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 510
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 2039 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 dont 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 patients 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 pregnants 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 Mothers 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 SelfManagement 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 selfmanagement 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 Orems
theory of self care.
Orems 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
clients 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 clients 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 individuals 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 Orems Theory of Self-Care and it is used throughout the theory as an
individuals 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 5075%.
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.
Orems 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 Individuals 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)
Orems 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

Orems 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
clients stress and enabling the client to act responsibly in matters of health (Orem).
Using Orems 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 Orems 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 selfcare agency concept is one of the key components in Orems Theory of Self-Care and
it is used troughout the theory as an individuals 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 rems
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 Orems Theory
os self care (Orem 2011). and it is used throughout the theory as an individuals
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 Orems theory of self
care.

Several studies have suggested that individuals 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 selfmanagement 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),
b.

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

c.

during pregnancy with DM.

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 selfmonitoring 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 selfmanagement 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
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

<
deficit

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 GDMs
exercise
- collaboration with doctor for inject
the insulin who need

NURSING PROCESS OF SELF CARE IN WOMEN PREGNANT WITH GDM

Nursing Diagnosis
Risk for disturbed
Maternal/ Fetal dyad
related
to
Risk
Factors: Complication
of
pregnancy
compromised
O2
transport
anemia,
hypertention),
impaired
glucose
metabolism (GDM)

Goals
Nursing Interventions
(NOC)
(NIC)
Client will cope with 1. Monitor sign and symptoms of the
discomforts of high
complication : Blood glucose <70mg/dL
risk pregnancy during
or > 300 mg/ dL, vital sign, moderate/
their pregnancy
large
ketones,
fetus
status)
By
following
Rational : The early diagnosis and
indicators :
treatment of complication in a client with
- Emotional
GDM is necessary. If gestational diabetes
attachment
to
is not detected and controlled there is a
fetus/
cooping
small risk of birth complications such as
with discomforts
shoulder dystocia.
2.
Determine the presence of medical factors
of
pregnancy/
that are related to poor pregnancy outcome
Mood labiality/
(diabetes) : Finances, occupation (sick
blood
glucose/
time), lifestyle, energy level, relationships\
Haemoglobin.
Rational : common frustration associated
- Fetal status
- No Keton in
with diabetes stem fom problems involving
urine
the disease itself, the treatment regimen,
- BP < 130/80
and the health care system.
beats/ minute
3. Standardize internal and external transport
- pulse
60-100
form using SBAR format (situation,
beats/ minute
background,
assessment,
- respiration 16-20
recommendation) to provide safe and
breaths/ minute,
efficient transport of a high-risk pregnant
- warm and dry
Rational : Using a standardized form
skin
troughout the hospital system decrease the
- fasting
blood
risk of errors, miscommunications, and
glucose 70-110
omissions (Edwards & Woodward, 2008;
mg/dL
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

6.

7.

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 2hour 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

1.

2.

3.

4.

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
Perform accurate blood pressure redings at
each clients 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.
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
Monitor blood glucose before meals at
bedtime. EB : Clients using multiple
insulin injections should do selfmonitoring 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)
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)
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)
Consider continuous blood glucose
monitoring (CGM). EB : CGM use
reduces time in hypo- and hyperglycemic
ranges and may improve glycemic control.

level is too low

CGM monitors also have alarms to warn
or too high
clients of high and low glucose levels
demonstrate
(ADA, 2009).
correct
5. Assess knowledge of the processes and
administration of
actions, including the relationship of the
prescribed
disease with diet, exercise, stress and
medications
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 clients 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 clients 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

Ineffective self health Client do self health

management
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.

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 skillseducation 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).
1. Listen to the persons 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 persons
illness story positively by recognizing
their part in the illness story. (Haidet,
Kroll & Sharf, 2006)
2. Explore the meaning of the persons
illness
experience
and
identify
uncertainties and needs trough openended questions. EB : Even though
providers and client views (Rogers et all,

client will describe

2005)
activity/ exercise 3. help the client identify the self in selfmanagement; show respect for the clients
patterns that meet
self-determination.
EBN
:
Self
therapeutic goals
client will describe
management means that the person uses
scheduling
of
self determination to adapt medical and
medication
that
nursng recommendations for thei own
meets therapeutic
lives and personal needs (Farrell, Wicks,
goals
& Martin, 2004)
verbalize ability to 4. Help the client enhance self-efficacy or
manage
confidence in his or her own ability to
therapeutic
manage the illness. EBN : A review of the
regimens
literature indicates that enhancement of
client
will
self-efficacy was important to achieve
collaborate
with
optimal self-management (Sole et al,
health providers to
2005).
decide
on
a 5. Establish a collaborative partnership with
therapeutic
the client for purposes of meeting healthregimen that is
related goals. EBN : At least one study
congruent
wth
showed
that
the
professionalss
health goals and
perceptions of partnership behaviors were
lifestyl
actually paternalistic behaviors (Pellatt,
2004).
6. Involve family members in knowledge
development,
planning
for
selfmanagement 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 selfmanagement (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 selfmanagement were found to be
significantly related to better selfmanagement. (Greene, & Yedidia, 2005).
9. Assess the influence of cultural beliefs,
norms and values on the individuals
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).

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