INTRODUCTION

NAME : Patel Megha A.

CLASS : Second Year M.Sc. Nursing

SUBJECT : Obstetrics And Gynecology Nursing

TOPIC : Gestational Diabetes Miletus

DATE : 12/05/2021

As a part of our clinical experience in obstetrical and gynecology Nursing, We were

posted in postnatal ward, Shrimad Rajchandra Hospital, Dharampur. There I get chance to give
care to the patient with GDM.

1
 DEMOGRAPHIC INFORMATION:

 Name : Mrs. Babitaben Nareshbhai Ghodi

 Age : 28 years
 Sex : Female
 Address : karanj, umargam valsad, gujrat.
 Religion : Hindu
 Marital status : Married
 Occupation : Housewife
 Income : 18,000 /- per month
 Ward : post-natal ward-2
 Date of admission : 12/05/2021 at 5:45 pm
 I.P. No :181230
 O.P.D. no : 00042
 Obstetrical score : G1 P1 L1 A0 D0
 Diagnosis :PNC mother with gestational dm, jaundice, HELLPS syndrome,
preeclampsia

PRESENT HEALTH HISTORY

1. CHIEF COMPLAINTS (ON THE DAY OF ADMISION)
Patient was admitted with the complaint healing process not occur in episiotomy site and
bleeding also present at scare site
 Back pain
 Pain in perineal region
 weakness

2
2. PRESENT MEDICAL HISTORY DAY 1 (16/02/2018)
Patient was admitted in Shrimad Rajchandra Hospital, Vapi on 12/05/2021 at 5:45pm.
with the reference from umargam CHC. She was apparently not well because she was
delivered on 20/01/2019. At that time episiotomy was give and cervical tear also present
unfortunately she having gestational dm so healing prosses is delayed and she get
infection on perineal area and its lead to jaundice and perineal sepsis also present.
Examination finding:
 Temperature- 99.6 F
 BP-120/76 mm of hg
 Pulse-95 beats/min
 Respiration -25 beats /min
 DAY 1 (12/05/2021) :

 Patient complains  Medical intervention

- Delay healing process on - inj. Cefasalbatum 1gm
episiotomy
iv BD
- Pain at perineal area
- inj. Amikacin 500mg iv
- Loss of appetite
- Impaired sleeping
bd

- Discomfort - inj. Metrogyl 100 gm iv

tds
- inj. Pantop 40cc iv od
- tab. M 200mg bd
- inj. Plain insulin
according to chart
- tab. Lactacare 100gm
tds
- tab metformine 150gm
bd

3
DAY 2 (13/05/2021):

 Patient complains  Medical intervention

 pallor with weakness  Medication as per day one

 impaired sleeping  Added
 mild discomfort - Tab. Vit-c 100mg tds

 Loss of appite - Tab. Fe+2 300mg od

 Perineal pain - Calevdyla cream –la

- Daily ‘p’ wash
 Anxiety

 DAY 3(14\05\2021):

 Patient complains  Medication intervention

 Loose of skin integrity on - Daily ‘p’ wash with
legs and hand h2o2 and betadine
 Loose of appite dressing
 Discomfort - Daily urine albumin

 Anxiety check

 Perineal pain - Stricty b.p monitoring

- Insulin given
according to chart

4
 3. PRESENT SURGICAL HISTORY
Recently resuturing done on episiotomy site have been done in the present.
PAST HEALTH HISTORY:
1) PAST MEDICAL HISTORY
Patient has no any major or minor disease in the past.
2) PAST SURGICAL HISTORY
Patient has no any major or minor surgery in the past.
FAMILY HISTORY:

Sr Name Of The Age Sex Occupation Education Relation Health

No Family Status
Members
1 Babitaben 28Yrs Female Housewife uneducated Self Unhealthy
2 Nareshbahai 32Yrs Male Labor 10th pass Husband Healthy
worker
3. Baby girl 2mont female daughter malnourished

She belongs to the middle-class family. In her family patient’s husband has no any major
disease in present. but other family member also has no any type of communicable disease and
all are healthy

FAMILY TREE :

Nareshbhai (28 year) Babitaben (28yrs)

baby girl (2 days)

5
 PSYCHOSOCIAL AND ECONOMIC HISTORY:
Patient is house wife and her husband is bread winner of the family, total family monthly
income is about 15,000/-
Economic history : She belongs to middle class family and live in own home
Mother tongue : Marathi
Language known : Hindi , Marathi
Cultural group : Friends and Family
Mood : Social and cooperative

ENVIRONMENTAL HISTORY:
 She lives with her family in own house, her native place is in Maharastra.
 In her House has two rooms and a kitchen.
 They use toilet for defecation and getting water from the municipal water supply.
 She has adequate electricity supply.

PERSONAL HISTORY
a) PERSONAL HABIT
Patient has no any bad habit of smoking, alcoholism, drinking and tobacco chewing

b) NUTRITIONAL HISTORY:
Type of food : Non vegetarian
Likes/ dislikes : like spicy food, dislike sweet food
Allergies : no any allergy
Because of surgery and discomfort there is a loss of appetite.

c) ELIMINATION PATTERN:

6
 Bowel - one time per day.
Bladder - 6-8 times per day

d) MENSTRUATION HISTORY:
Puberty attained on : 16 years
Duration of cycle : 5-7 days
Amount of flow : normal
Any abnormality : absent

e) OBSTETRICAL HISTORY
G1P1L1A0
LMP : 03 / 04 / 2020
EDD : 08 / 01/2021

 ANTENATAL HISTORY
Mild anaemia present
Immunization: both TT dose taken

 INTRANATAL HISTORY
 No any perineal tear present. No vaginal
laceration present
 No bleeding from episiotomy site
 Small perimetral tear present at right
side bleeding present at that side.
 delivery of male child.

 POSTNATAL HISTORY
 Delay episiotomy wound healing due to patient having GDM

7
 PHYSICAL EXAMINATION:

1) GENERAL OBSERVATION
 Constitution : Poor nourished
 Stature : Normal
 Personal appearance : conscious , oriented
 Posture : steady
 Emotional stage : Restlessness
 Skin : Dry, cracked

8
  Cooperativeness : cooperative
 Mood : Sad and anxious
 Activity : Dull
2) VITAL SIGNS
 Temprature : 99.6 F
 Pulse : 89bpm
 Respiration : 25bpm
 Blood pressure : 130/90 mm of Hg

3) HEIGHT : 152 Cm

4) WEIGHT :47 Kg
weight (kg) 47
BMI= = 2 = 18.72
height ( m )
2
(1.52)

5) SKIN AND MUCUS MEMBRANE:

 Colour of the skin : pallor in colour
 Oedema : absent
 Moist temperature : dry and crackled
 Turgor : Dry
 Texture : pallor
6) HEAD
 Skull : normal
 Hair : Black in color and equally distributed
 Movements of the head : normal
 Forehead : Normal
 Face : conscious, no any scar
7) EYES
 Eyebrows : Equal
 Eyelids : Normal, no lesions

9
  Lacrimation : Clear fluid
 Conjunctiva : Pale in colour
 Sclera : White in colour, Normal
 Cornea : Clear
 Iris : Normal
 Edema : absent
 Pupils : PERLLA ,3mm size
8) EARS
 Appears : Both symmetrical
 Discharge : No any discharge
 Hearing : Normal
 Lesions : Absent

9) NOSE
 Appearance : Normal
 Discharge : No any discharge
 Patency : Both nostrils are patent
 Sense of smell : Good
 Septal deviation : Absent
10)MOUTH AND THROAT
 Lips : Dry
 Tongue : Moist
 Teeth : Intact in upper and lower jaw
 Gums : Pink
 Buccal mucosa : Clean, moist, no lesions
 Tonsil : No any enlargement
 Speech : slow speech
11) NECK
 General appearance : Normal

10
  Trachea : Normal in position
 Lymph node : No enlargement
 Thyroid gland : Feel smooth and firm
 Cyst and tumour : Absent
 Range of motion : painful

12) BREAST
 Symmetry : Symmetrical
 Shape : Normal
 Size : Normal
 Nipple : erect
 Discharge : milk secretion present
 Auxiliary Node : Absent
 Lesion : Absent
 Areola : primary and secondary areola differentiate
 Montgomery tubercle : evident
 Visible vein : not present
13)RESPIRATORY SYSTEM
 Inspection : chest expansion equal in both side, respiration rate 30bpm
 Palpation : No any lesion and mass
 Percussion : No abnormal sound in both lungs
 Auscultation : Normal breath sound and vesicular sound present

14)CARDIO VASCULAR SYSTEM

 Inspection : No enlargement of jugular vein
 Palpation : Peripheral pulse normal
 Percussion : No any abnormal sound
 Auscultation : S1 and S2 heart sound appear

11
15)ABDOMEN
POSTNATAL EXAMINATION
 Inspection : Straie albican present
No any previous scar present
 Palpation : Height of uterus : 14 cm
Abdominal girth : 70 cm
 Percussion : Presence Of Fluid
 Auscultation : Bowel Sound Heard
 Appetite : Anorexia Present
16)BACK
 Spine and curvature : Normal
 Movements : painful
 Tenderness : absent
 Pain : present

17)GENITELIA
 Haemorrhoids : absent
 Vaginal discharge : present
 Labia majora &minora : redness is present
18)UPPER EXTREMITIES
 Symmetry : symmetrical
 Range of motion : possible
 Oedema : absent
 Cyanosis : absent
 Joints : movable
 Deformity : absent
19) LOWER EXTRIMITIES:-

12
  Homan sign : negative
 Symmetry : symmetrical
 Range of motion : possible
 Oedema : absent
 Cyanosis : absent
 Joints : movable
 Deformity : absent

INVESTIGATIONS

Sr. Investigations Patient Normal value Remarks

No value
1. CBC:
Heamoglobin 8.1 g/dl 11-16 g/dl Decrease
Leukocyte count 22200/cmm 4000-11000/cmm Increase
WBC differential count:

13
 Neutrophils 85% 30-70% Increase
2. Lymphocytes 11% 20-40% Decrease
Eosinophils 02% 1-6% -
Monocytes 02% 1-8% -
Basophils 00% < 2% -
Platelets count: 478.00 150-450 -
thousand /cmm thousand /cmm
3. Renal function test
Urea 14.2 mg/dl 10-50 mg/dl -
S.creatinine 0.8 mg/dl 0.6-1.2 mg/dl
S.uric acid 2.0 mg /dl 2.6-6.0 mg/dl

4. Electrolytes:-
Serum sodium 142 mEq/l 135-147 mEq/l -
Serum potassium 4.5 mEq/l 3.5-5.5 mEq/l -
Serum chloride 96mEql 96- 107 mEq/l -

5. Biochemistry :-
RBS 289 mg/dl 70-110 mg/dl -

DRUG STUDY

Sr. Drug Dose Route Action Side effect Nurses

no Responsibility

14
1. Inj. Cefotaxim 1gm IV stat Inhibits bacterial cell -seizure -do not
wall synthesis, -bleeding break ,chrush or
rendering cell wall -diarrhea chew tab
osmotically unstable, -leukopenia -check bowel
leading to cell death -protenuria pattern

2. Inj. 40 IV Suppresses gastric -pnemonea -assess vit b12

Pantoprazole mg secrition by inhibiting -hypergly deficiency
hydrogen/potassium cemia -may take without
ATPase enzyme system -rash food
in gastric cells, known -abdominal -diabetic patient
as gastric acid pump pain should know
inhibitor -insomnia hyperglycemia
-headache may occur
3. Inj. Emeset 4 mg IV Prophylaxis of post Warm Check the
(ondasetron) operative nausea , feeling, head hydration level of
vomiting associated ache, patient
with radiation constipation
4. Tab. Folic acid 800 oral Folic acid helps the Fever Check the any
mcg body to produce and general allergic reaction
weakness or
maintain new cells, discomfort Stored at the
and also helps prevent reddened room temperature
changes to DNA that skin Assess the 10
may lead to cancer. As shortness of right of the
breath
a medication, folic patient before
skin rash or
acid is used to itching administer drug
treat folicacid deficien
cy and certain types of
anemia (lack of red
blood cells) caused
by folicacid deficiency

15
 .
5. Metrogyl 20mg IV Directed again Leucopenia Check the renal
elistolytical T- vaginal Pruritis function test ,
antibiotic.,actively Urticaria, dosage and
against variety of headache frequency of
organisms. drug
6.
7. Iron sucrose 200m Iv
g
dilute
d in
100m
l NS

ANATOMY AND PHYSIOLOGY ABOUT PANCREASE

16
 The pancreas is a long, slender organ, most of which is located posterior to the bottom
half of the stomach (Figure 1). Although it is primarily an exocrine gland, secreting a variety of
digestive enzymes, the pancreas has an endocrine function. Its pancreatic islets—clusters of
cells formerly known as the islets of Langerhans—secrete the hormones glucagon, insulin,
somatostatin, and pancreatic polypeptide (PP).

Cells and Secretions of the Pancreatic Islets

The pancreatic islets each contain four varieties of cells:

 The alpha cell produces the hormone glucagon and makes up approximately 20 percent of each
islet. Glucagon plays an important role in blood glucose regulation; low blood glucose levels
stimulate its release.
 The beta cell produces the hormone insulin and makes up approximately 75 percent of each islet.
Elevated blood glucose levels stimulate the release of insulin.

 The delta cell accounts for four percent of the islet cells and secretes the peptide hormone
somatostatin. Recall that somatostatin is also released by the hypothalamus (as GHIH), and the

17
 stomach and intestines also secrete it. An inhibiting hormone, pancreatic somatostatin inhibits
the release of both glucagon and insulin.

 The PP cell accounts for about one percent of islet cells and secretes the pancreatic polypeptide
hormone. It is thought to play a role in appetite, as well as in the regulation of pancreatic
exocrine and endocrine secretions. Pancreatic polypeptide released following a meal may reduce
further food consumption; however, it is also released in response to fasting.

REGULATION OF BLOOD GLUCOSE LEVELS BY INSULIN AND

GLUCAGON
Glucose is required for cellular respiration and is the preferred fuel for all body cells. The
body derives glucose from the breakdown of the carbohydrate-containing foods and drinks we
consume. Glucose not immediately taken up by cells for fuel can be stored by the liver and
muscles as glycogen, or converted to triglycerides and stored in the adipose tissue. Hormones
regulate both the storage and the utilization of glucose as required. Receptors located in the
pancreas sense blood glucose levels, and subsequently the pancreatic cells secrete glucagon or
insulin to maintain normal levels.

Glucagon

Receptors in the pancreas can sense the decline in blood glucose levels, such as during
periods of fasting or during prolonged labor or exercise. In response, the alpha cells of the
pancreas secrete the hormone glucagon, which has several effects:

 It stimulates the liver to convert its stores of glycogen back into glucose. This response is known
as glycogenolysis. The glucose is then released into the circulation for use by body cells.
 It stimulates the liver to take up amino acids from the blood and convert them into glucose. This
response is known as gluconeogenesis.

 It stimulates lipolysis, the breakdown of stored triglycerides into free fatty acids and glycerol.
Some of the free glycerol released into the bloodstream travels to the liver, which converts it into
glucose. This is also a form of gluconeogenesis.

18
Taken together, these actions increase blood glucose levels. The activity of glucagon is regulated
through a negative feedback mechanism; rising blood glucose levels inhibit further glucagon
production and secretion.

19
20
Insulin
The primary function of insulin is to facilitate the uptake of glucose into body cells. Red
blood cells, as well as cells of the brain, liver, kidneys, and the lining of the small intestine, do
not have insulin receptors on their cell membranes and do not require insulin for glucose uptake.
Although all other body cells do require insulin if they are to take glucose from the bloodstream,
skeletal muscle cells and adipose cells are the primary targets of insulin.

The presence of food in the intestine triggers the release of gastrointestinal tract
hormones such as glucose-dependent insulinotropic peptide (previously known as gastric
inhibitory peptide). This is in turn the initial trigger for insulin production and secretion by the
beta cells of the pancreas. Once nutrient absorption occurs, the resulting surge in blood glucose
levels further stimulates insulin secretion.

Precisely how insulin facilitates glucose uptake is not entirely clear. However, insulin
appears to activate a tyrosine kinase receptor, triggering the phosphorylation of many substrates
within the cell. These multiple biochemical reactions converge to support the movement of
intracellular vesicles containing facilitative glucose transporters to the cell membrane. In the
absence of insulin, these transport proteins are normally recycled slowly between the cell
membrane and cell interior. Insulin triggers the rapid movement of a pool of glucose transporter
vesicles to the cell membrane, where they fuse and expose the glucose transporters to the
extracellular fluid. The transporters then move glucose by facilitated diffusion into the cell
interior.

Insulin also reduces blood glucose levels by stimulating glycolysis, the metabolism of
glucose for generation of ATP. Moreover, it stimulates the liver to convert excess glucose into
glycogen for storage, and it inhibits enzymes involved in glycogenolysis and gluconeogenesis.
Finally, insulin promotes triglyceride and protein synthesis. The secretion of insulin is regulated
through a negative feedback mechanism. As blood glucose levels decrease, further insulin
release is inhibited. The pancreatic hormones are summarized in Table.

21
Hormones of the Pancreas (Table )

Associated hormones Chemical class Effect

Insulin (beta cells) Protein Reduces blood glucose levels

Glucagon (alpha cells) Protein Increases blood glucose levels

Somatostatin (delta cells) Protein Inhibits insulin and glucagon release

Pancreatic polypeptide (PP cells) Protein Role in appetite

Disorders of the…

Endocrine System: Diabetes Mellitus

Dysfunction of insulin production and secretion, as well as the target cells’ responsiveness
to insulin, can lead to a condition called diabetes mellitus. An increasingly common disease,
diabetes mellitus has been diagnosed in more than 18 million adults in the United States, and
more than 200,000 children. It is estimated that up to 7 million more adults have the condition
but have not been diagnosed. In addition, approximately 79 million people in the US are
estimated to have pre-diabetes, a condition in which blood glucose levels are abnormally high,
but not yet high enough to be classified as diabetes.

22
There are two main forms of diabetes mellitus.

Type 1: diabetes is an autoimmune disease affecting the beta cells of the pancreas. Certain
genes are recognized to increase susceptibility. The beta cells of people with type 1 diabetes do
not produce insulin; thus, synthetic insulin must be administered by injection or infusion. This
form of diabetes accounts for less than five percent of all diabetes cases.

Type 2 :diabetes accounts for approximately 95 percent of all cases. It is acquired, and lifestyle
factors such as poor diet, inactivity, and the presence of pre-diabetes greatly increase a person’s
risk. About 80 to 90 percent of people with type 2 diabetes are overweight or obese. In type 2
diabetes, cells become resistant to the effects of insulin. In response, the pancreas increases its
insulin secretion, but over time, the beta cells become exhausted. In many cases, type 2 diabetes
can be reversed by moderate weight loss, regular physical activity, and consumption of a healthy
diet; however, if blood glucose levels cannot be controlled, the diabetic will eventually require
insulin.

Two of the early manifestations of diabetes are excessive urination and excessive thirst.
They demonstrate how the out-of-control levels of glucose in the blood affect kidney function.
The kidneys are responsible for filtering glucose from the blood. Excessive blood glucose draws
water into the urine, and as a result the person eliminates an abnormally large quantity of sweet
urine. The use of body water to dilute the urine leaves the body dehydrated, and so the person is
unusually and continually thirsty. The person may also experience persistent hunger because the
body cells are unable to access the glucose in the bloodstream.

23
 DISEASE CONDITION

INTRODUCTION:

Diabetes mellitus is a chronic metabolic disorder due to either insulin deficiency

(relative or absolute) or due to peripheral tissue resistance (decreased sensitivity) to the action
of insulin. The pathophysiology involved are:

(i) decreased sensitivity of skeletal muscles and liver to insulin (insulin

resistance) and
(ii) inadequate secretion of insulin (β cell dysfunction). Pregnancy is a state of
chronic low-grade inflammation. This is associated with increased circulating
levels of C-reactive protein (CRP) and interleukin-6 (Il-6). Both these factors
enhance insulin resistance. The defect lies both In insulin secretion and action.
The ultimate effect is the hyperglycemia
DEFINATION:

GDM is defined as carbohydrate intolerance of variable severity with onset or first

recognition during the present pregnancy

CLASSIFICATION OF THE POSTNATAL ANEMIA

BOOK PICTURE PATIENT PICTURE

A.Type–1 (IDDM) is characterized by young age onset (Juvenile) and

absolute insulinopenia. They have genetic predisposition with presence of
autoantibodies.

B. Type–2 (NIDDM) is characterized by late age onset, overweight woman

and peripheral tissue (skeletal muscle, liver) insulin resistance
(hyperinsulinemia). Genetic predisposition is also observed.

24
C. Gestational Diabetes Mellitus (GDM) present

D. Others: Genetic, Drugs, MOD

ETIOLOGY
BOOK PICTURE PATIENT PICTURE
(a) Positive family history of diabetes (parents or
sibling).
Family history should include uncles, aunts and
grandparents
(b) Having a previous birth of an
overweight baby of 4 kg or more
(c) Previous stillbirth with pancreatic islet hyperplasia
revealed on
autopsy
(d) Unexplained perinatal loss
(e) Presence of polyhydramnios or recurrent vaginal present
candidiasis
in present pregnancy
(f) Persistent glycosuria present
(g) Age over 30 years present
(h) Obesity (
(i) Ethnic
group (East Asian, Pacific island ancestry)..

25
 HAZARDS

BOOK PICTURE PATIENT PICTURE

(1) Increased perinatal loss is associated with Present
fasting hyperglycemia. Fetal anomalies are
however not increased. This is due to the
absence of metabolic disturbance
during organogenesis
(2) Increased incidence of macrosomia
(3) Polyhydramnios
present
(4) Birth trauma
(5) Recurrence of GDM in subsequent
pregnancies is about 50%.

26
 MANAGEMENT
BOOK PICTURE PATIENT PICTURE
 Diet with 2,000–2,500 Kcal/day for normal Give Which available in the hospital
weight woman and restriction to 1,200–
1,800 Kcal/day forover weight woman is
recommended.
 Carbohydrate should be 40–50% of total
calories.
 Complex carbohydrates are preferred
because simple carbohydrates produce
significant post-prandial hyperglycemia.
Women should perform self-blood glucose
monitoring using reflectance meter. Women
with well controlled GDM have reduced
risk of complications like: IUFD,
macrosomia, shoulder dystocia,
preeclampsia, and cesarean delivery.
 The patient needs more frequent antenatal
supervision with periodic checkup of

27
 fasting plasma glucose level which should
be less than 90 mg%.
 Maintenance of mean plasma glucose level
between 105 mg/dl and 110 mg/dl is
desirable for good fetal outcome
(DIPSI – 2009).
 The control of high blood glucose is done
by restriction of diet, exercise with or
without Given as per doctor advice
insulin.
 Human insulin should be started if fasting
plasma glucose level exceeds 90 mg/dl and
2 hours postprandial value is greater than
120 mg/dl (repetitive) even on diet control.
Nearly 25% women with
GDM need insulin therapy.
 Exercise (aerobic, brisk walking) programs
are safe in pregnancy and may
obviate the need of insulin therapy.
 Obstetric management: Women with good
glycemic control and who do not require
insulin may wait for spontaneous onset of
labor. However, elective delivery (induction
or cesarean section) is considered
in patients requiring insulin or with
complications (macrosomia) at around 38
weeks.
 Follow-up: Nearly 50% of women with
GDM would develop overt diabetes over a
follow-up period of 5–20 years. Women
with fasting hyperglycemia have got worse

28
 prognosis to develop type-2 diabetes
and cardiovascular complications.
Recurrence risk in subsequent pregnancy is
more than 50%.
 Risks of being overweight for the infants of
mother with GDM is twofold and the risk
for metabolic.
 syndrome is about fourfold.

EFFECT OF PREGNANCY ON DIABETES

BOOK PICTURE PATIENT PICTURE

29
Complications of diabetes (Hyperglycemia and
adverse pregnancy outcome):
 MATERNAL:
During pregnancy:
 Abortion: Recurrent spontaneous abortion
may be associated with uncontrolled
diabetes.
 Preterm labor (26%) may be due to present
infection or polyhydramnios.
 Infection: Urinary tract infection and
vulvovaginitis.
present
 Increased incidence of preeclampsia
(25%).
 Polyhydramnios (25–50%) is a common
association. large baby, large placenta, fetal
hyperglycemia leading to polyuria,
increased glucose concentration of liquor
irritating the
amniotic epithelium or increased osmosis,
are some of the probabilities.
 Maternal distress may be due to the
combined eff ects of an oversized fetus and
polyhydramnios.
 Diabetic retinopathy (Class R) is
characterized by the proliferative
retinopathy having neovascularisation

and microaneurysms. T ese vessels may

rupture and may cause vitreous hemorrhage,
scarring, retinal detachment and loss of
vision. Severity of retinal pathology depends

30
 on (a) age (time) of onset, (b) duration
of the disease, (c) degree of rise in blood Hb
AIC and (d) association of hypertension
laser
photocoagulation is the preferred treatment.
 Diabetic nephropathy (Class F) is
diagnosed when creatinine clearance is
reduced or there is persistent
proteinuria (≥300 mg/24 hours) during the f
rst 20 weeks of gestation. Predictive factors
for perinatal outcome (e.g., low birth
weight, preterm delivery or preeclampsia)
are:
(a) Proteinuria > 3 g/24 hours,
(b) serum creatinine > 1.5 mg/dl
Most women (90%) develop
preeclampsia. Control of hypertension is
important to prevent further
deterioration of kidney function.
Calcium channel blocker is commonly
used.
These women have significantly reduced
life expectancy. T e disease progression
is characterized by
hypertension, falling glomerularal
filtration rate and creatinine clearance.
The end stage disease needs dialysis or
renal transplantation. Renal
transplantation improves survival of
women with diabetic nephropathy.
 Coronary artery disease (Class H): These
women run the high risk for ischemic heart
31
 THEORY APPLICATION

IMOGENE KING'S THEORY OF GOAL ATTAINMENT

INTRODUCTION
BASIC ASSUMPTIONS
 Nursing focus is the care of human being
 Nursing goal is the health care of individuals & groups
 Human beings: are open systems interacting constantly with their environment.
 Basic assumption of goal attainment theory is that nurse and client communicate
information, set goal mutually and then act to attain those goals, is also the basic assumption
of nursing process
 “Each human being perceives the world as a total person in making transactions with
individuals and things in environment”
 “Transaction represents a life situation in which perceiver & thing perceived are

32
 encountered and in which person enters the situation as an active participant and each is
changed in the process of these experiences”
MAJOR CONCEPTS
 Interacting systems:

o personal system
o Interpersonal system
o Social system
Concepts for Personal System

 Perception
 Self
 Growth & development
 Body image
 Space
 Time
Concepts for Interpersonal System
 Interaction
 Communication
 Transaction
 Role
 Stress
Concepts for Social System
 Organization
 Authority
 Power
 Status
 Decision making

PROPOSITIONS OF KING’S THEORY

 If perceptual interaction accuracy is present in nurse-client interactions, transaction will
occur
 If nurse and client make transaction, goal will be attained

33
  If goal are attained, satisfaction will occur
 If transactions are made in nurse-client interactions, growth & development will be
enhanced
 If role expectations and role performance as perceived by nurse & client are congruent,
transaction will occur
 If role conflict is experienced by nurse or client or both, stress in nurse-client interaction
will occur
 If nurse with special knowledge skill communicate appropriate information to client, mutual
goal setting and goal attainment will occur.
NURSING PARADIGMS
1.Human being /person
 Human being or person refers to social being who are rational and sentient.
 Person has ability to :
o perceive
o think
o feel
o choose
o set goals
o select means to achieve goals and
o to make decision
 Human being has three fundamental needs:
1. The need for the health information that is unable at the time when it is needed and
can be used
2. The need for care that seek to prevent illness, and
3. The need for care when human beings are unable to help themselves.
2.Health
 Health involves dynamic life experiences of a human being, which implies continuous
adjustment to stressors in the internal and external environment through optimum use of
one’s resources to achieve maximum potential for daily living.
3.Environment
 Environment is the background for human interactions.

34
  It involves:
1. Internal environment: transforms energy to enable person to adjust to continuous
external environmental changes.
2. External environment: involves formal and informal organizations. Nurse is a part of
the patient’s environment.
4. Nursing
 Definition: “A process of action, reaction and interaction by which nurse and client share
information about their perception in nursing situation.” and “ a process of human
interactions between nurse and client whereby each perceives the other and the situation,
and through communication, they set goals, explore means, and agree on means to achieve
goals.”
 Action: is defined as a sequence of behaviors involving mental and physical action.
 Reaction: which is considered as included in the sequence of behaviors described in action.
 In addition, king discussed:
o (a) goal
o (b) domain and
o (c) functions of professional nurse
 Goal of nurse: “To help individuals to maintain their health so they can function in their
roles.”
 Domain of nurse: “includes promoting, maintaining, and restoring health, and caring for
the sick, injured and dying.
 Function of professional nurse: “To interpret information in nursing process to plan,
implement and evaluate nursing care..

THEORY OF GOAL ATTAINMENT AND NURSING PROCESS

Assessment
 Assessment occur during interaction.
 The nurse brings special knowledge and skills whereas client brings knowledge of self and
perception of problems of concern, to this interaction.
 During assessment nurse collects data regarding client (his/her growth & development,

35
 perception of self and current health status, roles etc.)
 Perception is the base for collection and interpretation of data.
 Communication is required to verify accuracy of perception, for interaction and transaction.
Nursing diagnosis
 The data collected by assessment are used to make nursing diagnosis in nursing process.
 In process of attaining goal the nurse identifies the problems, concerns and disturbances
about which person seek help.
Planning
 After diagnosis, planning for interventions to solve those problems is done.
 In goal attainment planning is represented by setting goals and making decisions about and
being agreed on the means to achieve goals.
 This part of transaction and client’s participation is encouraged in making decision on the
means to achieve the goals.
Implementations
 In nursing process implementation involves the actual activities to achieve the goals.
 In goal attainment it is the continuation of transaction.
Evaluation
 It involves to finding out whether goals are achieved or not.
 In king description evaluation speaks about attainment of goal and effectiveness of nursing
care.

Nursing Process and Theory of Goal Attainment

Nursing process method Nursing process theory

A system of oriented actions A system of oriented concepts

Perception, communication and interaction
Assessment
of nurse and client

36
Planning Decision making about the goals
Be agree on the means to attain the goals
Implementation Transaction made
Evaluation Goal attained

37
 IMORGENE KING THEORY
NURSE
INPUT THROUGHPUT OUTPUT
Name PERCEPTION
: mrs. Babita n. ghai TRANSACTIONS
Age : 28 yrs OUTCOME
NURSE
Sex : female  Appraise the patients current
Mrs.Binali Patel Patient
Diagnosis :gestational dm level of knowledge.
1stM.Sc.Nursing
Religion : Hindu INTERACTION  Describe the disease process. understand
Client as a whole.
 Describe rationale behind about anemia
-Hyperthermia management hazards and
CLIENT related to infection  Explain about diet risk factor
have secondary to. management.
gastationaldm prevention
 Provide diversional therapy
INTERPERSONAL -Imbalanced  Advice to limit alcohol Patient
SYSTEM: nutrition less than  Discuss about life style understand
body requirement changes.
 Husband taking care about
related to anorexia  Explain importance about the
of her management
personal hygiene.
 Good interaction and -Activity and
 Eating regular meal at regular
communication with intolerance related complication
time.
family members and to weakness
 Explain to avoid cold drinks
society and junk food and salty food.
-Self-care deficit:
dressing, toileting  Advice to regular followup.
related to  Explain to adhere the
JUDGEME
SOCIAL SYSTEM generalize medication.
 Middle class family
CLIENT NURSE weakness  Explain about Complication of +ve
 own house Cooperative with all antenatal anemia. outcome
-Deficit knowledge
 Decision make by family member
satisfaction
related to
whole family Feedback
PATIENT -Impaired sleeping
pattern related to
Mrs. Jasmine patel
19Year discomfort
Nurse 38
-Risk for infection
AsCareprovider related to improper
hygiene
 NURSING DIAGNOSIS:
1. Deficient knowledge regarding disease condition and treatment and individual care related to unfamiliarity with information of facial
expression as evidence by verbal response.
2. Risk for unstable blood glucose related to inadequate blood glucose monitoring practice as evidence by blood glucose level above the
normal level
3. Risk for information related to decrease leukocyte to circulatory changes due to high blood glucose levels as evidence by delay wound
healing.
4. Risk for altered nutrition less then body requirement related to inability to utilize nutrients appropriately
5. Impaired skin integrity related to disease condition as evidence by delay wound healing process

39
Nursing care plan

40
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONAL IMPLIMENTATION EVALUATION
DIAGNOSIS OUTCOME
Subjective data Ineffective Short Term -Assess vital sign of -to check -Assess patientsvitals. - Now
Patient reported patient
thermoregulation patient will be the patient temperature of Temperature-99 F
that “my leg relieved from the patient Pulse-102 /min maintain
,Hyperthermia body
wound not heal the discomfort Respiration-34 ./min
temperatur
properly related to and reduced
e to
infection body -select and apply a -to promote -provide betadin dressing normal
temprature variety of measures comfort and instruct to apply i.e.98.6 F
secondary to
to heal the wound coconut oil - Patien fell
Objective data diabetes mellitus Long Term comfort at
Temperature- patient will be - -reduce factors that -reduce or eliminate some
as evidenced by
extent
99.c F maintain precipitate or -to reduce the factor that can precipitate
Delay wound
Warm bodyskin. normal body increase infection infection or increase the fever
healing temperature, experience
and early -control
wound heal environmental - control environmental
factors that may -to decrease factors that may
influence the discomfort and influence the patient’s
patient’s response to pain response to discomfort
discomfort like room temperature,
lighting, noise etc.
-administered
antipyretic drug -to reduce body -administered antibiotic
temprature like cefotaxim and
antipyretic drug

41
Sub.data:- Self-care Short -evaluate -establish -Reports of dyspnea, Now patient is
Patient reported that” deficit related Term client’s client’s needs increase weakness and able to do activity
I am hving so much to generalize patient response to and facilitate change in vital signs and maintain
weakness and not weakness will be activity choice of during and after activity personal hygiene
able to do daily secondary to maintain -assist client to interventions -assist client to assume
activity” adaibetes daily assume -client may be comfortable position for
mellitus as activity comfortable take easily rest and sleep
evidenced by Long position for breath -done the daily dressing
Obj.data:- and poor Term rest -To prevent -provide comfort
Patient is unable to grooming. patient -done the daily infection measures e.g. back rubs,
perform daily will be dressing -client change of position, quiet
activity take others maintain -provide enhance sense music or conversation
help for some personal comfort of well being -instruct and assist client
activity hygiene measures -to control of in selfcare activity
-instruct and discomfort
assist client in
selfcare
activity

42
ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS

Objective data: Risk for Short -monitor for -to determine monitor for systematic now patient
-patient HB level is Term localized sign if an infection and localized sign and WBC count in
infection
6.4g/dl patient will and symptoms is present symptoms of infection normal and
related to be reduce of infection infection risk
improper to get the also decrease.
infection -monitor WBC -to detect - monitor WBC count
hygiene
count presence of and differential results
secondary to Long -teach patient infection
lack of Term and family -teach patient and
patient will about infection family about infection
knowledge
be getting control -to prevent control measures
regarding adequate infection
diabetes knowledge -instruct -instruct patient on
mallitus about patient on appropriate hand
infection appropriate -to prevent washing techniques and
hand washing spread of other aseptic
techniques infection techniques

-to prevent - use universal

-use universal infection precautions and use
precautions among health aseptic technique to
care member treat patient

43
Timing Foods Quantity CHO Fat Protein Calaries
Breakfast Milk 1 glass 11.65 8.37 8.30 155
Bread 3 slices 36.72 2.88 7.8 195

Mid Thepla 2 29.2 2 7.28 152

morning Pickle 15gm 3 2 0 22

Lunch Chapati 2 26.2 1.3 5.28 128

Bitter 1 cup 4.2 13.8 1.6 145
guard 1 cup 7.24 8.82 24.58 210
Curd ½ cup 36.8 0.1 4.25 162.18
Rice ½ cup 45 0.5 3.5 10
Daal ½ cup 45 0.5 3.5 13

Evening Upma 50gm 45 0.05 0.28 182

Coffee 1 cup 9 50.78 13.98 2

Dinner Bhakhari 2 cup 50.78 50.78 13.98 8.64

Curd 1 cup 7.24 7.24 8.82 24.3
Cabbage 1 cup 4.97 4.97 13.71 1.28
sabji 50gm 6.82 6.82 0.25 2.08

Bed time Milk 1 glass 11.65 8.375 8.30 155

TOTAL 335.37 85.45 111.45 2439

HEALTH EDUCATION:

DIET
 Provide 3-4 smaller meals per day
 Avoid gas causing foods such as broccoli, cabbage, beans
 Use less salt and spice in the food
 Fruits and fruit juice to be given to the client, that is a good source of fiber
 Law fat diet like milk, yogurt, and cheese to be included in diet.
 Use less susgar diet.
 Avoid carbohydrate in diet
44
 PREVENTION

 Complete bed rest

 Do not Use alcohol and tobacco.
 Avoid straneous activity
 do not lift the heavy weight
 Avoid travelling during pregnancy

PSYCHOLOGICAL SUPPORT

 Give psychological support to patient and family

 Describe whole disease condition to family
 Give all the answer of those question which they asking.

45
 REHABILITATIVE ACTIVITY

 Teach regarding high calorie diet

 Teach walking techniques and bending techniques
 Follow up and take all medicine regularly

NURSES NOTES
 1st day (18/05/2021)
Patient had fever, body ache , generalized weakness and pallor with pervaginal
infection and wit postpartum period. Patients Temperature:-100 F, Pulse:- 102/ min,
Respiratory rate:- 28/min, blood pressure:- 110/70 mm of hg at time of admission.
Patient is conscious then assessed after that diagnosed with severe gestational
diabetes. for that investigation done that are ultrasonography , CBC . after that patient
received treatment, Inj- Cefotaxim., Inj- Tramadol, , Inj- Pantoprazole, inj. Febrinil&
600 ml, tab. Metformin of whole blood transfusion & I also Provide knowledge
regarding Mouth Care , personal hygiene and postnatal diet.

46
 2nd day (19/05/2021)

patient is conscious and have a complain of discomfort , generalized

weakness ,anorexia Temp-99 F, respiration 24/ min, pulse- 88 /min, BP- 110/80 mm of
hg,. So , Patient received treatment Inj- Cefotaxim., Inj- Pantoprazole, perineal
care .provide health education to relative regarding postnatal anemia prevention.

 3rd day (20/05/2021)

Patient is conscious Temp-99.4 F, respiration-22/min, Pulse- 80/min, Bp-

120/80 mm of hg. Patient received treatment Inj- Cefotaxim, Inj- Pantoprazole&tab.folic
acid and iron, . Provide education regarding prevention and rehabilitation of postnatal
gestational dm and how to take medicine in daily routinre.

SUMMARY
Patient was admitted in GMERS civil hospital on 26/05/2021 9 at 1:25 pm with
the complain of fever, body ache , generalized weakness and pallor with per vaginal
infection, delay wound healing . Then diagnosed with gestational dm .For that she was
under treatment by the Dr. Jignesh. After that mother has good prognosis.

47
 BIBLIOGRAPHY

1. Brunner and suddarth’s , “TEXTBOOK OF MEDICAL AND SURGICAL NURSING”,

11TH edition, published by Lippincott Williams and wolterskluwer (India) pvt.Ltd,New
delhi.2008. P.p. 2233-2235

48
2. AnnamaJacob , “A COMPREHENSIVE TEXTBOOK OF MIDWIFERY AND
GYNECOLOGICAL NURSING” , 3RD edition , published by jaypee brothersmedical
publisher pvt. Ltd , new delhi 2012 , page no.262-264

3. D C Dutta’s “textbook of obstetrics”7th edition , jaypee brother publication (p)

ltd.,newdelhi 2013 ,page no.303-315

4. Mosby’s , “NURSING DRUG REFERANCE”, 24 th edition, Published by Elsevier,

adivison of reed Elsevier india private limited, 2011. P.p-754, 947, 868

5. Lewis’s chintamani, “MEDICAL SURGICAL NURSING”, 1st edition, published by

Elsevier india private limited, 2011,P.p- 630-655

6. http://www.nhlbi.nih.gov/index.htm l

7. http://www.wikipedia.com

49