Crea t i ng a patient- educ a t i on pamphlet tor gestational diabetes / by Lucille K. Steele Morrison. Thesis Nurs. 1999 M879c CREATING A PATIENT EDUCATION PAMPHLET FOR GESTATIONAL DIABETES By Lucille K. Steele Morrison, MEd, BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: ?//?/? 7 Jugpm Schilling, CRNP, PhD. Committee Chairperson Date 'A ft np, MSN, ariet Newcamp, .... Committee Member RN Date 2 cf 4^.. CREATING A PATIENT EDUCATION PAMPHLET FOR GESTATIONAL DIABETES Abstract With patient education receiving such emphasis in today’s health care arena, multi-instructional aids are widely used to enhance the patient education process. Printed patient education materials remain the most common tool to supplement oral instruction (Bernier & Yasko, 1991). Gestational diabetes mellitus (GDM) patients require education about lifestyle modifications such as weight control, diet, exercise, and tight glycemic control in order to lessen risks of both maternal and fetal/neonatal complications (Ryan, 1998). These patients also need information about prognostic considerations. A patient education pamphlet was created following the Evaluating Printed Education Materials (EPEM) model developed by Bernier and Yasko (1991). This pamphlet is intended to reinforce oral instructions given to GDM patients referred for counseling to a hospital-based diabetes education center in northwestern Pennsylvania. The content of the pamphlet includes: the etiology of GDM, risk factors for developing GDM, screening tests to detect GDM, implications GDM has for the mother and the baby, maternal and fetal complications associated with GDM, management of GDM, and prognostic considerations of GDM. The McLauglin (1969) SMOG formula was used to place the pamphlet at the sixth grade reading level. Acknowledgments No scholarly project is completed without help. I would like to say thank you to many wonderful people. Leading all acknowledgments must be mine to my two beautiful children, Robert Blair and Ruth Louise Morrison, and my wonderful husband, William. They have offered an unwavering support throughout the development of this project. To my wonderful sister, Anna, and her husband, Dale Hodgkinson, who were willing to proofread the manuscript. To my church family who have supported me in their prayers. To Patty DiPanfilo for her computer support to illustrate the pamphlet. To Diane Harbaugh, diabetes nurse educator, for her valuable input. To Dr. Janet Geisel for providing critique of the first three chapters. To Janet Newcamp, committee member, my deep gratitude for her willingness to serve on my project committee and for providing many valuable suggestions. Lastly, to Dr. Judith Schilling, my deepest gratitude for acting as chairperson of my committee and for providing me with much guidance to bring this project to fruition. This scholarly project received partial support from Nu Theta Chapter, Sigma Theta Tau, Inc., on May 1, 1999. iii Table of Contents Content Page Abstract ii Acknowledgments iii Chapter I: Introduction 1 Background of the Problem 1 Educational reform 1 Educational materials 3 Educational opportunity 4 Theoretical Framework. 4 Problem Statement 5 Statement of Purpose 6 Assumptions 6 Definition of Terms 6 Summary. 8 Chapter II: Review of the Literature Gestational Diabetes Mellitus 9 10 Classification Pathogenesis 12 Detection Diagnosis iv Management 15 Maternal complications 19 Fetal/neonatal complications 19 Prognostic considerations 20 Education Process 21 Definition of education process 21 Steps of the education process 22 Goal of the education process 22 Patient education 23 Printed Education Materials (PEMs) 23 Research support for PEMs 24 Rationale for PEMs 24 Rationale for self-composing PEMs 26 Readability of PEMs 26 Guidelines for writing PEMs 27 Model for designing and evaluating PEMs Summary 29 Chapter III. Methodology Model for Evaluating Printed Education Materials Predesign phase Design phase.... v Pilot test phase 30 Implementation/distribution phase 32 Evaluation phase 32 Summary 32 References 33 Appendixes 40 A. Oral Glucose Tolerance Test Results for Screening and Diagnosing Tests 41 B. McLaughlin’s SMOG Formula 42 C. Classification of Gestational Diabetes Mellitus 44 D. Risk factors for Developing GDM 45 E. Nursing process, assure model, education process 46 F. Cover Letter Accompanying Pamphlet and Questionnaire 47 G. Questionnaire for Evaluation/Revise Phase 48 H. Pamphlet: A Guide to Understanding Gestational Diabetes 49 vi 1 Chapter 1 Introduction This chapter provides a discussion about patient education, patient education materials, and gestational diabetes mellitus as an opportunity for patient education. Dorothea E. Orem’s (1995) Self-care Deficit Theory of Nursing provided the conceptual framework for this scholarly project. Background of the problem, the problem statement, purpose of the study, assumptions, and pertinent definitions are provided. Background of the Problem Patient education is a means of improving the health status of the American people and advanced practice nurses have a major role in this educational process (Boyd, 1992). Today, education about preventive health care practices and health promotion is considered an essential component of comprehensive health care (Boyd, 1992). Educational reform. As early as 1918, the National League of Nursing Education advocated the importance of health teaching (Bastable, 1997). A renewed emphasis on health education has been steadily developing over the past 30 years and, today, education in health care is a topic of utmost interest in both rural and urban communities (Gibson & Kapp, 1994). The patient’s Bill of Rights, issued by the American Hospital Association in 1975 and revised in 1992, is adopted by hospitals nationwide and recognizes the rights of patients to be informed about their health, illness, and treatment 2 (Nelson, 1997; Weinrich & Boyd, 1992). As a result of this health consciousness, there has been federal legislation to support health education through the National Center for Health Education, the Centers for Disease Control and Prevention, and the Medicare and Medicaid Programs (Nelson, 1997). The federal government has established certain goals and objectives outlined in Healthy People 2000: National Promotion and Disease Prevention (U.S. Department of Health and Human Services [DHHS], 1990). If these health care goals are achieved nationally, health care costs would be dramatically reduced and Americans could lead healthier and more productive lives (Bastable, 1997). Health professional groups have also passed supportive statements about health education and consumer groups have become active in promoting consumer rights in health care (Boyd, 1992). As recently as 1993, in recognition of the importance of patient education, the Joint Commission on Accreditation of Health Care Organization (JACHO) delineated nursing standards for patient education (Nelson, 1997). Improved care outcomes and lowering health care costs are two desirable benefits of patient education (Gibson & Kapp, 1994). In this era of expanded knowledge, patients want to be, and are expected to be, more active participants in their own health care (Weinrich & Boyd., 1992). By providing patients with information and education, they can move beyond just learning facts to making judgments in daily living (Gibson & Kapp, 1994). 3 Educational materials. Patient education materials alone do not constitute patient education (Flavo, 1985). Patient education begins when the nurse practitioner clearly and effectively communicates the needed information to the patient (Flavo, 1985). However, the use of printed educational materials (PEMs) can clarify, supplement, and reinforce oral instruction and may be read by significant others (Weinrich & Boyd, 1992). There is a plethora of commercially prepared written instructional materials currently available (Bernier & Yasko, 1991; Boyd, 1992; Hainsworth, 1997). However, there are disadvantages to using commercially prepared PEMs (Hainsworth, 1997). These drawbacks include issues of cost, accuracy, adequacy of content, and readability of the materials (Bernier, 1993; Hainsworth, 1997). Despite the wide variety of commercially prepared materials for patient education, nurse practitioners may still choose to write their own. Reasons for self-composing instructional materials include cost savings or the need to tailor the content (Hainsworth, 1997). Bernier (1993) and Hainsworth (1997) pointed out that tailoring written materials to reinforce specific oral instructions will enhance efficacy and provide opportunities to clarify concepts that have been taught. In addition, PEMs can be read again and again by the patient which helps to reinforce teaching and answer questions when the practitioner is not available to provide feedback (Bernier, 1993; Gibson & Kapp, 1994; Hainsworth, 1997). 4 Educational opportunity. According to Orr (1990), informed patients are more likely to comply with medical treatment plans and are better able to manage the symptoms with fewer complications. One nonprofit consumer health care organization developed the philosophy that illness is an educational opportunity and that illness can become a teachable moment even though the patient may not be highly motivated (Orr, 1990). The medical condition, gestational diabetes mellitus (GDM), gives rise to educational needs for women with GDM (American Diabetic Association [ADA], 1998; Ryan, 1998). Illness-related information includes facts about symptoms, diagnostic tests, treatment modalities, therapeutic equipment, and outcomes of the illness (Boyd, 1992; Orr, 1990; Ryan, 1998). GDM patients need instructions regarding treatment modalities such as daily self­ monitoring of biood glucose, dietary modifications, and a routine exercise program (ADA, 1998; Landon & Gabbe.,1995; Reeder, Martin & KnoniakGriffin, 1997; Ryan, 1998; Stanley, 1996). Theoretical Framework Dorothea E. Orem’s (1995) Self-care Deficit Theory of Nursing provides the framework for this scholarly project. Orem (1995) described her theory based on the belief that adult persons have developed the capabilities to meet their own needs (self-care) and the needs of their dependents (dependent-care) for functioning, growing and developing. The ability to engage in self-care and dependent care activities is termed self-care agency 5 and dependent-care agency. The total requirement for regulation of functioning, growing, and developing is Orem’s (1995) therapeutic self-care demand. It is the deficit between the therapeutic self-care demand and the self-care or dependent­ care agency capability that concerns the nurse practitioner. When this deficit occurs the patient may need assistance in maintaining normal growth and development, in prevention or cure of potentially disabling processes, in prevention or compensation for resulting disability, or in the promotion of well-being. The nurse practitioner provides assistance to the self-care agent in meeting self-care requisites in one or more of the following ways: (a) acting for or doing for another, (b) guiding and directing, (c) providing physical or psychological support, (d) providing and maintaining an environment that supports development, and (e) teaching. The self-care agent that is pregnant and has developed GDM requires education in order to become competent to manage health-deviation self- care requisites. The goal of the nurse practitioner is to provide the support and guidance that is needed in order to meet these requisites of the self-care agent and to promote normal growth and development of the fetus, or dependent-care agent, and to contribute to future normalcy. Problem Statement Gestational diabetes mellitus (GDM) affects approximately 4% of pregnancies or 135,000 cases annually in the US (ADA, 1998; Ryan, 1998). 6 Women with GDM need patient education about how to make lifestyle modifications in order to reduce risks of complications for the mother and the fetus/neonate, and should be informed about prognostic considerations (ADA, 1998; Ryan, 1998). Statement of Purpose The purpose of this scholarly project was to construct a patient education pamphlet. This patient printed educational material is intended for use as a teaching tool to supplement specific oral instructions delivered to patients who have developed gestational diabetes mellitus. Assumptions For the purposes of this project, the following assumptions were made: 1. The patient is capable of reading English at the sixth grade level. 2. The patient is motivated and capable to actively participate in selfcare activities. 3. Learning is related to an immediate need/deficit. 4. The patient is diagnosed with gestational diabetes mellitus. Definition of Terms The following terms have been defined for this study: 1 The patient is one who is in need of instructions in order to effectively cope with a disease process (Orr, 1990). 2 The education process is a systematic, sequentially planned 7 course of action that includes two operations: teaching and learning (Bastable, 1997; Boyd, 1992). 3. Teaching is the deliberate intervention that involves planning and implementation to achieve identified learner outcomes (Bastable, 1997; Boyd, 1992). 4. Learning is a change in behavior, knowledge, skill, or attitude as a result of exposure to an environmental stimulus (Bastable, 1997; Boyd, 1992). 5. Patient education is a process of assisting a patient to learn healthrelated behaviors that can be incorporated into self-care activities with the purpose of achieving optimal health and independence in self-care (Bastable, 1997; Boyd, 1992; Orem, 1995). 6. Patient education materials are instruction sheets, pamphlets, brochures, and booklets commonly used in health care settings as a means of providing written information to patients (Bastable, 1997; Bernier & Yasko, 1991; Boyd, 1992; Hainsworth, 1997). 7. Gestational diabetes mellitus is a glucose intolerance of variable severity with onset or first recognition during pregnancy (Appendix A) (ADA, 1998; Ryan, 1998). 8. Glucose intolerance is an abnormal metabolism of glucose, a simple carbohydrate, that occurs when the pancreas produces an inadequate amount of insulin or there is insulin resistance at the cellular level 8 (ADA, 1998, Ryan, 1998). 9. Lifestyle modification is the change in one's behavior as the result of an identified health care deficit. Some examples of behavioral changes that affect health in a positive manner are as follows: (a) a calorie restricted diet, (b) weight control, (c) regular exercise program, (d) smoking cessation, and (e) limited alcohol intake (ADA, 1998; Ryan, 1998). Summary In today’s health care arena there is a major emphasis on patient education (Bastable, 1997; Boyd, 1992; Gibson & Kapp, 1994). The patient is expected to be an active participant in self-care activities (Boyd, 1992; Orem, 1995). PEMS are vehicles whereby oral instructions can be clarified and reinforced when the nurse practitioner is not available (Bernier & Yasko, 1991; Boyd, 1992; Gibson & Kapp, 1994). Even though there are many types of commercially prepared PEMs, the nurse practitioner may prefer to self-compose instructional materials (Bernier & Yasko, 1991; Boyd, 1992). Illness is an educational opportunity (Orr,1990). GDM is a medical condition that affords an opportunity to educate the patient so that a tight glycemic control can be achieved in order to insure optimal maternal health and fetal/neonatal well being (ADA, 1998, Reeder et al., 1997; Ryan, 1998). Dorothea E. Orem’s (1995) Self-care Deficit Theory of Nursing provided the theoretical framework for this scholarly project. Assumptions and definition of terms pertinent to this project have been provided. 9 Chapter 2 Review of the Literature The purpose of this scholarly project was to construct a patient education pamphlet. This patient education pamphlet will be utilized in a hospital-based diabetes education center in northwestern Pennsylvania as a supplement to oral instructions given to women diagnosed with gestational diabetes mellitus (GDM). The pamphlet was written at a sixth grade reading level, determined by the McLaughlin (1969) SMOG formula (Appendix B). This chapter provides a review of the literature concerning the definition, pathogenesis, detection, diagnosis, and management of GDM. In addition, maternal and fetal complications and prognostic considerations of GDM are addressed. Next, the process of education is discussed. Finally, this literature review focuses on the construction of printed education materials (PEMs) using the Evaluating Printed Education Materials (EPEM) model developed by Bernier and Yasko (1991). Gestational Diabetes Mellitus Approximately 4% of all pregnancies are complicated by GDM, resulting in 135,000 or more cases annually in US (ADA, 1998; Ryan, 1998). The prevalence could range from 1%to 14% of all pregnancies depending on the population studied and the diagnostic tests employed (Engelgau, Herman, Smith, German, & Aubert, 1995; Kjos et al., 1995; Solomon et al., 1997). In a study by Engelgau et al. (1995), a multi-variant analysis of data 10 was performed with the findings and revealed that the incidence of GDM was higher in African-Americans, Hispanics, Asians, and Native Americans, especially those residing in the southwest. Conclusions of this study indicated that there is a higher incidence of GDM than previously believed, and that more frequent testing is probably responsible for this increase in the diagnosis of GDM. Classification. GDM is defined as glucose intolerance of variable severity with onset or first recognition during pregnancy (Appendix A) (ADA, 1998; Moses, 1996; Landon & Gabbe, 1995; Stanley, 1996). The American College of Obstetricians and Gynecologists ([AGOG], 1986) accepts the White diabetes classification system that divides gestational diabetes mellitus into class A-1 and A-2 based on fasting and post prandial blood glucose levels (Appendix C). Pathogenesis. As a result of hormonal changes that occur during pregnancy, pregnancy is considered a diabetogenic state (Buchanan, 1997). A diabetogenic state is one in which there are progressive metabolic changes occurring that lead to increasing insulin resistance, a compensatory hyperinsulinism, and accelerating glucose intolerance that could cause gestational diabetes mellitus (Buchanan, 1997; Reeder et al., 1997). Buchanan (1997) wrote that pregnancy can be viewed as a stress test for the pancreatic beta cells. GDM occurs when the beta cells of a woman’s pancreas are stressed by this diabetogenic state and consequently cannot 11 adequately meet the increased demands for endogenous insulin (Buchanan, 1996; Landon & Gabbe, 1995; Ryan, 1998). During the first trimester of pregnancy, maternal insulin needs are decreased due to low levels of the insulin antagonist, human placental lactogen (Reeder et al, 1997; Stanley, 1996). This insulin antagonist is produced by the placenta and promotes lipolysis, the break down of fats. This lipolysis accounts for the increased amount of circulating fatty acids needed for maternal metabolic use while glucose, a simple carbohydrate and one of the most important fuels for fetal growth, is spared for fetal use. There are physiologic changes occuring in the kidneys during the first trimester of pregnancy that lead to a decreased renal threshold resulting in the excretion of glucose and ketones (Landon & Gabbe, 1995; Reeder et al., 1997). This may result in glycosuria and ketonuria. The physiologic changes that occur in the kidneys, the potential decreased nutritional intake due to anorexia or loss of appetite and vomiting, and the increased transfer of glucose to the fetus may cause the diabetic mother to experience hypoglycemia (Landon & Gabbe, 1995; Reeder et al., 1997); Hormonal changes that occur during the early stages of pregnancy, which include rising levels of estrogen and progesterone hormones, influence a woman's metabolic state by stimulating the beta cells in the pancreas to increase insulin production and secretion (Reeder et al., 1997). This increased insulin production, associated with decreased insulin 12 sensitivity at the cellular level, results in the liver mobilizing hepatic stores of glycogen (Landon & Gabbe, 1995). As the pregnancy progresses, maternal hyperinsulinism continues (Reeder et al., 1997). During the second and third trimesters of pregnancy, rising levels of several hormones: human placental lactogen, estrogen, progesterone, cortisol, prolactin, and insulinase, an enzyme that accelerates insulin degradation, accelerate the increased insulin resistance (Reeder et al., 1997). This is a glucose-sparing mechanism that allows for an increased blood level of glucose or hyperglycemia to provide for fetal growth (Reeder et al., 1997). During this time, maternal insulin requirements increase dramatically. Persistent elevations of glucose and amino acids may stimulate the fetal pancreas which results in beta cell hyperplasia and fetal hyperinsulinism (Reeder et al., 1997). Fetal glucose levels are normally maintained within narrow limits because the maternal glucose level is well regulated in a healthy, normoglycemic pregnancy state (Landon & Gabbe, 1995; Stanley, 1996). However, if a pregnant patient has a borderline pancreatic reserve, the endogenous insulin may be inadequate to overcome the effect of the placental hormones, and gestational diabetes mellitus is manifested (Landon & Gabbe, 1995; Stanley, 1996). Detection. The risk factors for GDM (Appendix D) are obesity, family history of diabetes mellitus. weight gain during pregnancy of more than 25 13 pounds, previous history of GDM or macrosomia, advanced maternal age, multipanty, unexplained pregnancy wastage, presence of hydramnios, previous newborn with congenital anomaly, hypertension, history of glucosuria, and being a member of an ethnic group with high prevalence of diabetes mellitus (ADA, 1998; Naylor, Phil, Sermer, Chen, & Farine, 1997; Reeder et al, 1997; Solomon et al., 1997). Excess risks for gestational diabetes and impaired glucose intolerance have been documented In ethnic groups such as African-American, Hispanic- and Latino-Americans, and Native-American women, as well as women from the Indian subcontinent and the Middle East (Homko, 1998). Until 1997, the ADA recommended that all pregnant women be routinely screened for GDM. If all risk factors are absent, the likelihood of GDM is so low that it may not be economical to do universal screening (ADA, 1998; Homko, 1998; Ryan, 1998). The new and current recommendation is that women between the 24th and 28th weeks gestation be screened only if they have one or more risk factors. Low risk women who do not need to be screened were identified as women younger than 25 years, of normal body weight, who do not have a first-degree relative with diabetes, and are not a member of a high risk ethnic group (ADA, 1998; Bashoff, Johnson, Jovanovic, LaRosa, & O’Brien, 1998; Genuth, Palmer, Zimmerman, & Glass, 1998). Solomon et al. (1997) wrote that there may be justification for 14 universal screening because approximately 3% of women with GDM have no identifiable risk factors. Several private practices of obstetricians and gynecologists in northwestern Pennsylvania continue to do universal screening between the 24th and 28th gestational weeks (P. Duda, H. Jackson, S. Patrick, personal communication, November 2, 1998). Diagnosis. The oral glucose tolerance test (OGTT) is specifically recommended for use in pregnant women in order to screen for and to make the diagnosis of GDM (ADA, 1998; Carpenter & Coustan, 1982). Screening and diagnosis of GDM is a two step approach: screening test and diagnostic test (ADA, 1998; Carpenter & Coustan, 1982). The screening test is a nonfasting 50 g oral glucose challenge test followed by a venous plasma glucose measurement 1 hour later (ADA, 1998). If a venous plasma glucose value of 140 mg/dL or greater is found on the screening test then a full diagnostic 100 g 3-hour OGTT is performed in the fasting state following 3 days of an unrestricted diet of 150 g or more of carbohydrate per day (ADA, 1998; Landon & Gabbe, 1995). A fasting venous glucose is drawn and 100 g of glucose is administered orally. A venous plasma glucose is drawn at 1,2, and 3 hours following the ingestion of the glucose (ADA, 1998). The diagnosis of GDM is made, after the 100 g 3-hour OGTT, when two out of four venous plasma glucose levels equal or exceed the levels listed in Appendix A (ADA, 1998). A study of 514 patients at the University of Miami/Jackson Memorial 15 Hospital concluded that a 1 -hour glucose screen value greater than 185 mg/dL was sufficient to diagnosis GDM without the inconvenience of the 3hour OGTT (Landy, Gomez-Marin, & O’Sullivan, 1996). Coustan et al. (1989) collected demographic and historical data on 6214 pregnant women representing a population of universally screened individuals and found a 95% probability of GDM in women with glucose results of 183 mg/dL or higher on the 1-hour glucose screening test. They recommended that the diagnosis of GDM be made using this upper limit. A second testing of women with an initial negative glucose tolerance test is recommended when the patient is over 33 years, has a first-degree relative with diabetes, and/or weighs more than 120% of ideal body weight (Bashoff et al., 1998; Naylor et al., 1997). Management. The management of GDM varies across the country but the common goal is to reduce the perinatal morbidity and mortality associated with GDM through the control of maternal plasma glucose levels (Fagan, King, & Erick, 1995). Medical nutrition therapy (MNT) is considered the cornerstone of treatment (Fagan et al., 1995; Gunderson, 1997). MNT should provide for adequate calories and nutrients to meet the demands of pregnancy and maintain maternal plasma glucose levels consistent with goals established (ADA, 1998). The goals of MNT are to keep maternal fasting plasma glucose levels below 95 mg/dl and 2-hour postprandial plasma glucose levels below 120 mg/dl (ADA, 1998; Homko, Sivan, & 16 Reece, 1998). Nutritional counseling should be done by a registered dietician, a licensed specialist in nutrition (Gunderson, 1997; Reeder et al., 1997). Women with GDM are started on approximately 2000 to 2500 calories daily excluding simple carbohydrates (ADA, 1998). Simple carbohydrates such as those found in candy, soft drinks and sweetened desserts should be avoided (ADA, 1998; Ryan, 1998). Limitation of total amount of carbohydrate, careful distribution of carbohydrate at several meals, and snacks throughout the day is the strategy used to prevent hyperglycemia, meet metabolic demands, and prevent starvation ketosis, an accumulation of ketones in the blood as a result of fat lipolysis (ADA, 1998; Gunderson, 1997; Ryan, 1998). Fagan et al. (1995) emphasized that until the optimal treatment of GDM is defined, dietary recommendations must be individualized to each patient. According to Gunderson (1997), GDM follows a pathological continuum that results in worsening glucose tolerance as gestation progresses; therefore, during the third trimester of pregnancy, MNT may need to be more restrictive than during the second trimester of pregnancy. Self-blood glucose monitoring (SBGM) is the second most important intervention in helping to maintain tight glycemic control for the GDM patient (ADA, 1998; Gunderson, 1997; Landon S Gabbe, 1995; Ryan, 1998). If MNT does not consistently maintain a fasting plasma glucose under 95 mg/dL and 2-hour postprandial plasma glucose level under 120 mg/dL on two or more 17 occasions within a 1 to 2 week interval, insulin therapy should be initiated (ADA, 1998; Homko, 1998). Repetitive fasting self-blood glucose levels above 95 mg/dL and 2-hour postprandial plasma glucose levels above 120 mg/dL mandate insulin therapy in order to prevent the fetal complication of macrosomia, a baby whose birth weight is greater than 9 pounds (ADA, 1998; Homko, 1998; Landon & Gabbe, 1995; Ryan, 1998). Coustan et al. (1989) recommended insulin therapy as soon as GDM is diagnosed. Human insulin is advocated to minimize the transplacental transport of anti-insulin antibodies and the risk of future allergic reactions to insulin in women who develop diabetes after pregnancy (Homko, 1998). Oral hypoglycemic agents are contraindicated during pregnancy because of their teratogenic effects on the fetus (ADA, 1998; Conrad, 1988; Ryan, 1998). One prospective study used 334 GDM patients who were taught to achieve euglycemia using a memory-based reflectance meter. These 334 subjects were matched for control of obesity, race, and parity. The results of this study suggested that a relationship exists between the level of glycemic control and neonatal weight and optimal pregnancy outcome in GDM (Langer et al., 1994). Fetal pancreatic beta cells are thought to be highly sensitive to maternal metabolism thus suggesting the need for tight glycemic control throughout pregnancy (Keller et al., 1990; Langer et al. 1994). The Fourth International Workshop on GDM advocated the use of reflectance meters that store results electronically for review by the health care provider 18 (Homko, 1998). The treatment regimen for GDM women requiring insulin therapy involves fetal ultrasonographic examinations beginning at 32 weeks gestation (Gunderson, 1997; Keller et al., 1990; Landon & Gabbe, 1995). These examinations include abdominal circumference (AC) and biparietal diameter (BPD) measurements (Gunderson, 1997; Keller et al., 1990; Landon & Gabbe, 1995). All women should be taught to perform fetal movement counting for at least the last 8 to 10 weeks of pregnancy (Homko, 1998). Weekly non-stress tests starting at 32 weeks gestation for women requiring insulin therapy, and at or near term for women controlled by MNT, are performed to confirm the well-being of the fetus (Homko, 1998). Most women with GDM can complete their pregnancy and begin labor spontaneously unless a complication develops (ADA, 1998; Homko, 1998; Landon & Gabbe, 1995). In the event of a complication, the physician may elect to do a cesarean delivery, a delivery of the fetus by means of a surgical incision into the uterus (Knuppel & Drukker, 1993). According to the ADA (1998), women with an active lifestyle should be encouraged to continue their usual activities. Pregnancy is not the optimun time to begin a strenuous exercise program; however, low to moderate intensity or aerobic exercise is thought to be safe (Reeder et al., 1997). During exercise there is an increased affinity for the binding of glucose: peripheral insulin sensitivity increases and maternal blood glucose 19 concentration is lowered (Homko, 1998; Zinman, 1997). Maternal complications. Maternal complications of GDM include an increased rate or cesarean delivery (Knuppel & Drukker, 1993). Other potential complications are pregnancy-induced hypertension (blood pressure of 140/90 mm Hg or higher) and proteinuria (protein in the urine above 0.5gm/24hr) (ADA, 1998; Ryan 1998; Reeder et al., 1997). E?.tel/neontal complications. Two significant complications associated with GDM are macrosomia and neonatal hypoglycemia (Ryan, 1998). The major determinants of macrosomia are maternal weight, maternal weight gain, parity, gestational age, and fluctuating and elevated maternal plasma glucose levels (Ryan, 1998). Rey, Monier, & Burns (1996) reported that macrosomia occurs in 20% of GDM pregnancies that are undiagnosed and untreated until late in pregnancy. Although macrosomia is linked to GDM, maternal obesity is a prominent and inseparable cofactor (Helton, Arndt, Kebede, & King, 1997). Neonatal hypoglycemia is related to fetal pancreatic hyperplasia (Ryan, 1998). Although in the neonate normal plasma glucose level can drop as low as 30 mg/dL, some neonates of mothers with GDM can drop below this level, and the neonate is susceptible to serious neurologic long-term consequences (Ryan, 1998). Other neonatal complications that are associated with GDM are: (a) hyperbilirubinemia (elevation of bilirubin in the blood), (b) respiratory distress syndrome (severe impairment of respiratory function), (c) shoulder dystocia causing difficult passage through 20 the birth canal, (d) birth trauma, (e) hypocalcemia (low level of calcium in blood), and (f) polycythemia (increased number of red blood cells) (Reeder et al.,1997; Ryan, 1998), The likelihood of stillbirth in a woman with appropriately managed GDM is no different than for the general population of pregnant women (Reeder et al., 1997). Prognostic considerations. The primary maternal considerations are that gestational diabetes mellitus will recur and that the patient will develop type 2 diabetes in the future (Buchanan, 1997). According to Reeder et al. (1997), approximately 60% of women with GDM will eventually develop type 2 diabetes. Buchanan (1997) indicated that the most useful clinical predictors that a woman will develop overt diabetes is the severity of maternal hyperglycemia during pregnancy, the gestational age at which GDM developed, and the oral glucose tolerance test result 1 to 4 months after delivery. In a study conducted by Greenberg, Moore, and Murphy (1995) with 238 patients, there was no single maternal, intrapartum, or neonatal variable that predicted postpartum glucose intolerance in all cases. However, their study concluded that a patient requiring at least 100 U/day of insulin has a 100% incidence of postpartum glucose intolerance. Conrad (1988) believed that women with GDM have a 30% to 40% chance of developing diabetes mellitus within 1 to 25 years while Basholf et al. (1998) and Reeder et al. (1997) estimated that as high as 60% will develop type 2 diabetes. The Fourth International Workshop Conference on GDM 21 recommended long-term, annual follow-up for women with a history of GDM (Homko, 1998). Women with GDM should be evaluated in the postpartum period using the 2-hour OGTT with a 75 g glucose load (ADA , 1998; Bashoff et al.,1998; Conrad, 1988; Homko, 1998; Reeder et al., 1997; Ryan, 1998). Counseling should be provided for women with a history of GDM about the use of lifestyle changes such as weight control and regular exercise to reduce the risk of developing type 2 diabetes (ADA, 1998; Homko, 1998). Scientists, from the Northwestern School of Medicine in Illinois, conducted a study of 90 children born to mothers with GDM and 80 children born to those who did not have GDM (Kahn, 1995). This study found that the children born of mothers with GDM had higher mean arterial pressure, higher systolic and diastolic pressure, higher body mass index, and higher insulin levels. Education Process When an individual becomes dependent upon the health care system for diagnosis, treatment, or rehabilitation she/he is exposed to health information that is focused upon the disease or condition and its implications (Boyd, 1992). Disease management techniques and other health promoting strategies can also be included in the patient education (Orr, 1990). Definition of education process. The education process according to iquential planned course of action that Bastable (1997) is a systematic, se' consists of two interdependent operations. teaching and learning. Teaching 22 is a deliberate intervention that involves assessing the learner’s deficits, creating the teaching plan, and implementing instructional activities using aids such as PEMs to reach established learner outcomes (Bastable, 1997). Learning is a change in behavior, knowledge, skill, or attitude that can occur at any time as a result of the teaching operation (Bastable, 1997). Bernier and Yasko (1991) related that a great deal of health education is done using oral communication and one-to-one teaching with PEMs given to the learner to reinforce teaching. Boyd (1987) wrote that people forget about one-half of all oral instructions within 5 minutes of receiving them, and lay persons often do not understand medical jargon. Steps of the education process. The steps of the educational process and the steps of the nursing process run parallel to each other but with a slightly different slant (Appendix E) (Bastable, 1997). A paradigm to assist the nurse practitioner in organizing and carrying out the education process is the ASSURE model (Rega, 1993). The acronym stands for (a) analyze the learner’s capabilities and deficits; (b) state objectives, both teachers and learner’s; (c) select instructional methods and tools; (d) use teaching materials (e) require learner performance, and (f) evaluate/revise the teaching and teaming process (Bastable, 1997; Rega, 1993). Goal of the education process. Patient education occurs when the nurse practitioner assists individuals in learning health-related behaviors in order to incorporate them into everyday life with the goal of achieving optimal 23 health and independence in self-care (Bastable, 1997; Orem,1995). The ultimate outcome of patient education in keeping with ideals of self-care is to transfer the responsibility for learning from the nurse practitioner to the patient (Bastable, 1997). Patient education. Patient education is considered an essential component of quality health care (Gibson & Kapp,1994). With the increasing emphasis on disease prevention, people are coming to understand that knowledge about illness and medical care is not the exclusive property of the health care professionals (Close, 1988). It is the responsibility of the primary care practitioner to provide patients with the necessary information and education so that they can become active participants in self-care (Close, 1988; Doak & Doak, 1980; Gibson & Kapp, 1994). Patient education provides the primary care practitioner and the patient an opportunity to form a partnership for improved health outcomes. (Gibson & Kapp, 1994). Printed Education Materials (PEMs) Bernier & Yasko (1991) described PEMs as the most economical and effective instructional mediums available. PEMs help Increase understanding of health problems and self-care regimens and are Important lor quality patient care (Bernier S Yasko, 1991). Patient education using PEMs has been an integral part of care for orthopedic patients, diabetic patients, gynecological patients, cardiovascular patients, and cancer patients (Bernier, 1993; Mahon, 1996). 24 Research support for PEMs In a randomized controlled trial, a package of educational materials was given to one group of 108 patients identified by their primary care provider as being depressed (Robinson et al., 1997). One week later these patients were surveyed by telephone and reported that the written materials were somewhat helpful: medication booklet 81%, behavioral health booklet 82%, and video 69%. This study concluded that educational materials may play a significant role in improving depression treatment outcomes (Robinson et al., 1997). A study by Rice and Johnson (1984) used a sample of 130 presurgical cholecystectomy and herniorrhaphy patients. One experimental group was given preadmission self-instruction booklets on specific exercise techniques, and the other experimental group was given booklets that had no specific instructions. The controlled group was given no instructions and no booklets. The two experimental groups required less post-surgery teaching time than did the controlled group that received no preadmission instruction (Rice & Johnson, 1984). Rice & Johnson (1984) also wrote that providing patients with booklets for self-care at home may allow them to have an increased sense of self-control. In a literature review to examine the role of nurses as patient teachers, Close (1988) expressed that giving information to patients and educating them will enable them to cope better with the stress of illness, reduce complications, and accelerate recovery. Rationale for PEMs. PEMs are often considered to be the backbone 25 of a comprehensive patient education program. They provide the nurse practitioner with ready access to information in a consistent and presentable manner, reinforce oral instruction, enhance the learning process, and provide a resource for the patient to find answers to questions when the nurse practitioner is not available (Farrell-Miller & Gentry, 1989; Hainsworth, 1997). PEMs have the following advantages: (a) consistency of message, (b) flexibility of delivery, (c) portability and usability, (d) economical to produce and update, and (e) permanence of information (Bernier, 1993). Various instructional tools can be employed to facilitate learning: written materials, displays, graphics, models, games, demonstrations, overhead transparencies, slides, cassettes, videos, television, and computer- assisted instruction (Boyd, 1992; Krishna, Balas, Spencer, Griffin & Boren, 1997). These teaching tools are intended to be used as adjuncts to teaching, not a replacement (Pohl, 1981). Pohl (1981) pointed out that learners’ concepts can be more fully developed using PEMs and learning is improved. Hainsworth (1997) emphasized that having a brochure that can be reread at the patient’s convenience and pace can reinforce earlier learning and minimize confusion involving oral instructions. Rationale for self-composing^EMs. The perfect pamphlet is rare, perhaps nonexistent; therefore, the nurse practitioner may decide to self­ compose written materials using the same criteria that should be availabie in 26 commercial prepared materials: accuracy, clarity, appropriateness, reader appeal, and appropriate reading level (Gibson & Kapp, 1994) Other reasons for self-composing PEMs are cost savings and the need to tailor the content in order to reinforce specific oral instructions that will enhance the efficacy of instructions and provide opportunities to clarify difficult concepts (Bernier & Yasko, 1991; Hainsworth, 1997). Readability of PEMs. Mathis (1989) reported that most patients read on or below eighth grade level. Consequently, a primary concern, in patient education, is the readability of PEMs to insure that the patients can read and understand the information (Bermier& Yasko, 1991; Hainsworth, 1997; Weinrich & Boyd, 1992). The readability of PEMs is recommended at or below seventh grade level, and medical jargon should be avoided unless fully explained (Gibson & Kapp, 1994; Hainsworth, 1997; Weinrich & Boyd, 1992). The patient education center at one northwestern Pennsylvania medical center selects PEMs that are at or below the sixth grade reading level (B. Magee, personal communication, November 17, 1998). Boyd (1992) and Mathis (1989) recommended that the nurse practitioner determine the average grade in school completed by the targeted population and write the patient education materials two to four grades below that level. There are a number of available formulas including Fog, SMOG, Flesch, and Fry that the nurse practitioner can employ to determine the readability of patient educational materials (Bernier & Yasko, 1991; Hainsworth, 1997; 27 McLaughlin, 1969), The McLaughlin SMOG formula was used in this project (Appendix B). GMJdelinejLfo^^ Of utmost concern, in designing or selecting PEMs, is the content accuracy and the readability level (Mathis, 1989). The following are guidelines for decreasing the reading level and increasing the ease of reading: (a) keep sentences short, (b) express one idea per sentence, (c) avoid complex grammatical structures, (d) write in conversational style using the active voice, (e) write using the second person, (f) use one or two syllable words, (g) limit the number of three or more syllable words, (h) limit column width to less than 60 to 70 letters, (i) present the most important information first, (j) use adequate spacing, and (k) avoid use of all capital letters (Farrell-Miller et al., 1989). Hanafin (1993) suggested employing the KISS formula when self-composing PEMs: Keep It Simple and Smart. Bernier (1993) suggested that if there is a lot of information to be given to the patient, it is better to construct several pamphlets rather than trying to put a lot of information into one pamphlet. Model for designing and evaluating PEMs. The Evaluating Printed Education Materials (EPEM) model is a standard that can be used to guide the development and evaluation of PEMs (Bernier 8 Yasko, 1991). This model has five phases that parallel the nursing process, the education process, and the ASSURE model (Appendix E). Just as the nursing process follows a circular path from assessment to evaluation, the phases of the 28 EPEM model follow a circular path: predesign, design, pilot test, implementation/distribution, and evaluation (Bernier & Yasko, 1991). Summary This literature review has discussed gestational diabetes mellitus. Implications that GDM has for the mother and the fetus/neonate have been presented. The prognostic considerations for the patient with GDM have also been detailed. The education process and the Assure model were described. Finally, the development and evaluation of PEMs using the EPEM model developed by Bernier and Yasko (1991) was presented. 29 Chapter 3 Methodology The purpose of this si■cholarly project was to construct a patient education pamphlet that can be used to supplement specific oral instructions delivered to women diagnosed with gestational diabetes mellitus (GDM). This chapter discusses the development of the pamphlet using as a standard the Evaluating Printed Education Materials (EPEM) model developed by Bernier and Yasko (1991). Model for Evaluating Printed Education Materials Bernier and Yasko’s EPEM model is composed of five phases: predesign, design, pilot test, implementation/distribution, and evaluation. The phases of the EPEM model parallel the steps of the nursing process, education process, and the Assure model (Appendix E). Predesiqn phase. During the predesign phase, the need for a pamphlet on GDM that would include information about prognostic considerations was determined through discussion with one of the diabetes nurse educators in a hospital-based diabetes educational center in northwestern Pennsylvania. The purpose of the pamphlet is to supplement specific oral instructions delivered by diabetes nurse educators to patients who have been diagnosed with GDM. The pamphlet reinforces oral instructions furnished to GDM patients seen in the diabetes education center. The content of the pamphlet Includes: the etiology of GDM, risk 30 factors for developing GDM, screening tests to detect GDM, implications GDM has for the mother and the baby, maternal and fetal complications associated with GDM, management of GDM, and prognostic considerations of GDM. Design phase. During the design phase, the most essential information was selected based on a review of the literature. As the content was organized, information points were presented in a logical sequence so that the flow of the pamphlet was smooth and readability was enhanced. Careful attention was given to expressing one idea per sentence, using one or two syllable words, avoiding medical jargon, and keeping sentences short and simple. A personal, conversational writing style was used in the pamphlet. Questions were used as headings to encourage active learning. The readability of the pamphlet was determined at the sixth grade level using McLaughlin’s SMOG formula (Appendix B). Pilot test phase. The pilot test phase of this project involved testing the first draft of the pamphlet with a random sample group of GDM patients and two health professionals at a hospital-based diabetes education center in northwestern Pennsylvania. The health professionals were asked to provide feedback on the clarity and accuracy of the content. The pamphlet ire for evaluation (Appendix G), and a cover letter (Appendix H), questionnaire accompanying the questionnaire (Appendix F) were distributed to five GDM patients. The patients were asked to read the pamphlet and to complete the 31 questionnaire. Feedback from the two heaith care professionals and the four GDM patients who returned the questionnai re was used to evaluate and revise the first draft of the pamphlet. The diabetes nurse educator stated that the purpose of the pamphlet was clear and that the content was accurate. The educator did suggest including that GDM usually goes away within 48-72 hours after delivery of the baby, and only if diabetes continues after the delivery, does the mother need to monitor more frequently her blood sugars while breast feeding. The suggestion that the dietician offered was that the word “temporary” be added to clarify that the newborn’s low blood sugar level is a temporary state rather than a permanent state. These revisions were made to the pamphlet. All four GDM patients felt that the purpose of the pamphlet was clear and that the information was helpful. The personal style in which the pamphlet was written was clear and understandable to all four patients. They all stated that the questions used in the headings were helpful. None of the four patients identified any unfamiliar words. Two patients suggested that information about the symptoms of type 2 diabetes be included in the pamphlet, and this revision was made. One patient suggested that additional information be included about the diet. Since the purpose of this pamphlet is to supplement oral instructions that are delivered to GDM patients, and a diet plan is tailored by a dietician to fit each patient's individual needs, no additional information about the diet was included in the pamphlet. 32 The comp|eted pa(ient educat.on pamphlet (Appendix H) was delivered to a hospital-based diabetes education center in northwestern Pennsylvania. The pamphlet will be included in an information packet that is distributed to all new GDM patients who are referred for diabetes education in this hospital-based diabetes education center. Evaluation phase. The final phase in the development of PEMs is the evaluation phase. The evaluation of this completed patient education pamphlet can be accomplished by asking a small number of GDM patients to participate in the evaluation phase. A similar questionnaire, used in the pilot phase, could be employed to receive verbal or written feedback. Answers to these questions can serve as a useful gauge in evaluating the quality of the pamphlet and the effectiveness of reaching desired outcomes, and for providing direction for future revisions of the pamphlet. Summary In summary, the purpose oif this scholarly project was to construct a patient education pamphlet that can be used to reinforce specific oral Instructions delivered to women who have developed gestational diabetes mellitus. The EPEM model developed by Bernier and Yasko (1991) was adopted as the standard for developing this patient education pamphlet. McLaughlin's SMOG formula was used to determine the readability of the pamphlet. 33 References American College of Obstetricians and Gynecologists (1986). Classification of diabetegjnpregnancy: Technical bulletin No. 92 Washington, DC: U.S. Government Printing Office. American Diabetes Association (1998). Gestational diabetes mellitus. Diabetes Care, 21(1), S60-S61. 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The recurrence rate of gestational diabetes in subsequent pregnancies. Diabetgs_Care, 19, 1348 Naylor, C. D. Phil, D„ Sermer, M„ Chen, E„ & Farine, C (1997). selective screening for gestational diabetes mellitus. The_NewEna!and 38 Journal of Medicine, 322, 1591-1597. Nelson, M. J. (1997) Ethical ipnai ’ cal, legal, and economic foundations of the educational process. In S. Bastable (Ed.), Nurse as educator: Principles of teaching and learning (pp. 16-30). Sundbury, MA: Jones and Bartlett. Orem, D. E. (1995). Nursing: concepts of practice (5th ed.). New York: McGraw-Hill. Orr, R. (1990). Illness as an educational opportunity. Patient Education and Counseling, 15, 47-48. Pohl, M. (1981). The teaching function of the nursing practitioner (4th ed.). Dubuque, IO: WMC Brown. Reeder, S., Martin, L, & Knoniak-Griffin, D. (1997). Maternity nursing: Family, newborn, and women's health care (18th ed.). Philadelphia: Lippincott. Rega, M. D. (1993). A model approach for patient education. Medsurg Nursing, 2, 477-479,495. Hey, E, Monier, B„ & Burns, W. (1996). Carbohydrate intolerance in pregnancy, incidence, and neonatal outcomes. Clinical InvestiqaUonai Medicine, 19, 406. Rice, V., S Johnson, J. (1984). Pre-admission, self-instruction booklets, post-admission exercise performance, and teaching time. Nursmi Research, 33, 147-150. Von Kortf.M., Bush, T„ Simon, G„ Lin. E.. Robinson, P., Katon, W 39 & Walker, E. (1997). The education of depressed nriman ^pressed primary care patients: What de patients think of interactive booklets and a video? TheJoUmalof Family Practice, 44, 562-571. Ryan, E. (1998). Pregnancy in diabetes. In J. S. Skyler(Ed.), The medical clinics of North America: Prevention and treatment of diabetes and it complications (pp.823-843). Philadelphia: W. B. Saunders. Solomon, C., Willet, W., Carey, V., Rich-Edwards, J., Hunter, D., ( Colditz, G., Stampfer, M., Speizer, F., Spiegelman, & D„ Manson, J. (1997). A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA, 278, 1078-1083. Stanley, A (1996). Multiple pregnancies and deliveries. St. Louis: Mosby-Year Book. United States Department of Health and Human Services (1990). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office. Weinrich, S. P, & Boyd, M. D. (1992). Teaching tools for the elderly: Evaluating for success. Journ^tGeron^^ 15’20' Zinman, B. (1997). Guidelines for the management of type 2 diabetes. In J. M. Olefsky (Ed.), Cumentafiproache^ diabetes (pp.19-22). San Diego: University of California. 40 1 Appendixes 41 Appendix A Oral Glucose Tolerance Test Results for Screening and Diagnosis of GDM Plasma Glucose mg/dL Time 50-gram screening OGTT OGTT >105 Fasting 1-hour 100-gram diagnostic >140 >190 2-hour >165 3-hour >145 Diagnosis of gestational diabetes mellitus. After 100 gram oral glucose load, diagnosis of GDM may be made if two venous plasma glucose values equal or exceed the above values (American Diabetes Association, 1998). 42 Appendix B Me Laughlin Smog Formula The SMOG formula was originally developed by G. Harry Me Laughlin in 1969. It will predict the grade-level difficulty of written material within 1.5 grades in 68% of the written passages tested. It is simple to use and faster than most other measures. The procedure is presented below: Instructions 1 ■ You will need 30 sentences. Count out 10 consecutive sentences near the beginning, 10 consecutive from the middle, and 10 from the end. For this purpose, a sentence is any string of words punctuated by a period (.), and exclamation point (!) or a question mark(?). 2. From the entire 30 sentences, count the words containing three or more syllables, including repetitions. 3. Obtain the grade level from Table on the next page, or calculate the grade level as follows: Determine the nearest perfect square root of the total number of words of three or more syllables and then add a constant of 3 to the square root to obtain the grade level Example. Total number of multi-syllabic (3 or more syllables) words....67 Nearest perfect square Square root Add constant 3 43 Grade 11 is the grade level. Smog Conversion Table Word Count Grade Level 0-2 4 3-6 5 7-12 6 13-20 7 21-30 8 31-42 9 43-56 10 57-72 11 73-90 12 91-110 13 111-132 14 133-156 15 157-182 16 183-210 17 211-240 18 McLaughlin, G. H. (1969). SMOG-grading: A new readability formula. ournal of Reading, 12. 639-645. 44 Appendix C Classification of Gestational Diabetes Mellitus Class A-1 A-2 Fasting Plasma Glucose Less than 105 mg/dL Postprandial Plasma Glucose and Less than 120 mg/dL More than 105 mg/dL and/or More than 120 mg/dL Therapy Diet only Insulin From the American College of Obstetricians and Gynecologists (1986). Classification of diabetes in pregnancy, Technical Bulletin No. 92. Washington, DC: U.S. Printing office. 45 Appendix D Risk Factors for Developing GDM * Obesity-weight > 200 lb * Positive family history of diabetes mellitus Previous history of GDM or macrosomia (newborn, 9 lbs or more) * Advanced maternal age Glucosuria on two successive occasions * Excessive weight gain > 25 pounds during pregnancy * Unexplained pregnancy wastage (spontaneous abortions, stillbirths) * Multiparity * Presence of hydramnios Previous newborn with a congenital anomaly * Hypertension Member of high risk ethnic group: Hispanic- and Latino-Americans African Americans Native American Indians Asian Indians Risk factors for developing GDM- From Reeder, S., Martin, L, a Knoniak-Griffin D. (1997), MalsmiS^^ health care (18» ad. >, Philadelphia: Lippincott, gnd ”men's 46 Appendix E Nursing Process Appraise physical and ASSURE Model -A- ASSESSMENT Education Process Ascertain learning needs psychosocial readiness to learn, and needs learning styles Develop care plan based -S- PLANNING Develop teaching plan to on mutual goal setting to -S- meet desired outcomes meet individual needs. Carry out nursing care - IMPLEMENTATION- Perform the act of teach interventions using -U- ing specific instructional standard procedures -R- Determine physical and -E- EVALUATION methods and tools Evaluate behavioral changes (knowledge, psychosocial outcomes attitudes, and skills. The education process, the ASSURE model, and the nursing process parallel each other. The ASSURE model: A= analyze the learner’s capabilities and deficits, S state the objectives, both the teacher’s and the learner's, S= select instructional methods and tools, U= use teaching materials, R= require learner performance, E= evaluate/revise the teaching and learning plan (Bastable, 1997, Rega, 1993). 47 Appendix F Cover Letter Accompanying Pamphlet and Questionnaire Dear Patient, I am a graduate student at Edinboro University of Pennsylvania. I am working on creating a pamphlet to give to women who develop Gestational Diabetes Mellitus. Creating this pamphlet is part of the requirements for me to graduate. I would like to request your help in revising this draft of the pamphlet. Would you take a few moments of your valuable time and read the entire pamphlet? After you have read the pamphlet, would you complete the questionnaire attached to the front of the pamphlet? I thank you in advance for your fine cooperation in reading the pamphlet and completing the questionnaire. Sincerely yours, Lucille K. Steele Morrison EUP Graduate student 48 Appendix G Questionnaire For Evaluation/Revise Phase 1. Is the purpose of the pamphlet clear to you? 2. Is the information new and helpful? 3. Is the pamphlet written in a style that is clear and understandable? 4. Are the questions in the headings helpful? 5. Are there any unfamiliar words? 6. Is there any other information that you think should be included in the pamphlet? 49 A Guide to Understanding Gestational Diabetes 50 What is gestational diabetes mellites? Your body gets sugar from the food you eat. This sugar goes into your blood and then into the cells of your body. ou then make energy from this sugar in your body’s cells. Insulin is a hormone made by your body’s pancreas. Insulin helps sugar leave the blood and go into your body’s cells. When this happens the way it should, the level of sugar in your blood goes down. Your body’s cells can then make all the energy you need to do things. When you have diabetes, your body does not make as much insulin as it needs. The sugar cannot leave your blood like it should. Instead, the sugar stays in your blood, and the level gets higher and higher. You also cannot make enough energy in your body’s cells. 51 Gestational diabetes mellitus (GDM) is a kind of diabetes that you can only develop when you are going to have a baby. (Gestation is another word for pregnancy.) GDM develops between the 24th and 28th weeks of pregnancy. Who can If you are over 30 years old, are overweight, have a get GDM? family history of diabetes, or have a previous history of GDM or delivery of a baby over 9 pounds, you have a greater chance of developing GDM. Any pregnant woman can get GDM, but it is more common in: ♦ Hispanic Americans ♦ African Americans Native Americans ♦ Middle Easterners 52 How will I know if I have GDM? Y ou may not feel any differently if you have GDM, and that is why all pregnant women should be checked. A blood test is the only way to be sure if you have it. ♦ If you have had GDM before, your doctor may do the blood test at your first visit. ♦ If you have never had GDM before, your doctor may do the blood test between the 24th and 28th week of your pregnancy. How is the test done? When you are tested for GDM, you will be asked to drink a sugary drink. You will then have a blood test one hour later. If the result of the test is above a certain level, you will then be asked to take a three-hour test. You should do this test as soon as you can and you cannot eat before it. The results from this test will tell your doctor if you have GDM. If you end up having GDM, you will need to start treatment right away. 53 What does having GDM mean to me and my baby? When you are pregnant, everything your baby needs to grow and be healthy comes from you. Vitamins, minerals, and sugar are carried in your blood to your baby. If everything works as it should during your pregnancy, you will be able to give your baby all that it needs. When you have GDM, this process does not work as well. Instead of sugar being used to make energy, sugar stays in your blood. A high level of sugar in your blood is not healthy for you or your baby. 54 Will GDM hurt my baby? GDM will not cause your baby to have diabetes after it is bom. In fact, if you keep your blood sugar level in the normal range during your pregnancy, you have a very good chance of having a healthy baby. If you do not keep your blood sugar level in the normal range, your baby can have some problems. Large birth size When you have a higher than normal blood sugar level, a lot of the extra sugar goes to your baby. Your baby makes extra insulin to try and lower this blood sugar level, but this extra insulin and sugar causes your baby to grow very big. This makes it harder for you to give birth to your baby. Sometimes an operation called a cesarean section is needed to help deliver your baby. 55 Low blood sugar in your baby after birth If you have high blood sugar levels during your pregnancy, your baby will continue to make extra insulin. After birth, your baby will still make extra insulin even though it does not need to. This extra insulin will cause your baby’s blood sugar level to drop very low temporarily, and a low blood sugar level can hurt your baby. For several hours after delivery, your baby’s blood sugar level will be checked often. Jaundice A slight yellow skin color (jaundice) is normal in a new baby. Usually the yellow skin color goes away by itself. When you have GDM, jaundice in your baby may be more severe. Your baby might even need a special kind of light treatment to help the jaundice go away. 56 Other problems High blood sugar levels can cause your baby to be bom early, which in turn gives your baby the possibility of having breathing problems. It is rare that a life­ threatening problem develops, because now there are easy ways to check your baby before and during birth. Labor and delivery How can GDM affect Most women with GDM can have a regular vaginal ma? delivery, but you need to keep your blood sugar levels in the normal range so your baby will not grow too big. If your baby grows too large, you may need to have a cesarean delivery. Greater risk for infection With GDM, you have a greater WIWI chance of getting vaginal, bladder and PILLS kidney infections. You may have to take medicine to treat the infections. 57 High blood pressure |C When you have GDM. your blood pressure can go up. This is not healthy for you or your baby and you will need treatment to bring your blood pressure down. This could mean that you would have to stay in bed most of the time until your baby is bom. It could also mean your baby will have to be delivered early. Diabetes after your baby is born The most serious problem for you if you have GDM is that your diabetes may not go away after pregnancy. You also have a greater chance of developing type 2 diabetes when you are older. Being overweight puts you at an even higher risk of developing diabetes later in life. You should have an oral glucose tolerance test at your six-week check-up after your baby is bom to make sure that your blood sugar level has returned to normal. After that, you should have your blood sugar level checked once each year. 58 If you have GDM, you may develop it again the next time you are pregnant. Because of this, you will need to have your blood sugar level checked as soon as you know that you have become pregnant. What can I By keeping your blood sugar levels normal, you do the do to take best you can to keep yourself and your baby healthy. care There are several things you can do. of my baby and Work with your health care team myself? Before you knew you had GDM, your regular doctor cared for you. Now you may also need others to help you. The best way to get this help is from a health care team. Your health care team may include: • a doctor who treats diabetes (an endocrinologist) • a nurse who will help you learn how to control your blood sugar levels (diabetes nurse educator) • a person who can teach you about the foods you should eat (a dietician) 59 Follow your meal plan You will need to eat healthy. It is important to include all of the basic food types in your meal plan. A dietician will help you come up with a meal plan that will keep your blood sugars normal and keep your baby healthy. You should stay away from: A alcohol V caffeine V foods high in sugar, such as candy, soft drinks, and sweetened desserts Test your blood sugar You may need to test your blood sugars several times each day. You will need to do this before you eat in the morning and two hours after you eat. Your blood sugar goals are the same as in normal pregnancy. The nurse will show you how to test your blood sugar level. Ideal Blood Sugar Values Before Breakfast 2 hours after meals ....................... less than 95 mg/dL ...less than 120 mg/dL 60 You will also be asked to keep a written record of your blood sugar levels. You will need to bring this record with you whenever you go to visit your doctor. Testing your urine for ketones Your body’s cells use sugar to make energy. Sugar cannot be used if your body does not make enough insulin. When you do not make enough insulin, your body will start to break down fat to make energy. When your body uses fat to make energy, ketones are left over. Ketones in your blood may harm your baby. Ketones can also leave your body through your urine. Your body may make ketones if you go too long without eating. You should eat a snack before you go to bed at night. You should not skip meals. You should eat your meals at regular times and eat everything that is on your meal plan. 61 You will need to check your urine each morning for ketones, and record the results in a logbook. The nurse will show you how to do this. Exerciso Exercise helps you feel better and helps you control your weight. Exercise also helps keep your blood sugar levels in the normal range. Good forms of exercise are: fast walking V swimming "V stretching exercises Ask your doctor about the kinds of exercise that you should do. If you need more help If your meal plan and exercise plan does not keep your blood sugar levels in the normal range, you may have to take insulin shots. If you need to take insulin shots, you will be taught how to give yourself the shots. 62 Keeping written records T ou need to keep a written record of: V Your blood sugar test results V Your urine ketone test results V Any change in your diet "V Any change in your exercise V Any change in your insulin What tests will my doctor do? you have GDM) your doctor wil1 want t0 see y°u often. Starting around the 34th to 36th week of pregnancy, your doctor will do tests to see how well your baby is growing. Some of the tests are: • ultrasound (sonogram) - This is a safe and painless test. It checks to see how big your baby is. • baby movement counts - You will be asked to count the number of times your baby moves during a specific amount of time each day. Call your doctor at once if you think your baby’s movements have slowed down. 63 • non-stress test - This test is also painless. This is a test to find out how fast your baby’s heart is beating o every time your baby moves. After my Breast-feeding baby is It is okay for you to breast-feed your baby. Breast milk born, what is good for your baby, and it helps to keep your baby should I do? healthy. Breast-feeding can also help you with weight control. If your diabetes does not go away after your Y baby is bom and you choose to breast-feed, you will need to check your blood sugar levels more often. 7\ After your baby is born You should have a glucose tolerance test six weeks after your baby is bom. This will let you and your doctor know for sure if your diabetes is gone. In most women with GDM, the diabetes goes away within 48 hours after the baby is bom. 64 If your blood sugar level does not return to normal, you will need to see your doctor for medical care. Even if your blood sugar level returns to normal, you still need to watch your weight. You need to be careful what you eat and you still need to eat using a healthy meal plan. You also need to have a regular exercise program. You should have your blood sugar level checked every year to make sure you are not developing type 2 diabetes. What if I gat pregnant again? Once you have GDM, you are more likely to develop it again with your next pregnancy. With each future pregnancy, you should ask your doctor to test you for diabetes at your first visit. If the test is normal, then \ you should be checked again at 24th to 28th weeks of pregnancy. 65 What about my future health? About one-half of all women who have GDM will develop type 2 diabetes. It may happen right after your baby is bom or years later. It is important that you have a blood sugar test each year. You should also learn the symptoms of type 2 diabetes. You will need to watch for symptoms, such as increased thirst, hunger, frequent urination, fatigue, blurred vision, yeast infections, or numbness in your hands or feet. You should have your blood sugar tested before you get pregnant again. V You should always eat using a healthy meal plan. V You should not gain a lot of weight. V You should exercise regularly.