Gestational Diabetes and Implementation Orem Self-Care Model - Research Paper Example

?Introduction Gestational diabetes is a type of diabetes mellitus with initial onset during pregnancy, frequently occurring in the last trimester (Harvard Medical School, 2009). Risk factors include: placental hormones; obesity with body mass index (BMI) of 30 or more; family history of Type 2 diabetes mellitus; age of 35 and above; high blood pressure; history of delivering babies heavier than 4000g; women of Hispanic, African American, Native American, South or East Asian and Pacific Islands descent (Manzella, 2008). One possible physiologic effect of pregnancy is the alteration of specific cytokines associated with inflammation, insulin resistance, and angiogenesis; which eventually lead to the development of gestational diabetes mellitus (GDM) and preeclampsia (PE) (Thadhani, 2009). Insulin resistance in pregnant women is an adaptive change that ensures delivery of glucose from the mother’s system to the fetus. According to Wada et al. (2010), placental hormones, such as placental growth hormone and progesterone, increases the activity of p85 in the 3T3-L1 found in adipose cells; and inactivates the second messenger system responsible for insulin response. Unhealthy eating habits, such as too much sugar in the diet, can cause glucose to accumulate in the mother’s blood; and prolong its clearance from the system eventually leading to gestational diabetes. The complications associated with GDM include: preeclampsia--blood pressure above 140/90 mmHg and protein in the urine; preterm labor; and increased risk of infection. GDM effects on the baby include: macrosomia (birth weight of 4000 to 4500 g); neonatal hypoglycemia; jaundice; calcium or magnesium imbalance; and stillbirth. Health Issue “Each year, nearly 135,000 American women develop type 2 diabetes while they are pregnant...even though their blood sugar levels were normal before pregnancy” (Metzger, 2006, p. 243). According to the Center for Disease Control (2011), gestational diabetes (GDM) accounts for 2% to 10% of pregnancies. Five to ten percent of women with gestational diabetes were discovered to have undiagnosed diabetes mellitus (DM), usually type 2; while 35% to 60% of women suffering from GDM will likely develop type 2 diabetes mellitus in the next 10 to 20 years (Center for Disease Control, 2011). The complications associated with gestational diabetes can jeopardize the health of the mother and the fetus; and can lead to death. Macrosomic infants are predisposed to shoulder dislocation and suffocation while the probability that the mother will have to undergo emergency caesarean section is increased (Vidarsdottir, Geirsson, Hardardottir, Valdimarsdottir, & Daqbjartsson, 2011). According to Ekabua et al. (2005), perinatal mortality rate is highest in infants weighing 4.0 to 4.4 kg (4000 to 4400 g), as well as in macrosomic babies delivered via caesarean section. Cause of death includes obstructed labor, which cut-off the oxygen supply to the fetus and ruptured uterus that cause the mother to hemorrhage as well as cut-off the oxygen supply to the fetus (Ekabua et al., 2005). According to Thadhani (2009), gestational diabetes and preeclampsia are linked to a high incidence and a high death rate during pregnancy and increases the woman’s predisposition to develop diabetes and cardiovascular diseases after pregnancy. Planned Intervention Prenatal care ensures that the pregnant woman and the fetus are healthy for the entire duration of the pregnancy. Prenatal care allows the obstetrician to detect early signs of pregnancy-induced complications, especially gestational diabetes and prevent it from causing untoward effects to the mother, as well as the fetus. Due to the increasing incidence of gestational diabetes, Leu and Zonszein (2010) suggests that early screening of all pregnant women, unless categorized under the low risk group, should be employed by health care providers. Glucose tolerance test should be administered between the 24th and 28th weeks of pregnancy, or earlier if gestational diabetes has occurred in past pregnancies, or the woman belongs to the high risk group (Harvard Medical School, 2009). Eating a balanced diet and exercising prevents blood sugar levels from rising above normal during pregnancy (Harvard Medical School, 2009). Modifying lifestyle habits lessens the risk of developing gestational diabetes. Weight control reduces the tendency for the woman to become obese; eating healthy prevents high blood pressure; and planning pregnancy before the age of 35 lessens the risks associated with pregnancy at a later age. Adjusting risk factors that can be modified, such as obesity and high blood pressure, helps prevent the development of gestational diabetes. According to Harvard Medical School (2009), “...insulin resistance tends to increase in the latter part of pregnancy” (p. 34). If blood glucose level goes over 105mg/dl, it is best for the pregnant woman to consult her doctor (Harvard Medical School, 2009). Physicians may administer insulin to control blood sugar (Harvard Medical School, 2009). Theoretical Model Dorothea Orem’s Self-care Model is composed of three related parts: Self-care Theory; Self-care Deficit Theory; and Nursing Systems Theory (“Dorothea Orem: Nursing Theory,” n.d.). This model emphasizes persons’ self-reliance; and accountability for oneself, as well as the family’s health and well-being (“Dorothea Orem’s Self-care Theory,” 2011). Orem pointed out the importance of health teaching, and believed that awareness of impending health problems is an important tool in promoting self-care practices (“Dorothea Orem’s Self-care Theory,” 2011). She also asserts that self-care, as well as dependent care behaviors, are influenced by society and culture (“Dorothea Orem’s Self-care Theory,” 2011). The first part of Orem’s model, Self-care Theory, encompass four concepts: self-care; self-care agency; self-care requisites; and therapeutic self-care demand (“Dorothea Orem: Nursing Theory,” n.d.). Self-care is a practice that a person performs independently to advance and maintain life, as well as to promote health and well-being (“Dorothea Orem: Nursing Theory,” n.d.). Self-care agency, on the other hand, is the person’s capacity to practice self-care activities (“Dorothea Orem: Nursing Theory,” n.d.). It involves two agents: a self-care agent--one who provides care; and a dependent care agent--one who provides care apart from the self (“Dorothea Orem: Nursing Theory,” n.d.). Self-care requisites are actions or efforts done to provide self-care (“Dorothea Orem: Nursing Theory,” n.d.). It is composed of universal requisites--”...needs that are common to all...” developmental requisites--”...needs resulting from maturation...or due to a condition or event...”; and health deviation--”...needs resulting from illness, injury...disease or its treatment...” (“Dorothea Orem: Nursing Theory,” n.d., slide 10). The Self-care Deficit Theory is the highlight of Orem’s model. It describes instances where nursing can be applied. It elucidates ways and methods of assisting people through nursing; it describes certain outcomes that result when a person is unable to provide or administer self-care and it outlines the 5 methods of help through which nursing care can be delivered (“Dorothea Orem: Nursing Theory,” n.d.). The five methods of nursing help include: acting or doing for; guiding; teaching; supporting; and providing an environment that can advance the patients’ capacity to comply with present or future health demands (“Dorothea Orem: Nursing Theory,” n.d.). The Nursing Systems Theory describes the role of a nurse, as the provider of health care, and that of a patient, as the recipient of health care (“Dorothea Orem: Nursing Theory,” n.d.). It is composed of three systems: wholly compensatory; partly compensatory; and supportive-educative. The wholly compensatory system is when the patient is unable to, or has difficulty in providing self-care (“Dorothea Orem: Nursing Theory,” n.d.). This usually happen in coma patients, where the ability to provide self-care is absent and so the responsibility of meeting self-care needs rest upon the nurse or the family members. Feeding tubes are used to nourish the patient; bed baths to keep them clean and prevent pressure ulcers; and diapers for toileting activities. This employs the acting for or doing for method of nursing outlined in the Self-care Deficit Theory portion of Orem’s model. Partly compensatory system, on the other hand, means that the patient is capable of attaining some of the self-care requisites but require assistance in meeting others (“Dorothea Orem: Nursing Theory,” n.d.). Patients’ with an arm cast or a leg cast are capable of feeding themselves but require help in bathing or dressing. Methods of nursing help included in this system are guiding, and providing an environment that promotes self-care practices addressing current needs. Supportive-educative system is when the patient is capable of meeting self-care requisites but require assistance in “...decision-making, behavior control, or knowledge acquisition...” (“Dorothea Orem: Nursing Theory,” n.d., slide 15). Patients’ who are intervened by this type of system are those who lack knowledge about certain aspects of their health; are having a hard time quitting an unhealthy habit, like smoking and alcoholism; and are having trouble deciding what choice to make in relation to health promotion and general well-being. Nursing intervention is often focused at providing pertinent data, and teaching certain skills that will aid in acquiring self-care requisites. This can be achieved through teaching, supporting, and providing an environment that promotes present and future practices to meet self-care requisites. Orem defines the person as an individual who has the capacity to learn and develop; who is capable of acquiring knowledge, and uses this to direct and perform activities that will allow for the acquisition and accomplishment of self-care needs (“Dorothea Orem: Nursing Theory,” n.d.). The person’s main role is to focus all efforts in providing care for the self in order to preserve life, as well as to promote health, and well-being (Rosas & Constantino, 1992). She defines nursing as a collaborative art between patients and nurses that are geared towards promoting and achieving health care, as well as patient independence, and satisfying self-care requisites. Through the coordinated efforts of the nurse and the patient, health can be maintained by promoting the patients’ ability to function as a self-care agent independent of nursing interventions. According to Kimball (2006), Orem’s Self-care Model provides a framework that concentrate nursing intervention on developmental practices. The focus of this model is to shift the patients’ role, from a passive recipient of health care, to a more active and independent promoter of one’s health. Hartweg further asserts that, Orem views self-care as a “learned behavior” (as cited in Kimball, 2006, p. 33). One of the nurse’s roles is to educate the patient; to provide information to supplement knowledge deficiencies and to guide patients in their decision-making. Landim, Milomens, and Diogenes (2008), identified that “...self-care deficiencies [in patients with GDM are] related to eating habits, physical activities, sleep and rest, and social interaction.” By employing Orem’s supportive-educative nursing system, and using teaching and supporting as the primary methods for nursing help, knowledge deficits and unhealthy lifestyle practices can be altered. Nursing interventions for gestational diabetes should be focused on increasing the capability of the woman to control blood glucose, as well as to employ practices that prevent the development of complications. Health education should tackle subject areas unknown to the patient. The nurse should also explore the patients’ prior knowledge on the subject matter in order to correct misconceptions, and give supplement health teaching. Through this, the nurse can promote health care independence, as well as empower the woman to be her own self-care agent. Learning to take care of self is a challenge that can be influenced by many factors. The changes that accompany pregnancy can make a woman anxious, and make self-care practices difficult. The nurse can partly compensate for this by guiding patient action and providing an environment that will help the patient become the master of her own health. According to Armstrong et al. (1991), nurses can help the patient control the course of GDM by doing follow-up education; teaching the patient to measure meal portions and find substitute ingredients for sugar. Developing a plan together with the patient, that serves as a guide for dealing with special occasions--such as festivities and illness, can help the patient choose the right food in accordance with the nutritional meal plan (Armstrong et al., 1991). This can allay patient anxiety, and can give her the energy, as well as the inspiration, to employ self-care practices independently. Gestational diabetes is a lifestyle disease that can be prevented and controlled. Risk factors, such as obesity and high blood pressure, are the two causes that can be altered, provided that a healthy lifestyle will be practiced. Through Dorothea Orem’s Self- care Model, women can be made aware of its causes and can then take actions to promote well-being, maintain health, and prevent the development of gestational diabetes. 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