. This patient is on different medications, she is on eltroxin 100mg (od) due to her hypothyroidism, Asprin 75mg (od) to prevent Preclampsia and finally she is on paracetamol when needed for her migraines.When undergoing a nursing assessment on this patient her vital signs were as follows, blood pressure: 135/89. Patients with gestational diabetes and hypertension should be treated to a target blood pressure of systolic blood pressure 110–129mmHg and a diastolic of 65–79 mmHg (ADA, 2016). Heart rate: 79, spo2: 97%, respirations:16 Temperature: 36.6 degrees, the patient is alert and feeling well. Eating and drinking is very important for this patient. A meal plan will was made for this patient which I will talk about later in my assignment. There will be special dietary requirements. A referral to the dietician would be made for the patient to help her understand the importance of following a strict diet. Once a healthy eating lifestyle and the patient undertakes physical activity she should undergo a normal pregnancy. My patient is five foot five in height and 75kg. when ensuring her BMI she is slightly over weight. Her physical appearance is very well along with very good skin condition. My patient was referred to a dietician after she was screened for gestational diabetes to help her with her nutritional care plan and also her levels of physical activity. The patient had told her that her diet was scattered for the last couple of weeks and she was feeling stressed with all the new diet and physical activity plans. The patient seemed content and agreed to follow a nutritional care plan that she altered to suit her needs with the dietician. Approimatley 10 percent of gestational diabetes have type one and 90 percent have type 2 diabetes. (womens health, 2013). My patient has type 2 diabtete. It is esitmatied that around 7 % of women that have GDM ranging from 1- 14% varying by the population numbers according to ADA, 2011.The main goals of my patients care plan was to eat the correct meals advised by the dietician and keep monitoring her blood glucose levels Adjustments in Lifestyle: Diet, Weight, and exercise Adjustments in Lifestyle: Glucose Monitoring: Blood glucose testing is recommended before (pre-prandial) and either 1-2 hours after (post prandial) start of each meal, bedtime and during the night (Blumer, et al, 2013). Target blood glucose values are: Pre-prandial blood glucose: <95 mg/dl (5.3 mmol/L), 1 hour post prandial:< 140 mg/dl (7.8 mmol/L), 2 hours post prandial: <120 mg/dl (6.7 mmol/L)Gestational diabetes is increasing and is in recent times. It can be hard to diagnosis it so at every hospital visit it should be asked about and checked because patients may be asymptomatic. Firstly, this patient has to undergo some lifestyle changes for example, diet and exercise and undergoing regular blood sugar monitoring. This will alter the patient’s nutritional status because she has to have meal plans and to eat the correct foods to look after herself and her baby. Foods you eat contain three basic nutrients: protein, fat and carbohydrate. Carbohydrates have the largest effect on your blood glucose level as they all break down into glucose after you eat them (HSE.ie, 2019). The first step in my patients nutritional plan is to consume carbohydrates as advised by the dietician. Patient with gestational diabetes they still have to consume carbohydrates for energy and to give their baby energy. Examples include wholegrain bread, oat cereal and sweet potatoes. It is vital that they choose the right type of carbohydrates, ones with low sugar and high fibre to prevent a rise in blood sugar levels. My patient should avoid carbohydrates like white bread or yogurts as it has a very high sugar content and a low nutritional value. According to the HSE, a pregnant lady with GDM should consume 1-2 carbohydrate “choices” at breakfast (max 30g carbohydrate) 3-4 carbohydrate “choices” at other main meals (45-60g carbohydrate) and 1 carbohydrate “choice” at snacks (10-15g carbohydrate).(HSE, 2019). My patient was told to eat Protein foods example, meat chicken eggs and nuts. Finally, fats eating healthy fats seeds, nuts and avocados. Healthy eating for GDM means getting enough nourishment from a variety of foods to help baby’s growth and development. (HSE.ie,2019) this means eating often more than leaving long gaps between eating times, this helps to maintain blood glucose levels. Eating every four to five hours apart while having snacks in between.The main goal for my patient was for her to maintain her blood glucose levels by eating the correct foods and undergoing daily actives to provide the best variety of foods to help her baby grow and be healthy. My patient found it very difficult to accept she had gestational diabetes even though she had a mild form of it and had type 2. She felt extremely worried about things and began to over thing them throughout her pregnancy. Firstly, I feel that my patient should have been referred to a psychologist early in her pregnancy because she was feeling everything was getting on top of her and she was under pressure. She found it hard to eat the recommended amount of carbohydrate and found the daily physical activity the hardest. If she had an early referral and regular appointments with a psychologist that could have helped her with coping strategies it may have been easier for her. She found that the dietician was very good to give her sample diet plans when some of them weren’t working for her. She found it hard to get used to checking her blood glucose levels all the time when she never had to do it before then. Overall the patient got on well through her pregnancy by taking the advice of the dietician in the correct amounts of foods to enhance her nutritional intake. From my analysis on my patients physical activities, instead of telling her she needed 30 mins a day they should have told her that it can be split up throughout the day. She felt it had to be 30 solid minutes a day. It might have been easier to do 3 10 minutes throughout the day and she could have rested in between. Having a Dietary for her daily food intake and physical activities may have been helpful to her. The patient did have a diary for her blood sugar levels but not the rest. This may have been a valuable idea when she was suffering along the way. It may have helped her feel as if she was progressing getting things right instead of not achieving all of her goals.https://www.hse.ie/eng/services/publications/topics/diabetes/eating-well-with-gestational-diabetes.pdfAmerican Diabetes Association [ADA] (2016). Standards of medical care in diabetes. Diabetes Care, 39(1), S1-S112. Retrieved from: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016- Standards-of-Care.pdf —-referce for above (ADA)https://www.hse.ie/eng/Nice.org.uk. (2019). 1 Recommendations | Diabetes in pregnancy: management from preconception to the postnatal period | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng3/chapter/1-Recommendations#gestational-diabetes-2 [Accessed 13 Nov. 2019].Youngkin, Ellis Quinn et al. (2013) Women’s health : a primary care clinical guide. Fourth edition / Ellis Quinn Youngkin, PhD, WHNP-BC, ARNP, Marcia Szmania Davis, MS, MS edition, RNC, WHCNP-BC, ANP-BC, Diane Marie Schadewald, DNP, MSN, RNC, WHNP-BC, FNP-BC, Catherine Juve, PhD, MSPH, RNC, WHNP-BC. Boston: Pearson.