SELF CARE OF PREGNANT WOMEN WITH GESTATIONAL DIABETES MELLITUS IN INDONESIA

256 713 Theoritical Perseptives in Nursing

Presented to Assist Prof. Dr. Pattama Surit

Windha Widyastuti 565060126-8

Master of Nursing Science Program

Faculty of Nursing, Khon Kaen University

First Semester, Academic Year 2013

I. PHENOMENA

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which

women without previously diagnosed diabetes exhibit high blood glucose levels during

pregnancy (especially during their third trimester). Gestational diabetes is caused when the

insulin receptors do not function properly. This is likely due to pregnancy related factors

such as the presence of human placental lactogen that interferes with susceptible insulin

receptors. This in turn causes inappropriately elevated blood sugar levels. Diagnostic tests

detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-

10% of pregnancies, depending on the population studied so may be a natural phenomenon.

The excess glucose from the mother crosses the placenta to the baby, but insulin does not.

The baby's pancreas has to produce insulin for the baby. When the baby's pancreas produces

extra insulin to keep up with the excess sugar, the sugar that the baby's body does not use is

stored as fat. After approximately the 20th week of pregnancy, insulin's action can be

impaired enough to be dangerous to the health of the mother and child. Women who have

had gestational diabetes are more likely to develop type 2 diabetes later than other women,

and they can get the other complication of pregnancy ( pre eclampsia, diabetic ketoasidosis,

vascular disease, etc), which increases the risk of a difficult birth, having your labour induced

or a caesarean section.

Women with gestational diabetes have a significantly higher risk of having a baby with

macrosomia, or a "fat baby". While it may not seem all that serious at first, baby's who are

born with macrosomia face significant health problems. They can have problems being born

due to their large size, including difficulty passing through the pelvis and birth canal due to

their large size, premature birth, breathing problems, low blood sugar after birth, and an

elevated risk for obesity and type 2 diabetes as adults.

The prevalence of gestational diabetes (GDM) is increasing all over the world, especially

among the developing countries.. Worldwide explained that one in 10 pregnancies may be

associated with diabetes, 90% of which are gestational diabetes (GDM). In highrisk groups,

up to 30% of pregnancies may involve diabetes. Gestational diabetes occurs in pregnancy 7%

annually (Seshiah Veeraswamy, et all, 2012,

http://www.sciencedirect.com/science/article/pii/S0168822712001581#, search in July 10).

Incidence (annual) of Gestational diabetes: 135,000 pregnant women get the condition

every year; 3-5% of pregnant women. Incidence Rate for Gestational diabetes: approximately

1 in 2,014 or 0.05% or 135,000 people in USA. The rate of gestational diabetes was also

shown to be 5–10 times higher in pregnant Asian women than in white women. Data from

Gestational diabetes in Southeastern Asia (Extrapolated Statistics) in Indonesia had

extrapolated incidence 118,349 population..The prevalence of prediabetes in Indonesia in

2007 by 10%, while the prevalence of gestational diabetes mellitus in Indonesia of 1.9% -

3.6% of pregnancies in general (Soewardono and Pramod, 2011).

In 2010 there were an estimated 22 million women with diabetes in the reproductive age

group of 20–39 years; an additional 54 million in this age group had IGT or pre diabetes with

potential to develop gestational diabetes if they become pregnant [5]. Thus over 76 million

women are at risk of their pregnancy being complicated with pre gestational (existing)

diabetes or gestational diabetes (diabetes occurring or first recognized during pregnancy). In

pregnant women with a family history of diabetes mellitus, gestational diabetes prevalence of

5.1% (Maryunani, 2008). The risk of having GDM in pregnant women aged less than 21

years is 1%, more than 25 years was 14%, maternal age between 21-30 years is less than 2%

and in women older than 30 years is 8 - 14% follow the statistics obtained from the book

Diabetology of Pregnancy, by M.Porta, F.M. Matschinsky Vol 17 with the publication year

2005. With this, we can wrap up that Asian women in the State or in the State of Indonesia

itself risk of GDM should be entitled to receive and the scope of age over 30 years have a

high risk of getting GDM.

The number of GDM in Indonesia still high. It is possible because people have a habit

bad, unhealthy diet, lack of movement, and the environmental conditions do not support

health (Wahyudi, 2008). One of the important reason is the increasing of obesity due to

changes of lifestyles . The recently data statistics of GDM cases in Indonesia, the author can

not get the data because there is no valid research that has been done in the country of

Indonesia about GDM. The figure is lower than the prevalence in the State of United States.

Nonetheless, the issue of gestational diabetes in Indonesia still requires serious treatment see

the number of people who get much as well as the impact on pregnant women and fetuses. In

addition, the management of Diabetes Mellitus in pregnancy, how to screening, diagnosis

method, antenatal care and how her labor is still no consensus among obstetricians in

Indonesia recently, based on fetomaternal team, Agus Abadi (2010).

The program for GDM in health care system in Indonesia there are same treatment with

diabetes mellitus. One of the best ways to keep blood sugar under control is by eating

according to a gestational diabetes diet plan developed with the help of a doctor or

nutritionist. From the prescribing diet, for women pregnant with GDM in Indoneisa is

become more non-compliant. The characteristic of Indonesian people in general are

consumtion the high carbohydrate intake, because rice is staple food. Whereas, rice contain

high sugar which give effect for women pregnant. On other hand, Indonesian food contain

especially who leave in semi urban especially in Pekajangan area that was once the third

highest in Indonesia and number 4 in ASIA in 2003 with 9,2% population (Darmono, 2005).

Many foods are sold in fatty food, because of that people like to eat fatty foods. This can

aggravate the condition of high blood sugar experienced.

In other hand, Exercise is also an important part of keeping blood sugar stable. Exercise

stimulates the body to move glucose into cells and increases the cells sensitivity to insulin.

The Aim for 30 minutes of activity exercise three times a week, but for women pregnant with

GDM have to Check blood sugar levels before and after any activity, especially if they use

insulin. Based on researcher observasion, actually women pregnant worry with their baby if

they be exhaustion by exercise, so they don’t have sufficient exercise during their pregnancy.

They scared if exercise will give negative effect for their baby. It is match with research by

Yayuk Hariyanti, et all in 2012 in Indonesia, said that there was a significant association

between energy intake and rate of weight gain. Self-reported levels of physical activity of

women pregnant were very low, with 23%. This can be compounded by the absence of group

gymnastics diabetes in pregnant women as well as on the gymnastics group from diabetes.

In addition, monitoring blood sugar will help give a more complete picture of blood

sugar spikes. This is simple to do and the doctor can give the pregnant woman detailed

instructions as to how she should monitor her blood sugar. Some doctors tend to lean toward

insulin because they are concerned about the safety of oral medications during pregnancy

because some women (between 10% and 20%) will need oral hypoglycaemic agents or

insulin therapy if diet and exercise are not effective in controlling gestational diabetes (NICE

clinical guideline 63, 2008). It is difficult things for some patient who live in urban area like

Pekajangan,can not perform regular blood sugar monitoring due to the distance to health care

is far, and they do not have blood sugar measuring device itself, and they have some financial

limitations to do blood sugar monitoring in health care system.

Furthermore, there are only less of information for women who already have diabetes and

are pregnant or who would like to become pregnant, because of that many womens with

gestational diabetes can not control her blood sugar during pregnancy, also with their

medication (Yayuk Hariyanti, et all in 2012). Patient education is a critical component in

pregnancy that is complicated by diabetes; a patient’s understanding of her disease enhances

her ability to manage her disease effectively.

If gestational diabetes is not detected and controlled, it can increase the risk of birth

complications, and also in most cases, gestational diabetes develops in the third trimester

(after 28 weeks) and usually disappears after the baby is born. However, women who

develop gestational diabetes are more likely to develop type 2 diabetes later in life.

Assesment GDM in health care system is started from antenatal care program. There

should be continuity of care throughout the antenatal period. It is absolutely necessary

because it makes sure that women pregnant and the baby are fit and well.

Antenatal care, visits every 2 weeks until the age of 36 weeks pregnant then 1 week until the full

term (when blood glucose levels are well controlled). Target blood glucose levels as normal as

possible with fasting glucose = 100 mg / dL and 2-hour pp = 140 mg / dL were achieved with diet,

exercise and insulin. Check women pregnant’s blood sugar at the first visit, when normal, recheck

the week on a visit to the 26-28, for early detection of gestational diabetes mellitus. If the pregnant

women have high glucose level after recheck they will referred to a doctor to continue the

management for maintaining blood glucose level.

The antenatal care in Pekajangan, the women pregnant will be monitor the blood glucose

level by urin test by benedict test. If they have result +1 which green colour of the urin, it

means that the blood glucose level increase in the fisrt level, they will get the health

education from nursing about the nutrition during the pregnancy. This education has aim to

change the habit of eating in women pregnant, to prevent the diabetes mellitus during their

pregnancy. Nevertheless, they do not get GDM education from nursing earlier, because of

that they do not really understand the treatment for preventing the diabetes mellitus in the

pregnancy. It can make the self management of women pregnant with GDM is low. It is a

problem for nursing to decrease the prevalence of GDM and the complication that derived

from GDM.

All of the program for women pregnant with GDM describe that the pregnancy

management in GDM depend from Mother’s self-management during in her pregnancy. They

have to manage their therapy program for GDM byself. It will be the difficult things to them

around their pregnancy about 9 months to change their lifestyle to follow the program for

decreasing their blood glucose levels. They should be able to build a strong desire to

participate in each program therapy.

Many factor related the process of self management of women pregnant with GDM. The

impact of a diagnosis of GDM may lead to increased stress in pregnancy due to the demands

of adherence to a treatment regimen and maternal concern about adverse outcomes for the

mother and baby. Based on the research of Lydon K, Dunne FP, et all in 2012, they found

that elevated levels of diabetes-related distress were found in 40% of women with GDM. In

addition, the GDM group reported less social support from outside the family. The study

indicates that the experience of GDM appears to be associated with increased psychological

distress in comparison to the experience of non-diabetic pregnant women.

The association between women's social support from family and friends for healthy diet

and self-efficacy for not overeating and their dietary habits also were examined. Finally, the

association between all of these psychosocial constructs and body mass index (BMI) were

assessed before and after adjustment for covariates. Self-efficacy and social support from

family and friends for physical activity were associated with physical activity. Social support

from family and friends for a healthy diet was associated with better dietary scores, and the

association between self-efficacy for not overeating and healthy diet bordered on significance

(Catherine Kim, 2008).

However, for an individual with diabetes to perform self-management activities, they

must acquire self-care agency or capability for diabetes self management. Diabetes Self-

Management as the actual performance of diabetes self-care activities according to Sousa

(2003) and Sousa and Zauszienwski (2005). Diabetes self-care agency as capability for self-

management according to Sousa (2003) and Sousa and Zauszniewski (2005). The items of the

scale were worded to be consistent with this definition and its conceptual bases in the Orem’s

theory of self care.

Orem’s self care deficit theory provided a theoritical framework to guide assistance of a

client with diabetes to meet self-management requirements (Orem, 2001). Ideally, the

interpersonal relationship between a nurse and a client contributes to the alleviation of the

client’s stress and that of the family, enabling the client and the family to act responsibly in

matters of health. In addition, there are a link concepts called basic conditioning factors which

include age, developmental state, health care system, sociocultural orientation, environmental

factor, patterns of living and resource availability (Orem). In the long term, family members

may affect the client’s adherence to behavioral changes and treatment regimens and overall

outcomes, which addresses the importance of knowledge, attitudes, and skills that enable the

individual to engage in self-care (Rutledge et al, 1999).

Several studies have suggested that individual’s self-care agency are critical factors for

the performance of specific diabetes self-care activities to maintain glycemic control.

(D.Sousa, Valmi D, Susan W Hartman. 2009). The self-care agency concept is one of the key

components in Orem’s Theory of Self-Care and it is used throughout the theory as an

individual’s capability for self-care activities to achieve a goal-oriented outcome. The goal of

GDM is normal blood glucose level.

Lifestyle in self-care activities and medical treatment resulting in tight glucose control

have been shown to delay the onset of or reduce diabetes complications by 50–75%.

Lifestyle in self- care activities is most effective when augmented with careful medical

supervision and a patient who is well educated in lifestyle behaviors. There is a significant

knowledge gap relating to the socio-cultural factors that may affect self management of

women with gestational diabetes (GDM). Such understanding may inform culturally

sensitive interventions and educational programmes to improve self- care activities. It is

important to explore ways of preventing GDM,to put in management GDM well during

pregnancy,and to reduce the later risk of developing type2 diabetes. The Pregnancy is a

unique opportunity for education and intervention as women have repeated contact with the

health system during this time. This way help nurse to give obvious intervention for women

pregnant with GDM successfully, to decrease their blood sugar and to keep their pregnancy

in well condition.

Based on data collected from the various studies, it is clear the mother

pregnant in Indonesia have a high risk for GDM received. In other hand, the prevalence of

GDM still increase. In addition, the health care system not sufficient give the GDM treatment

for women pregnant with GDM.It has attracted the attention of writers and encourage writers

to do researchthe GDM on. The authors hope this study can reduce the prevalence and

incidence of GDM cases with provide counseling to built self care in pregnant womens

regarding GDM and well can derive GDM cases that often prevail among pregnant women in

in Indonesia and also in ASEAN for general. This is of concern as increased migration from

this part of the world means that midwives and other health professionals must increasingly

provide pregnancy care for these women. Because of these risks, GDM is a significant

concern for health professionals, including mid- wives, nurses, and doctors.

II. REVIEW THEORY

The theory of self-care describes why and how people care for themselves and suggests

that nursing is required in case of inability to perform self-care as a result of limitations.

Orem’s model supports nursing trough the following three central theories :

1. Nursing is required because of the inability to perform self-care as the result of limitation

(Theory of self-care deficit)

Supporting concepts derived from self-care deficit care :

a. Self care agency is an acquired ability of mature and maturing persons to know and

meet their requirements for deliberate and purposive action to regulate their own

human functioning and development

b. Therapeutic self-care demand consists of the summation of care measures necessary

to meet all of an Individual’s known self-care requisities

c. Basic Conditioning factors refer to those factors that affect the value of the

therapeutic self-care demand or self-care agency of an individual.

Ten factors are identified : age, gender, developmental state, health state, pattern of

living, health care system factors, family system factors, socio cultural factors,

availability of resources, and external environtmental factors

2. Maturing or mature adults deliberately learn and perform actions to direct their survival,

quality of live, and well-being (Theory of Self-Care)

Orem’s identifies three types of self care requisities that are :

a. Universal self-care requisities : Maintenance of sufficient intake of air, water, food,

provision of care associated with elimination processes and excrements, maintenance

of a balance of activity and rest, between solitude and social interaction, prevention

of hazards to human life, preventing of hazards to human life, human functioning

and human well-being, and promotion of human functioning and development within

social groups in accordance with human potensial, known limitations, and the human

desire to be normal.

b. Development self-care requisites : needs concerned with process associated with

human development troughout the life cycle as well as situations that have the

potential to adversely affect development

c. Health-deviation self-care requisites are related to deviations in structure or function

of a human being.

3. The product of nursing is nursing system(s) by which nurses use the nursing process to

help individuals meet their self care requisites and build their self-care or dependent-care

capabilities (Theory of Nursing System). Three types of nursing systems are identified :

a. Wholly compensatory is unable to perform any self-care activities and relies on the

nurse to perform care.

b. Partially compensatory system : one in which both nurse and client participate in

meeting self-care needs

c. supportive-educative : one in which the client is able to perform or is able to learn to

perform sef-care actions as a self-care agent.

III. APPLIYING THE THEORY IN THE PHENOMENA

Orem’s self care deficit theory provided a theoretical framework to guid assistance of a

client with diabetes to meet self-management requirements (Orem, 2001). Ideally, the

interpersonal relationship between a nurse and a client contributes to the alleviation of the

client’s stress and enabling the client to act responsibly in matters of health (Orem).

Using Orem’s nursing theory, concepts can be integrated with middle range theories

pertaining to health promotion and family systems to guide health assessment, selection of

appropriate health outcomes, and carrying out nursing interventions. Comprehensive

functional health pattern assessment, including health promotion patterns, and family system

assessment, are essential to empower women pregnant with GDM in the self-management of

DM.

The assessment and plan of care which utilize Orem’s using three major concepts :

1. Self-care deficits

The theory of self-care describes why and how women pregnant with GDM care for

themselves and suggests that nursing is required in case of inability to perform self care

as a result of limitations. This theoy includes the concepts of self care agency and

therapeutic self-care demand. In addition, Basic conditioning factors refer to those factors

that affect the value of the therapeutic self-care demand or self-care agency of an

individual such as age (over the age of 30), Health State (Gestational diabetes mellitus),

Sociocultural Orientation (Indonesia, No sufficient management of GDM), Health care

system, Family system (Married, husband working), Patterns of Living (At home with

husband o family), Environtment (Rural area, items for ADL not in easy reach, no special

precautions, to prevent complication), Resources (Nurse, Midwive, Husband, Mother).

a. Self-care agency

Women pregnant with GDM use they power or self care ability that affected by

the environtment which addresses the importance of knowledge about GDM, attitudes

as changing their lifestyl, and skills that enable the individual to follow the treatment

of GDM such as exercise and prescribing diet.

If women pregnant with GDM feels powerless to control the corse of her disease,

and the environtmental factors that are negatively influencing their self management

such as have no support from their family, difficult to access the health care system,

low understanding about GDM, and burden of women pregnant to change their

lifestyle for the example women pregnant with GDM fell too tired to engage in an

exercise program. In addition, if they have a low self esteem, this will be negatively

impact on self-care agency.

Adherence to a self-treatment regimen that includes eating healthy, being active,

monitoring blood glucose and taking medication is referred to as self-management

and a critical factor in maintaining glycaemic control. However, for an individual

with diabetes to perform self-management activities, they must acquire self-care

agency or capability for diabetes self management.

Diabetes Self-Management as the actual performance of diabetes self-care

activities according to Sousa (2003) and Sousa and Zauszienwski (2005). The self-

care agency concept is one of the key components in Orem’s Theory of Self-Care and

it is used troughout the theory as an individual’s capability for self-care activities to

achieve a goal-oriented outcome. Self-care agency consists of three trait component

described in detail elsewhere.

Self-care agency can be affected by age, health status, educational level, diabetes

knowledge, type of diabetes, duration of diabetes, self-care agency and self efficacy

(Ailinger & Dear 1993, Lukkarinenm * Hentinen 1997, Hart & Foster 1998, Sousa

2003, Sousa et al. 2004, 2005, 2006).

Diabetes self-care agency as capability for diabetes self-management according

to Sousa (2003) and Sousa and Zauszniewski (2005). The items of the scale were

worded to be consistent with this definition and it is conceptual bases in the rem’s

theory self-care and all the items were written as a corollary to the DSMS described

above. The self care agency concept is one of the key components in Orem’s Theory

os self –care (Orem 2011). and it is used throughout the theory as an individual’s

capability for self-care activities to achieve a goal-oriented outcome. Self-agency can

be affected by age, health status, educational level, diabetes knowledge, type of

diabetes, duration of diabetes and self-care agency.

Diabetes self-care agency as capability for self-management according to Sousa

(2003) and Sousa and Zauszniewski (2005). The items of the scale were worded to be

consistent with this definition and its conceptual bases in the Orem’s theory of self

care.

Several studies have suggested that individual’s self-care agency are critical

factors for the performance of specific diabetes self-care activities (self management)

to maintain glycaemic control.

(D.Sousa, Valmi D, Susan W Hartman. 2009. New Measure of Diabetes self-care

agency, diabetes self-care agency, diabetes diabetes self-efficacy, and diabetes self-

management for insulin-treated individuals with type 2 diabetes. Journal of Clinical

Nursing. Accepted for publication : 21 August 2008)

b. Therapeutic self-care demand

Therapeutic self-care demand refers to those actions that women pregnant with

GDM should perform over time to maintain life, health and well being during live

with DM. The demand for therapeutic self-care of women pregnant with GDM in

regard to health deficit refers to those health changes for the example if women

pregnant with GDM get a diabetes complication , that bring about needs for action to

prevent further problems or to control or overcome the effects of the complication, by

therapy program that exist.

The women pregnant self-care deman is they will respon to change in diet which the

role of diet is simple sugars, rely more on complex carbohydrates and increase lean

protein and vegetable consumption; exercise around 30minute to 1 hour daily which

current intensity and type of exercise should be modified for obvious safety issues

(e.g., activities involving balance, direct contact sports); take a medication (oral

hypoglycaemic agents or insulin therapy if diet and exercise are not effective in

controlling gestational diabetes; and they should be instructed in self monitoring of

blood glucose, because they should be informed that good glycemic control troughout

pregnancy will reduce the risk of fetal macrosomia, trauma during birth, induction of

labour or caesarean section, neonatal hypoglycemia and perinatal death. In addition

women pregnant with GDM should be offered information covering : the role of diet

body weight, exercise and the increased risk of having a baby who is large for

gestational age, which increase the likelihood of birth trauma, indication of labour

and caesarean section.

2. Self care needs

Explanation about Therapeutic self-care will be clear if it is described in each types, that

are :

a. Universal self-care requisities such as Food (Food contain low sugar, Food contain

low carbohydrate, no cafein and alcohol, no fatty foods. Hb > 11gr%, Adjusted BMI

criteria for Normal Body Weight Increase In Pregnancy), Water Fluid (intake is sufficient,

Edema present over ankles, turgor normal for the age), Activity/ Rest (Sufficient

activities not do heavy physical exercise and make exhaustion), Social Interaction

(Communicates well the husband, also both the nurse and doctor for the therapy),

Prevention of hazard (Need instruction on exercise for GDM, and prevention the

complication, Need instruction on improvement of nutritional status), Promotion of

normalcy (Has good relation with nurse, midwive and doctore).

b. Development self-care requisites

Development self-care requisites is a self care regiment to overcome or prevent

effects of life experience that can impact human development. In this case the

development is a pregnancy that need the regiment to prevent the complication

during pregnancy with DM.

c. Health-deviation self-care requisites

Health-deviation self-care requisites for women pregnant with GDM is Adherence to

medical regimen (Report the Follow the treatment include activities such as self-

monitoring of blood glucose and the integration of a prescribed diet, exercise, and

medication regimen into daily living), Awareness of potential problem associated

with the regimen (Not Aware about the actual disease process, Not in accordance

with the recommended diet and exercise, not monitor blood glucose levels regularly,

rule out health education on GDM, Not aware about the side effect of the

medicationsa), Modification of self-image to incorporates changes in the health

status (Has adapted to limitation in mobility, The adoption of new ways for activities

leads to the complication and progression of the disease), Adjustment of lifestyle to

accommodate changes in the health (Avoid the food that contain high sugar, Take a

sufficient exercise every day, Take a health education of GDM in health care system,

Monitoring blood glucose levels routinely, controlling emotions to avoid stress and

take an insulin injection who need in health care system).

3. Nursing system

Nursing system in this case is means that the nursing action and interaction of nurses and

women pregnant with GDM in nursing practice situation to prevent the complication of

GDM and to support women pregnant change their lifestyle to live with DM during their

pregnancy. There are three type of nursing systems : Wholly compensatory, partly

compensatory and supportive educative. Women pregnant with GDM required a

supportive educative nursing system because they perform all self-care action requiring

ambulation and movement. The nurse performed action to support and educate women

pregnant with GDM. In addition the nurse provide information about diabetes self-

management and supprotedtheir psychologically, thus enhancing her self-care agency.

Diabetes self-management is key to successful outcomes for women pregnant with

GDM..

FRAMEWORK OF SELF CARE IN WOMEN PREGNANT WITH GDM

R R

R

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R

R

women pregnant with GDM optimism to control blood glucose level by : prescribe diet, take sufficiency exercise, take an education of GDM, monitoring Blood glucose level routinely, take an medication who neeed

women pregnant with GDM unable to follow the treatment :prescribe diet, take sufficiency exercise, take an education of GDM, monitoring Blood glucose level routinely, take an medication who neeed

Development : pregnancy

Universal : need to avoid food with high Glucose, exercise program , monitoring blood glucose level, Awareness of potential problem

associated with the regimen.

self-care requisites : Promotion of normalcy, Adherence to medical regimen. (Adjustment of lifestyle to accommodate changes in the health)

- maintaining blood glucose level- monitor prescribing diet- give an education of GDM- make a program for exercise to women

preganant with GDM’s exercise- collaboration with doctor for inject the

insulin who need

deficit

NURSING PROCESS OF SELF CARE IN WOMEN PREGNANT WITH GDM

Nursing Diagnosis Goals(NOC)

Nursing Interventions(NIC)

Risk for disturbed Maternal/ Fetal dyad related to Risk Factors: Complication of pregnancy compromised O2

transport anemia, hypertention), impaired glucose metabolism (GDM)

Client will cope with discomforts of high –risk pregnancy during their pregnancyBy following indicators :- Emotional

attachment to fetus/ cooping with discomforts of pregnancy/ Mood labiality/ blood glucose/ Haemoglobin.

- Fetal status- No Keton in

urine- BP < 130/80

beats/ minute- pulse 60-100

beats/ minute- respiration 16-20

breaths/ minute,- warm and dry

skin- fasting blood

glucose 70-110 mg/dL

1. Monitor sign and symptoms of the complication : Blood glucose <70mg/dL or > 300 mg/ dL, vital sign, moderate/ large ketones, fetus status)Rational : The early diagnosis and treatment of complication in a client with GDM is necessary. If gestational diabetes is not detected and controlled there is a small risk of birth complications such as shoulder dystocia.

2. Determine the presence of medical factors that are related to poor pregnancy outcome (diabetes) : Finances, occupation (sick time), lifestyle, energy level, relationships\Rational : common frustration associated with diabetes stem fom problems involving the disease itself, the treatment regimen, and the health care system.

3. Standardize internal and external transport form using SBAR format (situation, background, assessment, recommendation) to provide safe and efficient transport of a high-risk pregnantRational : Using a standardized form troughout the hospital system decrease the risk of errors, miscommunications, and omissions (Edwards & Woodward, 2008; Guise &Lowe, 2008)

4. Provide information on the effects of pregnancy on diabetic conditions and future expectations.Rationale: Increased knowledge can reduce fear, increase cooperation, and help reduce fetal complications

5. Offer flexible visiting hours, private space of families and nursing support for management of family stressors when a women is hospitalized with high-risk pregnancy. EBN : In qualitative studies of women hospitalized for complications of pregnancy, accommodating individual

family need recommended, such as flexible visiting hours and private space for family visits, and nursing support

6. Perform accurate blood pressure redings at each client’s clinic encounter. EB : women who have a history of chronis hypertention and are at risk for preeclampsia need to be identified to decrease isk fo inadequate placental perfusion or a multisystem shutdown.

7. Evaluate the sign and symptoms of the complication : Blood glucose <70mg/dL or > 300 mg/ dL, vital sign, moderate/ large ketones, fetus status)Rational : To evaluate the progress of the program and to modify the program to achieve the goal

Risk for unstable blood glucose level related to risk factos deficient knowledge of diabetes management (e.g , action plane), developmental level, dietary intake, inadequate blood glucose monitoring, lack of acceptance of diagnosis, lack of adherence to diabetes management, mental health status, physical activity level, physical health status, pregnancy, rapid growth periods, stress, weight gain

Client will maintain blood glucose during their pregnancy by following indicators :- preprandial blood

glucose ≤ 95 mg/dl, 1-hour pc level ≤ 140 mg/dl, and 2-hour pc level ≤ 120 mg/dl (ADA, 2009)

- demonstrate how to accurately test blood glucose

- identify self care actions to take to maintain target glucose levels

- identify self-care actions to take if blood glucose level is too low or too high

- demonstrate correct administration of prescribed medications

1. Monitor blood glucose before meals at bedtime. EB : Clients using multiple insulin injections should do self-monitoring of blood glucose (SMBG) three or more times daily. SMBG is also useful as a guide to therapy in clients on less frequent injections (ADA, 2009)

2. monitor blood glucose every 4 to 6 hours in clients who are NPO or who are continuously fed. testing every 4 to 6 hours is usually sufficient for determining correction insulin doses (ADA, 2009)

3. Monitoring blood glucose hourly for clients on continous insulin drips, may decrease to every 2 hours once stable. Beside monitoring can be done rapidly where therapeutic decisions are made (ADA, 2009)

4. Consider continuous blood glucose monitoring (CGM). EB : CGM use reduces time in hypo- and hyperglycemic ranges and may improve glycemic control. CGM monitors also have alarms to warn clients of high and low glucose levels (ADA, 2009).

5. Assess knowledge of the processes and actions, including the relationship of the disease with diet, exercise, stress and insulin requirements.

Rational: Gestational Diabetes Mellitus risk of glucose uptake in cells that are not effective, the use of fats and proteins for energy excessively and cellular dehydration when water flows out of the cell by hypertonic glucose concentration in serum.

6. Evaluate client’s medication regimen for medications that can alter blood glucose. Some antipchotic agents, diuretics, and glucocorticoids, among others, can cause hyperglycemia. Alcohol, aspirin, and beta blockers are among agents that can cause hypoglycemia (Diabetes in Control, 2005)

7. Consider the client’s ability and readiness to learn(e.g., mental acuity, ability to see or hear, existing pain, emotional readiness, motivation, and previous knowledge). EB : each client is unique, and client motivation, beliefs and expectations will influence learning (Price, 2008)

8. Refer client to dietitian for carbohydrate counting instruction. EB : “Monitoring carbohydrate, wether by carbohydrate counting, exchanges, or experience-based estmation remains a key strategy in achieving glymic contol” (ADA, 2009)

9. Refer overweight clients to dietitian for weight loss counseling. EB : “In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance” (ADA, 2009)

10. Teach family how to use an emergency glucagon kit (if prescribed). Severe hypoglycemia in which client is unable to take oral glucose should be treated with glucagon (ADA, 2009)

11. Provide “survival skills”education for clients, including information about : (1) diaebetes and its treatment, (2) medication administration, (3) nutrition therapy, (4) self-monitoring of blood glucose, (5) symptoms and treatment of hypoglycemia, (6) basic foot care, (7) follow-up appointments for in-depth training. client

need enough information to be safely discharged, and can then be followed up with outpatient instruction. (Nettles, 2005).

12. Teach client the benefits of regular adherence to prescribed exercise regimen. EB : A systematic review found that “exercise significantly improves glycemic control and reduces visceral adipose tssue and plasma triglycerides, but not plasma cholesterol

13. Evaluate clients’ monitoring technique initially at regular intervals. Accuracy of SMBG is instrument-and use-dependent (ADA, 2009).

Ineffective self health management

Client do self health management during pregnancy effectively by knowledge disease process, knowledge treatment regimen, participation in health care decision, by following indicators :- client will describe

daily food and fluid intake that meets therapeutic goals.

- client will describe activity/ exercise patterns that meet therapeutic goals

- client will describe scheduling of medication that meets therapeutic goals

- verbalize ability to manage therapeutic regimens

- client will collaborate with health providers to decide on a

1. Listen to the person’s story about her illness self-management. EB : the implication of a study of the meaning of active participation in self-management were that physicians and other providers may be able to influence the person’s illness story positively by recognizing their part in the illness story. (Haidet, Kroll & Sharf, 2006)

2. Explore the meaning of the person’s illness experience and identify uncertainties and needs trough open-ended questions. EB : Even though providers and client views (Rogers et all, 2005)

3. help the client identify the “self” in self-management; show respect for the client’s self-determination. EBN : Self management means that the person uses self determination to adapt medical and nursng recommendations for thei own lives and personal needs (Farrell, Wicks, & Martin, 2004)

4. Help the client enhance self-efficacy or confidence in his or her own ability to manage the illness. EBN : A review of the literature indicates that enhancement of self-efficacy was important to achieve optimal self-management (Sole et al, 2005).

5. Establish a collaborative partnership with

therapeutic regimen that is congruent wth health goals and lifestyl

the client for purposes of meeting health-related goals. EBN : At least one study showed that the professionals’s perceptions of partnership behaviors were actually paternalistic behaviors (Pellatt, 2004).

6. Involve family members in knowledge development, planning for self-management and shared decision making. EBN : Family support was one of two predictors for self-management strategies in a study of 53 women with type 2 diabetes (Whittermore, Melkus, & Grey, 2005). In a review of research related to self-management, family management was found to be integral to self-management (Grey, Knafl, & McCorkle, 2006).

7. Develop a contract with the client to maintain motivation for changes in behavior. EBN : The nursing intervention of client contracting provides a concrete means of keeping track of actions to meet health-related goals (Bulechek, Butcher & Dochterman, 2008)

8. Provide support forself-management troughout the process of care. EB : In a survey of 956 people in 17 locations troughout the country, respondents perceptions of provider support for self-management were found to be significantly related to better self-management. (Greene, & Yedidia, 2005).

9. Assess the influence of cultural beliefs, norms and values on the individual’s perception of the therapeutic regimen. EBN : Reseacrh studies involving culture, helath behaviors and self-management show that culture significantly affects decision making for meeting therapeutic goals and is related to self-management strategies (Degazon, 2006, Grey, Knafl & McCorkle, 2006)

10. Refer to health care professionals for questions and self-care management EBN : Nursing case management may

both improve self-care and reduce emotional distress for clients with diabetes (Stuckey et al, 2009).

11. Monitor self-management of the medical regimen. EBN : Home visits (both daily and weekly) were associated with reductions in fasting blood sugar postmeal blood sugar, and hemoglobin A1c (Huang et al, 2004).

REFERENCE

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P.Kumar, Coleen. 2007. Application of Orem’s Self-Care Deficit Theory and Standardized Nursing Language in a Case Study of a Women With Diabetes. International Journal of Nursing Terminologies and Classifications Volume 18

Deakin, T, et al. (2005). Group based training for self-management strategies in people with type 2 diabetes mellitus. The Cochrane Collaboration, United Kingdom.

D Sousa, Valmi, et al. 2009. New Measure of Diabetes self-care agency, diabetes self-efficacy, and diabetes self-management for insulin-treated individuals with type 2 diabetes. Journal of Clinical Nursing.

Gallant, M.P. (2003). the Influence of social support on chronic illness self-management : A review and directions for research. Health Education & Behavior, New York

Heisler, M. (2010). Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research. Oxford University, United Kingdom.

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International Diabetes Federation. (2012). Diabetes Atlas. Retrived from http://www.idf.org/diabetesatlas

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National Institute for Health and Clinical Excellence. 2008. NICE clinical guideline 63 : Diabetes in pregnancy : Management of diabetes and its complications from pre-conception to the postnatal period. Midcity Place, London.

Sutanegara, Dwi, et al. 2000. The Epidemiology and Managemen of Diabetes Mellittus in Indonesia. Elsevier Science, Ireland.

Warsi, A, et.al. (2004). Self-Management Education Programs in Chronic Disease : A systematic Review and Methodological Critique of the literature. American Medical Association, Boston.

….. . 2011. Gestational Diabetes : Screening and Treatment Guideline. Group Health Cooperative.