Introduction

As a part of my clinical posting, I was posted in Gynae ward there I selected a patient name
Mrs. Surbhi who got admitted with the complaints of of increased thirst, increased blood
sugar (RBS 140mg/dl ) and positive OGTT test. She admitted to the hospital on 28/5/19 at
1:30 pm.The details of the case are as follow.
1. Patient Profile

Full name : Surbhi

Age : 28years/ f
Hospital No 247849
Martial status : Married
Educational status : 10th standard
Occupation : House Wife
Husband Name : Parteek
Age : 29 years
Educational status : B.Ed
Address : fatehabad
Occupation : teacher
Type of family : Nuclear
Per capita income :Rs. 13,000/
Diagnose : Gestational Diabetes Mellitus
Obstetric Score : G1P0L0A0
Gravida : G1

Gynaecological History
Mrs.Surbhi who got admitted with the complaints of increased thirst, increased blood
sugar (RBS 140mg/dl ) and positive OGTT test. She admitted to the hospital on 28/5/19 at
1:30 pm

Menstrual history

 Age of Menarche 14 years

 Regularity : regular
o Flow : Normal
o Duration of cycle : 30 days
o No of days : 5 days
o Last menstrual period : 14/10/ 20

a. Past Medical and surgical history

NIL

2. Family history
Mrs Surbhi belongs to nuclear family. There is no history of any hereditary like
diabetes or hypertension in the family
 3. Socio economic history
She belongs to a low income group family. She maintains a good relationship
with family members.
Personal history
She is poorly built and nourished. She is taking mixed diet. She does not have any
allergy to any food items
4. Psycho- Sexual
She got married at the age of 18 years. She has a good sexual relationship with his husband.
There is no pre-marital or extra- marital sexual relationship.

GENERAL PHYSICAL EXAMINATION

Nourishment : poorly nourished

Posture : erect

Body built : weak built

Weight : 60 kg

Activity : dull

Height : 145 cm

Vital signs

Parameters Patient’s value Normal value

Temperature 99.4 F 98.6 F

Pulse 84 beats / min 60-100 / minute

Respiration 24 breath / min 16- 20 / minute

Blood pressure 110 /70 mm of Hg 120 / 80 mm Hg

Mental Status

Conscious :

conscious Mood :

worried Skin

condition

Color : whitish

Texture : dry

Head to Foot Examination

Head

Scalp : clean

Dandruff : no dandruff is present / pediculi

Face

Pallor : present

Puffines : not present

Eyes

Eyebrows : symmetrical

Conjunctiva : red in

color Vision : normal

Eyelashes : no any infection

Sclera : white in color

Pupils: equally reacting to light

Eyeballs : are not sunken

Ear

Alignment :

symmetrical Hearing :

normal Discharge :

absent Nose

Nostrils : normal

Nasal discharge : absent

Nasal septum : not deviated

Mouth

Lips : not cracked or pale

Lip texture : dry

Odour : No halitosis

Mucous membrane : Glossitis/ Stomatitis / bleeding

Gums : no bleeding

Tongue : dry coated

Teeth : No dental carries

Throat and pharynx

Neck

lymph nodes : palpable / not enlarged

Thyroid gland : Not enlarged

Chest

Symmetry of expansion : Symmetrical

Breast

Shape : round

Tenderness : not present

Palpation : No dilated veins or lumps

Breath sounds

Vesicular sound like vesicular bronchovesicular , bronchial are heard ,

Wheezing are not present

Heart

Heart rate is 84/min

Cardiac murmurs absent

Abdomen

Abdomenial distension : absent

Scar marks : present

Tenderness : absent

Palpable : no mass felt, no spleenomegaly and hepatomegaly

Genitals and rectum

Vaginal discharge : absent

Color : nil

Retention of urine : present

Constipation : present

Vulval oedema : absent

Extremities

Range of motion : possible in all direction

Ankle oedema / pedal oedema : absent

Varicose vein : absent

 Investigation

Investigation Normal value Patients value

Haemoglobin 12-14 gm% 10.5gm%

Blood group - O+ve

Total WBC 4000-11000 cells /cumm 15500

VDRL Non reactive Non reactive

Hep B Non reactive Non reactive

HIV Non reactive Non reactive

Medications:

Trade name Generic name Dosage frequency Action

Inj Iron Iron Sulphate 100 mg TID Iron Supplement

Inj Calcium Calcium 1000mg TID Calcium

Supplement
Inj Insulin Insulin 10 IU BD Hypoglycemia
agent
DESCRIPTION ABOUT DIABETES MELLITUS

Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes—is a group of metabolic diseases in
which a person has high blood sugar, either because the body does not produce enough
insulin, or because cells do not respond to the insulin that is produced.
Incidence

Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed. In
the United States, approximately 800,000 new cases of diabetes are diagnosed yearly
(Mokdad et al., 2000) Incidence continue Diabetes is especially prevalent in the elderly,
with up to 50% of people older than 65 suffering some degree of glucose intolerance.
Among adults in the United States, diagnosed cases of diabetes increased 49% from 1990 to
2000, and similar increases are expected to continue (Centers for Disease Control and
Prevention [CDC], 2002).

Types of diabetes

Type 1 diabetes: results from the body's failure to produce insulin, and presently requires
the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM
for short, and juvenile diabetes.)

Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use
insulin properly, sometimes combined with an absolute insulin deficiency.

Gestational diabetes

Gestational diabetes: is when pregnant women, who have never had diabetes before, have a
high blood glucose level during pregnancy. It may precede development of type 2 DM.

Secondary diabetes Accompanied by conditions known or suspected to cause the disease:

pancreatic diseases, hormonal abnormalities, medications such as corticosteroids and
estrogen- containing preparations. Depending on the ability of the pancreas to produce
insulin, the patient may require treatment with oral antidiabetic agents or insulin.

Etiology
Hereditary

• Autoimmune • Viral • Environmental factor Predisposing factors

• Diagnosed over the age of 40 years • Overweight/obesity • Pancreatic infection

Clinical manifestation

• Polyuria (frequent urination),

• Polydipsia (increased thirst) and

• Polyphagia (increased hunger)

 • Visual blurring • Fatigue • Weight loss • Coma

Clinical feature
In my patient

• Polyuria • Polydipsia

• Polyphagia • Visual blurring • Fatigue

Investigation
Condition 2 hour glucose Fasting glucose Normal <7.8 (<140) <6.1 (<110)

Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126)

Diabetes is diagnosed by examining glucose levels in blood samples using one or more of
the following tests:

• Random glucose test — a glucose level above 11.1mmol/L taken at a random time
on two occasions is a diagnosis of diabetes. • Fasting glucose test — a glucose level
above 7.8mmol/L measured without anything to eat and on two different days is a
diagnosis of diabetes.

• Glucose tolerance test — a blood glucose test is taken two hours after a glucose drink
is given to the patient. A level above 11.1mmol/L is a diagnosis of diabetes, while a level
below 7.8 is normal.

Treatment
Management

Complete history taking and physical examination

• Blood test-FBS, RBS, PP,glycocylated, hemoglobin,

• Urine analysis • Insulin therapy • Diabetic Diet •

Medicine Management of my patient • Diabetic diet

Management

PREVENTION

• prevention of obesity
• Prevention of illness
• Reduction of environmental stressor
• Prevention and control of hypertension
• Exercise

EMERGENCY CARE

A)Deabetic ketoacidosis
 • Goal of the treatment for this acute condition are rehydration, restoration of
electrolyte balance and reduction of blood glucose level
• Administer regular insulin

• Administer IV fluid
• Blood glucose level should not be lowered
B) hyperglycemic hyperosmolar non ketotic syndrome

Is characterized by extreme hyperglycaemia, profound dehydration, mild or undectable urea

and the absence of Acidosis.Hyperosmolarity of plasma and elevated blood urea nitrogen.
Is treated with vigorous fluid replacement and administration of insulin and electrolyte
.infusion N/S over 2 hrs period followed by hypotonic saline solution . Insulin is given
infusion pump, if blood glucose levels decreases rapidly about 250 mg/dl dextrose saline is
added to prevent hypoglycemia

Diet and exercise

 Patients are encouraged to follow a diet that is relatively low in fat and contains
adequate amounts of protein.

 In practice about 30 percent of calories should come from fat, 20 percent from protein,
and the remainder from carbohydrates, preferably from complex carbohydrates rather than
simple sugars.

 The total caloric content should be based on the patient’s nutritional requirements
for growth or for weight loss if the patient is obese.

 In overweight or obese patients with type 2 diabetes, caloric restriction for even just a
few days may result in considerable improvement in hyperglycemia.

 weight loss, preferably combined with exercise, can lead to improved insulin sensitivity
and even restoration of normal glucose metabolism.
Insulin therapies
Modern human insulin treatments are based on recombinant DNA technology. Human
insulin may be given as a form that is identical to the natural form found in the body, which
acts quickly but transiently (short-acting insulin), or as a form that has been biochemically
modified so as to prolong its action for up to 24 hours (long-acting insulin).
.
The optimal regimen is one that most closely mimics the normal pattern of insulin
secretion, which is a constant low level of insulin secretion plus a pulse of secretion after
each meal.
This can be achieved by administration of a long-acting insulin preparation once daily plus
administration of a rapid-acting insulin preparation with or just before each meal.

Drugs used to control blood glucose levels

There are several classes of oral drugs used to control blood glucose levels, including
sulfonylureas, biguanides, and thiazolidinediones. Sulfonylureas, such as glipizide
and glimepiride, are considered hypoglycemic agents because they stimulate the release of
insulin from beta cells in the pancreas, thus reducing blood glucose levels.
Biguanides, of which metformin is the primary member, are considered antihyperglycemic
agents because they work by decreasing the production of glucose in the liver and by
increasing the action of insulin on muscle and adipose tissues.
 Thiazolidinediones, such as rosiglitazone and pioglitazone, act by reducing insulin
resistance of muscle and adipose cells and by increasing glucose transport into these tissues.
These agents can cause edema(fluid accumulation in tissues), liver toxicity, and adverse
cardiovascular events in certain patients.
Pramlintide is an injectable synthetic hormone (based on the human hormone amylin) that
regulates blood glucose levels by slowing the absorption of food in the stomach and
by inhibiting glucagon, which normally stimulates liver glucose production.
Exenatide is an injectable antihyperglycemic drug that works similarly to incretins, or
gastrointestinal hormones, such as gastric inhibitory polypeptide, that stimulate insulin
release from the pancreas.

Glucometer monitoring
All patients with diabetes mellitus, particularly those taking insulin, should measure blood
glucose concentrations periodically at home, especially when they have symptoms of
hypoglycemia. This is done by pricking a finger, obtaining a drop of blood, and using an
instrument called a glucometer to measure the blood glucose concentration.

NURSING DIAGNOSIS AND CARE PLAN WITH THEORY APPLICATION

DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF

CARE DEFICIT
1.BASIC CONDITIONING FACTORS
Age 28 Years

Gender Female

Health Status Therapeutic Self –Care Demand

Development State Ego Integrity Vs Despair

Sociocultural Orientation Graduate,Indian, Hindu

Health Care System Institutional Health Care

Family System Married

Patterns Of Living At Home With Partner

Environment Rural Area

2.UNIVERSAL SELF- CARE REQUISITES

Air Breaths without difficulty,no pallor cyanosis

Water Need to maintaine fluid intake is to prevent

dehydrationTurgor is not normal for the age.
Food Food intake is maintained according to disease
codition
Elimination Voids and eliminates bowel without difficulty
Excessive urination
Activity/Rest Frequent rest is required due to fatigue
Activity level has come down
Social Interaction Commumicates well with family members and
neighbour
Prevention Of Hazards Need health education on dietary pattern and
lifestyle modification after pancreatities
Promotion Of Normalcy Has good relation with wife

3.DEVELOMENTAL SELF-CARE REQUISITES

Maintenance of developmental environment Unable to feed, difficulty in doing daily
activity due to disease process.
Prevention/management of the conditions She believes that disease is for his own
threatening the normal development behaviour

4.HEALTH DEVIATION SELF CARE REQUISITES

Adherence to medical regimen Report the problems to the physician when in
the hospital .cooperates with the medication.
not much awar about the use and side effects of
medicines
Awareness of potential problem associated She is aware about the actual disease processs
with regimen she is complaint with the restricted diet and
prevention of hazards
Modification of self –image to incorporates She adopted dietary pattern and, life style
changes in health status changes to improve health status
APPLYING, THE OREM’S THEORY OF SELF-CARE DEFICIT, A POST-
OPERATIVE NURSING, CARE PLAN FOR MR PAWAN IS PREPARED AS
FOLLOWS…
The patient Mr. Surbhi has the areas that need assistance were-

NURSING DIAGNOSIS

 Imbalanced Nutrition: Less Than Body Requirements realted to Decreased oral intake:
anorexia, nausea as evidenced by recent weight loss.
 Risk for deficit fluid volume related to excessive urination as evidenced by excessive
thirst, weight loss secondary to dehydration.
 Fatigue related to hyper metabolic state/infection as evidenced by inability to maintain usual
routines, decreased performance
 Deficit knowledge related to dietary modification and exercise as evidenced by inadequate follow of
instruction
NURSING THEORY APPLICATION

DOROTHEA E. OREM’S SELF CARE THEORY:

Dorothea Elizabeth Orem, one of America’s foremost Nursing Theorists, was born in Baltimore,
Maryland. In the early 1930s she received her diploma certificate of nursing from Providence
Hospital School of Nursing, In 1939, BSN and 1945 Master in Nursing Education, In 1976
Doctorate in Nursing.

A conceptual framework for nursing:

PATIENT Self-
care
R
R

Therapeuti
Self-care
c self-care demand
capabilities

R
NURSE R
Nursing capabilitie
s

R=relationship

V= deficit relationship, current or projected

NEEDS OF THE PATIENT:

 Need for prevention from infection due to prolong bed rest and hospitalization.
 Need for maintenance of personal hygiene.
 Need for proper sleep and rest.
 Need for fluid and electrolyte balance.
 Need for health education to the patient’s caregivers about patient heath condition.

NURSING DIAGNOSIS:

 Imbalanced Nutrition: Less Than Body Requirements realted to Decreased oral intake: anorexia, nausea as evidenced by recent weight loss.
 Risk for deficit fluid volume related to excessive urination as evidenced by excessive thirst, weight loss secondary to dehydration.
 Fatigue related to hyper metabolic state/infection as evidenced by inability to maintain usual routines, decreased performance
 Deficit knowledge related to dietary modification and exercise as evidenced by inadequate follow of instruction.
 Nursing Nursing Goa Planning Implementation Rationale Evaluation
assessmen Diagnosi l
t s
Sujective Data: Imbalanced To maintain - Weight daily - Weighted daily Measuring weight Maintained
The client
Nutrition: the - Assess the - Assessed the indicator of food the
complaint
Less Than nutritional patient’s dietary patient’s dietary intake. nutritional
that she has
Body states as program and usual program and usual states as
lack of
Requirements evidenced by pattern . pattern . evidenced by
appetite.
related to adequate - Discuss eating adequate
Decreased weight habits and - Discussed eating habits Identifies deficits weight
Objectiv
oral intake: management encourage diabetic and encourage diabetic and deviations from management
e data:-
anorexia, diet (balanced diet) diet (balanced diet) as therapeutic needs.
Patient
nausea as as prescribed by prescribed by

has following evidenced by physician. physician.

symptoms show recent weight - Auscultate bowel To achieve health

-dehydration loss. sounds. Note needs of the patient

- Auscultated bowel
-excessive thirst reports of with the proper food
sounds. Note reports of
-headache abdominal pain, diet for his condition.
abdominal pain,
-weight loss bloating. bloating.
- Provide liquids Poor intestinal motility
- Provide liquids
containing may suggest autonomic
containing nutrients
nutrients and neuropathies affecting
and electrolytes as
electrolytes as the GI tract and
soon as patient can
soon as patient can requiring
tolerate oral fluids
tolerate oral fluids symptomatic treatment.
 To monitor
Risk for deficit Administer regular Administered regular Regular insulin has
Subjective
hydration as Maintain
fluid volume insulin by intermittent insulin by intermittent or a rapid onset and
data: Patient
evidenced by hydration as
related to or continuous IV continuous IV method thus quickly helps
Complaints, “I
stable vital method evidenced by
am unable to
excessive move glucose into
signs, good stable vital
take urination as Assessed patient for cells.
skin turgor signs, good
adequate food evidenced by Assess patient for duration or intensity of
appropriate skin turgor
Objective data: excessive duration or intensity symptoms such as
urinary appropriate
Client looks dull, thirst, weight of symptoms such as vomiting, excessive Presence of infectious
output, and urinary output,
lethargy, anxiety. loss secondary vomiting, excessive urination. process results in fever
electrolyte and electrolyte
to dehydration. urination. and hypermetabolic
levels within levels within
Monitor vital signs state, increasing
normal range. normal range.
Assess peripheral Monitored vital signs insensible fluid losses.
pulses, capillary refill, Assessed peripheral
and mucous pulses, capillary refill, and
membranes. mucous membranes.
Indicators of level of
Maintain fluid intake Maintained fluid intake of hydration, adequacy
of at least 2500 at least 2500 mL/day of circulating
mL/day within cardiac within cardiac tolerance volume.
tolerance when oral when oral intake is
intake is resumed. resumed. Maintains hydration
Increase patient and circulating
participation in ADLs Increase patient volume.
as tolerated. participation in ADLs as
tolerated.
 - -
- Monitor pulse, - Monitored pulse,
Subjective data:
Fatigue related To respiratory rate, respiratory rate, and Increases
to Hyper improved and BP before and BP before and after confidence level, Improved
Patient says that
metabolic ability to after activity. activity. self-esteem and ability to
I can’t
state/infection participate - Alternate activity tolerance level. participate in
stand without as evidenced in desired with periods of - Alternateed activity desired
help and how I by inability activities. rest or with periods of rest or Adjusting activities.
will manage to maintain uninterrupted uninterrupted sleep. frequency, duration
with my work. usual sleep. and intensity until
Objective data: routines, - Instruct patient to - Instructed patient to desired level is
decreased perform deep perform deep achieved.
I found that the performance breathing breathing exercises. To prevent
patient is unable exercises. excessive fatigue.
to carry out - Provide dcomfort
daily activity. - Provide comfort and safety measures.
and safety Helps promote relaxation.
measures. - Administerd oxygen
as ordered.
- Administer To be free from
oxygen as Explained that long-acting injury during
ordered. insulin (Lantus)only need activity.
to be injected once or
Explain that long- twice To provide
acting insulin (Lantus) daily.
only need to be proper
injected once ventilation.
or twice daily.
 -
Patient will - Teach patient to - Taught patient to follow
Subjective data:
Deficit get follow a diet that is a diet that is low in Illness or infection
Patient’s
knowledge
caregiver knowledge of low in simple simple sugars, low in may increase insulin Patient will
related to dietary
is asking insulin sugars, low in fat, fat, and high in fiber requirements. be able
modification and
questions that injection, and high in fiber and whole grains.
exercise as to
“what symptoms, and whole grains.
evidenced by expaline about
Taught patient to treat
is going inadequate
and treatment - Teach patient to
hypoglycemia with insulin
on? follow of of treat hypoglycemia Three daily meals and
crackers, a snack, or injection,
How long time instruction. hypoglycemia with crackers, a an evening snack is
glucagon injection. symptoms,
will be and diet. snack, or glucagon recommended.
- and treatment
necessary for injection.
- Conformed that the
recovery? of
patient understands and
Objective data: Confrom that the hypoglycemia
demonstrates the
patient understands Hypoglycemia should and diet.
I observe that technique and timing of
and demonstrates the be treated with a
the patient is home monitoring
technique and timing carbohydrate snack.
looking very glucose
of home monitoring of
anxious and
glucose.
curious
Identifies the need

about ongoing for changes in the

management. insulin
dosage.
HEALTH EDUCATION:

Health education and maintenance are important since health status is good indicator of the one’s
ability to adopt to rapid changes. Health education to Mr Surbhi was very important because he
was post-operative patient.She was discharge on 29/05/2019.During discharge I had given health
on following topics.

SPECIFIC HEALTH EDUCATION:

I explained about ill status and alteration and variation in vital sign, its reason and ongoing
management of the patient to him and his caregivers.

MEDICATION:

I taught to patient and his caregivers about ongoing medication.

REST AND EXERCISE:

Rest and exercise helps to strengthen the body tissues but heavy exercise should be avoded
.Adequate rest was enhanced with early ambulation is encouraged. She was instructed to avoid
heavy lifting, coughing, straining and strenuous activity for at least 6 weeks.

NUTRITIOUS DIET :

Diet is important for the Diabetic patient. She was encouraged to intake less sugar diet.
Encouraged for fluid intake.

HYGIENE

Personal hiygiene is important to prevent infection. So , essentiality of personal hygiene was

explained.

CARE OF THE WOUND

The wound was instructed to keep dry and alternate day dressing was was instructed
FOLLOW UP:

I advised him to co-operate with all health care team members.

.
Bibliography :

Dutta D.C, “textbook of obstetrics”:200, sixth edition, published by Central book agency.

Bennett Ruth. V, “Myles textbook of Obstetrics ,” 13 edition ,published by

Churchill Livingstone.

Jacob Annamma, “ A Comprehensive textbook of midwifery” third edition, published by Jaypee

Brothers

Internet

https://care.diabetesjournals.org/content/26/suppl_1/s103

https://en.wikipedia.org/wiki/Gestational_diabetes