RELATIONSHIP BETWEEN LEVEL OF STRESS AND BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS CLIENTS IN THE REGION OF Hubungan Tingkat Stres Terhadap Kadar Gula Darah Pada Klien Diabetes Melitus Tipe 2 Di Wilayah Kerja Puskesmas Jayengan Surakarta.

i

RELATIONSHIP BETWEEN LEVEL OF STRESS AND BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS CLIENTS IN THE REGION OF

WORK PUSKESMAS JAYENGAN SURAKARTA

Submitted as Partial Fulfillment of the Requirements of Bachelor Degree of Nursing

By

MAWAR NINDITA P J 210.112.002

HEALTH SCIENCE FACULTY

UNIVERSITAS MUHAMMADIYAH SURAKARTA 2016

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RELATIONSHIP BETWEEN LEVEL OF STRESS AND BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS CLIENTS IN THE REGION OF

WORK PRIMARY HEALTH CENTER JAYENGAN SURAKARTA

SCIENTIFIC PUBLICATION

By:

MAWAR NINDITA P J 210.112.002

Have been inspected and approved to be tested by :

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PAGE OF CONFIRMATION

RELATIONSHIP BETWEEN LEVEL OF STRESS AND BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS CLIENTS IN THE REGION OF

WORK PRIMARY HEALTH CENTER JAYENGAN SURAKARTA

By

MAWAR NINDITA P J 210.112.002

It has been Maintained in Front of the Board of Examiners Health Science Faculty

Muhammadiyah University of Surakarta At the day Thursday, 13 October 2016

and have been declared ineligible Board of Examiners:

1. Okti Sri Purwanti, S.Kep., M.Kep.,Ns.Sp.Kep.M.B (……..……..) (Chief Board of Examiners)

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(Member I Board of Examiners)

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STATEMENT

I hereby certify that this scientific publication there were works that have been asked to obtain a degree at a university and all my knowledge also does not have work or opinions ever written or published another person, except in writing referred to in the text and were mentioned in the list library.

If it was found there wass untruth in my statement above, then I will fully accountable

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Surakarta, 13 October 2016 Author,

MAWAR NINDITA P J 210.112.002

RELATIONSHIP BETWEEN LEVEL OF STRESS AND BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS CLIENTS IN THE REGION OF WORK PRIMARY

HEALTH CENTER JAYENGAN SURAKARTA

Abstract

Diabetes mellitus was a kind of metabolic diseases with characteristic hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. Diabetes Mellitus disease was a chronic disease that affects the client's psychological the incidence of stress, while stress itself have an impact on an increase in stress hormones epinephrine and cortisol. Hormones epinephrine and cortisol both increase levels of glucose and fatty acids in the blood thereby increasing blood glucose levels. This study aims to determine the relationship of the level of stress on blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta. This research was descriptive analytic with cross sectional approach. The study population was all clients of type 2 Diabetes Mellitus in the working area of Primary Health Center Jayengan Surakarta in 2015 which amounted to 2394 clients. The research sample as many as 94 clients Diabetes mellitus obtained by purposive sampling. The research data in the form stress levels and blood glucose levels of clients (fasting blood glucose and Blood Glucose 2 hours post prandial) measured by questionnaires, glucometers and blood glucose stick. The research data analysis used chi square test. The results showed 2obs value of level of stress with Fasting Blood Glucose (2obs =15,467 with p-value = 0,000) and level of stress with Blood Glucose 2 hours post prandial (2obs =19,779 with p-value = 0,000) so the test was H0 decision rejected. Conclusion of research was there was a relationship stress levels with blood glucose levels in type 2 diabetes mellitus client in Primary Health Center Jayengan Surakarta, is the higher the stress client type 2 diabetes, the higher the blood glucose levels or abnormal.

Keywords: stress, blood glucose levels, type 2 diabetes mellitus client

Abstrak

Diabetes Melitus (DM) adalah suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia yang terjadi karena kelainan sekresi insulin, kerja insulin atau kedua-duanya. Penyakit DM merupakan penyakit kronis yang berdampak pada psikologis klien DM salah satunya adalah timbulnya stres, sedangkan stres itu sendiri berdampak pada terjadi peningkatan hormon-hormon stres epinefrin dan kortisol. Hormon epinefrin dan kortisol keduanya meningkatkan kadar glukosa dan asam lemak dalam darah sehingga meningkatkan kadar gula darah. Penelitian ini bertujuan untuk mengetahui hubungan tingkat stres terhadap kadar gula darah pada klien Diabetes Melitus tipe 2 di Wilayah kerja Puskesmas Jayengan Surakarta. Penelitian ini merupakan penelitian deskriptif analitik dengan pendekatan cross sectional. Populasi penelitian adalah seluruh klien DM tipe 2 di Wilayah kerja Puskesmas Jayengan Surakarta tahun 2015 yang berjumlah 2394 klien. Sampel penelitian sebanyak 94 klien DM yang diperoleh dengan teknik purposive sampling. Data penelitian berupa tingkat stres dan kadar gula darah pasien (GDP dan G2JPP) yang diukur dengan kuesioner, glukometer dan GDS stick. Analisis data penelitian menggunakan uji chi square. Hasil penelitian menunjukkan nilai 2

hitung pada GDP sebesar 15,467 dengan (p-value = 0,000) dan pada

G2JPP sebesar 19,779 dengan (p-value = 0,000) sehingga keputusan uji adalah H0 ditolak.

Kesimpulan penelitian adalah terdapat hubungan tingkat stres dengan kadar gula darah pada klien DM tipe 2 di wilayah kerja Puskesmas Jayengan Surakarta, yaitu semakin tinggi stres klien DM tipe 2, maka kadar gula darahnya semakin tinggi atau tidak normal.

1. INTRODUCTION

Diabetes mellitus was a chronic disease which was still a major health problem in the world or in Indonesia. Diabetes Mellitus was a kind of metabolic diseases with characteristic hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. More than 90 percent of all diabetic population of type 2 diabetes mellitus was characterized by decreased insulin secretion due to reduced function of pancreatic beta cells progressively caused by insulin resistance (American Diabetes Association, 2012).

According to the World Health Organization / WHO (2012) explains that the number of clients with diabetes in the world reached 347 million people and more than 80% of deaths due to diabetes occurs in poor and developing countries. Would estimated that by 2020 there will be some 178 million Indonesian population aged over 20 years, assuming the prevalence of diabetes of 4.6% will be obtained 8.2 million clients who suffer from diabetes. Plus the results of research carried out in all provinces in Indonesia showed that the national prevalence for impaired glucose tolerance (IGT) was 10.25% and for the diabetes mellitus was 5.7% (Balitbang Depkes RI, 2008).

Reports from Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan from Riset Kesehatan Dasar (Riskesdas) in 2013 mentions an increase in the prevalence of diabetes mellitus clients in 2007 increased 1.1% in 2013 to 2.4%. While the prevalence of diabetes was based on the doctor's diagnosis or symptoms in the year 2013 by 2.1%, the highest prevalence was in the region of Central Sulawesi (3.7%) and lowest in the West Java region (0.5%). Health Profile Data Central Java province in 2012 the prevalence of diabetes was 0.6%.

Diabetes Mellitus disease was a chronic disease that has a negative impact on the client's physical and psychological, physical disorders that occur as polyuria, polydipsia, polyphagia, complained of fatigue and drowsiness (Price & Wilson, 2005).

One of the psychological impact experienced in clients with diabetes was stress. Stress was a feeling that was created when a person reacts to a specific event. The reaction of body's way of rising to a challenge and preparing to meet a tough situation with focus, strength, stamina, and increased alertness. The events that trigger stress are called stressors, and they cover a wide range of physical situations, such as injury or illness. The body prepares to take action in response to stress. This preparation was called fight or flight response. Diabetes itself was also a cause of stress (Eom, et al., 2011).

Stress on the client diabetes mellitus compared with the general population, have higher stress levels, and as stress levels rise, worsened glycemic control may result in disruption of controlling blood glucose levels (Eom, et al., 2011). In times of stress would increase the stress

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hormones epinephrine and cortisol. Hormones epinephrine and cortisol both increase levels of glucose and fatty acids in the blood thereby increasing blood glucose levels (Sherwood, 2001).

Data on the number of type 2 diabetes mellitus client in Primary Health Center Jayengan Surakarta in 2015 as many as 2394 clients. Clients type 2 diabetes mellitus in general are experiencing stress due to fear of complications, lifestyle changes that will be experienced by the client and make the long-term treatment of diabetes mellitus client stress.

Based on the background of the above problems, researchers interested in conducting research entitled relationship between the level of stress on blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta.

2. RESEARCH METHODOLOGY

This type of research based on the problems and the goals to be achieved, then the research was quantitative. This study highlights the relationship between variables and analyzed or tested hypotheses formulated. The method used was descriptive analytic method in which researchers attempted to describe the reality of a situation encountered objectively and will be analyzed research results. This study used cross sectional approach (cross sectional), the research by taking measurements or observations at the same time.

The study population was all clients of type 2 diabetes mellitus in the working area of Primary Health Center Jayengan Surakarta in 2015 which amounted to 2394 clients. The research sample as many as 94 clients diabetes mellitus obtained by purposive sampling. The research data in the form stress levels and blood glucose levels of clientss measured by (fasting blood glucose and Blood Glucose 2 hours post prandial),questionnaires DDS (Diabetes Distress Scale) modified from the Improving Access to Psychological Therapists (2013) adopted on research Wohpa (2015), glucometers and blood glucose stick. Research data analysis using chi square test.

Implementation of the data collection is respondent fasting at least 8 hours before the examination of blood glucose. After clients fasting at least 8 hours, researchers take measurements of fasting blood glucose using glucometers and blood glucose stick. Furthermore, clients were asked to break fasting for the next examination measured blood glucose 2 hours post prandial using glucometers and blood glucose stick.

3. RESULTS AND DISCUSSION

3.1Characteristics of Clients

Table 1. Frequency Distribution of Clients by Age

Number Age Frequency Percentage (%)

1 2 3

40 – 50 years 51 – 60 years > 60 years

34 43 17 36 46 18

Total 94 100

3.1.2 Frequency Distribution of Clients by Gender

Table 2. Frequency Distribution of Clients by Gender

Number Gender Frequency Percentage (%)

1 2 Female Male 61 33 65 35

Total 94 100

3.1.3 Frequency Distribution of Clients by Education

Table 3. Frequency Distribution of Clients by Level of Education Number Level of Education Frequency Percentage(%)

1 2 3 4 5

No receive education Elementary school Junior High School Senior High School University Collage 4 23 37 18 12 4 25 39 19 13

Total 94 100

3.1.4 Frequency Distribution of Clients by Marital Status

Table 4. Frequency Distribution of Clients by Marital Status Number Marital Status Frequency Percentage (%)

1 2 Married Widow/Widower 75 19 80 20

Total 94 100

3.1.5 Frequency Distribution of Clients by Sports Activity

Table 5. Frequency Distribution of Clients by Sports Activity Number Sports Activity Frequency Percentage (%)

1 2 No Yes 44 50 47 53

Total 94 100

3.1.6 Frequency Distribution of Clients by Suffer Long Term

Table 6. Frequency Distribution of Clients by Suffer Long Term Number Suffer Long Term Frequency Percentage (%)

1 2

< 10 years 11 – 20 years

79 15

84 16

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3.1.7 Frequency Distribution of Clients by Drugs Used

Table 7. Frequency Distribution of Clients by Drugs Used

Number Drugs Used Frequency Percentage (%)

1 2 3

No taking medication

Medication from health workers Drugs sold in the market

42 41 11 45 44 11

Total 94 100

3.1.8 Frequency Distributions of Clients by Dietary Foods

Table 8. Frequency Distribution of Clients by Dietary Foods Number Dietary Foods Frequency Percentage (%)

1 2 No diet Diet 5 89 5 95

Total 94 100

3.2Univariate Analysis

3.2.1 Stress Levels in Type 2 Diabetes Mellitus

Research tool used to measure the stress level was the DDS (Improving Access to Psychological Therapists, 2013) consists of 17 questions. Based on the data obtained, the stress levels of clients can be grouped into three categories, namely no stress or mild stress if score <50%, moderate stress if a score of 51-75%, and severe stress if the score >75%. Furthermore, the frequency distributions of clients by the stress levels are as follows:

Table 9. Frequency Distribution by Levels of Stress Number Level of Stress Frequency Percentage (%)

1 2 3

No stress/mild stress Moderate stress Severe stress 37 42 15 39 45 16

Total 94 100

3.2.2 Blood Glucose Level

Blood glucose levels are measured clients from the recent examination results of fasting blood glucose and blood glucose 2 hours post prandial type 2 diabetes mellitus client using glucometers and blood glucose stick. Categories blood glucose levels are divided into two categories: normal, if fasting blood glucose 70-110 mg / dL, blood glucose 2 hours post prandial <140 mg / dl and not normal, if fasting blood glucose> 110 mg / dL, blood glucose 2 hours post prandial> 140 mg / dl. Furthermore, the frequency distribution of clients by blood glucose levels was as follows:

Table 10. Frequency Distribution by Blood Glucose Level Number Blood Glucose Level Frequency Percentage (%)

1 2 Normal Abnormal 36 58 38 62

3.3Bivariate Analysis

The bivariate analysis was conducted to analyze the correlation between stress and blood glucose levels in type 2 diabetes mellitus client in Primary Health Center Jayengan Surakarta. The analysis technique used was Chi Square test at a significance level of 5%. The results of analysis of Chi Square relationship stress levels with blood glucose levels of type 2 diabetes mellitus client are as follows:

3.3.1 Relationship Between Level Of Stress with Blood Glucose Levels (Fasting Blood Glucose) in Type 2 Diabetes Mellitus Client

Tabel 11. Relationship Between Level Of Stress with Blood Glucose Levels (Fasting Blood Glucose) in Type 2 Diabetes Mellitus Client

Level of Stress

Fasting Blood Glucose Normal Abnormal Total Freq % Freq % Freq % No Stress/ mild stress 21 57 16 43 37 100 2

obs = 15,467

Moderate stree 10 24 32 76 42 100 p-value = 0,000 Severe Stress 1 7 14 93 15 100 Decision =H0 rejected

Total 32 34 62 66 94 100

Cross tabulation of blood glucose levels (fasting blood glucose) in terms of stress levels showed that the clients who have high levels of stress category does not stress or mild stress most of their blood glucose levels to normal as many as 21 clients (57%), then the clients stress levels were mostly have abnormal blood glucose levels as many as 32 clients (76%), and clients with high stress levels most have abnormal blood glucose levels as many as 14 clients (93%).

Chi Square test results obtained 2

obs value of 15.467 with a significance value

(p-value) of 0.000. P-value less than 0.05 (0.000 <0.05) so that the test is H0 rejected the decision, so it concluded there is a relationship with the stress level of blood glucose levels (fasting blood glucose) in type 2 diabetes mellitus client in Primary Health Center Jayengan Surakarta, namely the higher the stress client type 2 diabetes, the blood glucose levels (fasting blood glucose) higher or abnormal.

3.3.2 Relationship Between Level Of Stress with Blood Glucose Levels (Blood Glucose 2 hours post prandial) in Type 2 Diabetes Mellitus Client

Tabel 12. Relationship Between Level Of Stress with Blood Glucose Levels (Blood Glucose 2 hours post prandial) in Type 2 Diabetes Mellitus Client

Level of Stress

Blood Glucose 2 hours post prandial

Normal Abnormal Total Freq % Freq % Freq % No Stress/ mild stress 25 68 12 32 37 100 2

obs = 19,779

Moderate Stress 13 31 29 69 42 100 p-value = 0,000 Severe Stress 1 7 14 93 15 100 Decision =H0 rejected

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Cross tabulation of blood glucose levels (Blood Glucose 2 hours post prandial) in terms of stress levels showed that the clients who have high levels of stress category does not stress or mild stress most of their blood glucose levels to normal as many as 25 clients (68%), then the clients stress levels were mostly have abnormal blood glucose levels as many as 29 clients (69%), and clients with high stress levels most have abnormal blood glucose levels as many as 14 clients (93%).

Chi Square test results obtained 2

obs value of 19.779 with a significance value

(p-value) of 0.000. P-value less than 0.05 (0.000 <0.05) so that the test is H0 rejected the decision, so it concluded there is a relationship with the stress level of blood glucose levels (Blood Glucose 2 hours post prandial) in type 2 diabetes mellitus client in Primary Health Center Jayengan Surakarta, namely the higher the stress client type 2 diabetes, the blood glucose levels (Blood Glucose 2 hours post prandial) higher or abnormal.

4. DISCUSSION

4.1Characteristic of Clients

Distribution of clients by age showed that the highest distribution was 51- 60 years of age. A general increase causes a person at risk of increased incidence of diabetes, people are entering the age of 55 years and above, with regard to the occurrence of diabetes because of old age, the body functions physiologically decreased due to a decrease in secretion or insulin resistance so that the functional capability of the body to control high blood glucose less optimal (Suyono, 2007).

Distribution characteristics of clients by sex shows are mostly women. The prevalence of diabetes in women was evidenced in research Jelantik (2014), that there was a relationship of risk factors of age, sex, obesity and hypertension with the incidence of type 2 diabetes in the region of Primary Health Center Mataram in 2013, where mostly female.

Distribution of clients according to education shows the highest distribution was a junior. The level of education a person related to a person's knowledge. The level of education can increase knowledge about health. Education person associated with that person's knowledge about health. Research Galveia, Cruz & Deep (2012) about the influence of demographic factors on adherence clients diabetes in the management of stress, anxiety and depression concluded that education factor was one of the variables that had a significant relationship with diabetes client compliance in the management of stress, anxiety and depression.

Distribution of clients according to marital status shows the highest distribution was married. Several previous studies such as research that has been done by Casado et al in

Joshi et al (2003) in Nurkhalim (2012), a widow or widower who has been left died had the possibility to greater stress levels. This was due to the loss of life companion, causing grief long and deep depression.

Distribution according to sports activities showed most clients are doing physical activity. Physical activity was all the gestures that burns calories, such as sweeping, up and down stairs, ironing, gardening and specific exercise. This includes walking, swimming, cycling, jogging or gymnastics (Tandra, 2008). Relationship of physical activity with blood glucose levels, as concluded in the study Anani, (2012) in hospitals Arjawinangun Kab. Cirebon by cross sectional study showed that physical activity was associated with blood glucose levels (p = 0.012).

The results of this study showed that most clients had diabetes for less than 10 years. Niven (2002) states that those who undergo treatment of the disease more than four years has been able to adjust to the disease. The longer a client in therapy diseases, the more obedient, because the client has reached the accepted (accept). The opinion concluded in research Kalda et al (2008), and Reid et al (2009) in Yusra (2011) that the old diabetes mellitus significantly related to the quality of life for clients who are generally lower in the long duration of diabetes.

Distribution of drugs used by the respondent showed the highest distribution was not taking medicine regularly, then drugs from health professionals (health center or doctor) and drugs freely in the market (drugstores or pharmacies). One of the problems encountered in the management of diabetes mellitus client, diabetes mellitus client was the level of knowledge that was generally still low. Relation between education and knowledge, as concluded in the research Omar & San (2014) concluded that one of the factors associated with diabetes mellitus client knowledge was the education level of the diabetes mellitus client. The level of knowledge that was less impact on the diabetes mellitus client behavior was wrong, among others, the majority of clients do not comply in consuming diabetes mellitus diabetes mellitus diet or calorie consumption accordingly, as well as most of the clients diabetes mellitus disobedient in taking the medication.

Distribution of clients by showing the distribution of the highest food diet clients was diet. The result showed that dietary compliance was done the client was good, this was caused by several factors that affect adherence. Factors affecting compliance one of which was the support of their families, with the support of the family expected the clients will feel happy and at ease, because with such support would cause her confidence to deal with or manage the disease better.

9 4.2Level of Stress Clients

Based on the results of the study stress levels of clients indicated that the majority of moderate stress. Illness suffered by a person can be a source of stress, this could be caused by the level of understanding about the disease, so that people who suffer from fear and stress eventually arise. Disease was a life threatening condition and it has been known that, in normal circumstances before someone dies will get sick in advance or death caused by accidents and others. For that diseases are a common source of stress was very high, and people who are suffering from an illness that do not understand what was experienced and treatment (Eom, et al., 2011).

This study indicates that clients largely stress levels are moderate stress because it was caused by a large majority of clients experienced a diabetes mellitus of less than 10 years and most do not experience complications of diabetes mellitus. By sex in this study found that women with type 2 diabetes mellitus client more stress than type 2 diabetes mellitus client men. Similar results were also found in the study Galveia, Cruz & Deep (2012). The study concluded that women with diabetes clients generally have high levels of stress; anxiety and depression were higher than men.

Age distribution of clients showed most clients aged less than 60 years. Sociodemographic risk factors that are important associated with depression in type 2 diabetes mellitus client was a younger age, lower socioeconomic status, lack of education, unmarried, poor social support, and female gender (Katon, 2008). The highest level of depression occurs on the client with type 2 diabetes aged less than 60 years. The high stressors on the client type 2 diabetes under the age of 60 years due to their fears of livelihood in the future was uncertain and the decline in the health of the body, while on the client type 2 diabetes over the age of 60 years have had a sense of resignation so as to decrease the stressors receipt as a result of the diabetes mellitus disease (Wulandari, 2011).

Long suffering from diabetes experienced by respondents in this study the majority of clients had long diabetes mellitus less than 10 years. Factors old diabetes mellitus experienced by clients were also related to stress levels of clients. Factors affecting stress was a factor psikoedukatif / socio-cultural consisting of the development of personality, experience, and other conditions affecting (Maghfirah, 2013). Some of the factors affecting the level of stress on the client type 2 diabetes mellitus was a client there was information that the disease was refractory and the clients should be able to change his lifestyle by doing a strict diet if you want to heal, the clients will feel his suffering never broke and always pictured a bleak future , the client will feel that life with diabetes can be difficult in the face

of a complex, demanding, and often confusing in self-care, the client may be disappointed, angry, overwhelmed, and despair (Widayati, 2008).

4.3Blood Glucose Levels

The frequency distribution of blood glucose levels clients showed the highest distribution was not normal that has a fasting blood glucose of> 110 mg / dL and blood glucose 2 hours post prandial> 140 mg / dl. Suyono (2007) that diabetes mellitus was a syndrome that was characterized by elevated blood glucose levels caused by abnormalities of the islets of Langerhans beta cells of the pancreas gland. In type 2 diabetes blood glucose levels rise because of insulin resistance due to wrong lifestyle. Diabetes Mellitus was a group of metabolic diseases with characteristic hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. Inzucchi, et.al (2015) revealed that client type 2 diabetes tends to increase blood glucose levels due to the decreased ability of the pancreas to produce insulin.

4.4Relationship Level of Stress with Blood Glucose Level in Diabetes Mellitus type 2 clients

The result of Chi Square test was concluded there is a relationship between the level of stress in blood glucose levels (fasting blood glucose) on the type 2 diabetes mellitus clients in Primary Health Center Jayengan Surakarta, is the higher levels of stress client type 2 diabetes, the blood glucose levels (fasting blood glucose) higher or abnormal ((2

obs = 15.467 with p-value = 0.000). The results of Chi Square test also concluded that

there is a relationship between the level of stress in blood glucose levels (blood glucose 2 hours post prandial) on the type 2 diabetes mellitus clients in Primary Health Center Jayengan Surakarta, is the higher level of stress client type 2 diabetes, the blood sugar levels (blood glucose 2 hours post prandial) higher or abnormal ((2

obs = 19.779 with

p-value = 0.000).

Stress is a factor that affects important for people with diabetes mellitus, due to increased production of stress hormones can cause blood glucose levels to be increased. Conditions to relax can control counterproductive hormonal regulation of stress and allows the body to use insulin more effectively. Effect of stress on the increase in blood glucose levels associated with a bunch of the neuroendocrine system, namely through the Hypothalamic-Pituitary-Adrenal (Dewi, 2014). The hypothalamus secretes corticotropin-releasing-factor, which will stimulate the anterior pituitary to produce adrenocorticotropic hormone (ACTH). Then ACTH stimulates the anterior pituitary to produce glucocorticoids, especially cortisol. Cortisol stimulates catabolism of protein, releasing amino acids, stimulates the uptake of amino acids by the liver and its conversion into

11

glucose (gluconeogenesis) and inhibits glucose uptake (anti-insulin action) by various cells of the body other than the brain and heart. Induced metabolic effects of cortisol will provide a ready source of energy during times of stress. There are various important implications to this effect that people suffering from diabetes when experiencing stress, as a result of infection, will need more insulin than usual. Every client who experience stress (disease, surgery, prolonged psychological stress) will mengkatabolisme body that require additional protein. (Potter & Perry, 2010)

Diabetes Mellitus and stress are the two things that affect each other both directly and indirectly. Less control on Blood Glucose lead to feelings of stress and vice versa. The same thing also as expressed by Hawari (2010), that stress has become one of the factors that appears on the client with diabetes mellitus. Sara (2015) echoed that physical or emotional stress triggers the release of hormones called catecholamines, which often leads to hyperglycemia (high blood sugar). Research Faulenbach, et al (2011) on the effects of psychological stress on blood glucose control in patients with diabetes mellitus type 2. This study concluded that acute stress affects the increase in blood glucose concentrations in patients with type 2 mellitus diatebes.The results also supported by research conducted Wilda (2011), revealed no association with Blood Glucose Stress.

Research shows that higher levels of stress, the blood glucose levels of clients increased. However, in this study there were 16 clients who do not stress or mild stress but fasting blood glucose levels are abnormal, and clients who experience stress but normal fasting blood glucose levels. Similarly, the blood glucose levels two hours post prandial there are 12 clients who do not stress or mild stress but not normal blood glucose levels and one person who had a severe stress levels but normal blood glucose levels. Irregularities or differing conditions of the conclusions of this research possible because of other factors associated with blood glucose levels of patients with type 2 diabetes mellitus eg behavioral factors exercise, consumption of drugs and dietary or diet. This research shows the majority of clients who have abnormal blood glucose levels are not taking good diabetes medications from health workers or traditional medicine. Relationships compliance diabetes drugs with blood glucose levels, as concluded in the study Hapsari (2014) about the relationship between compliance of drug use and the success of therapy in patients with diabetes mellitus. The study concluded that there is a relationship of compliance of drug use with the success of the treatment of patients with diabetes mellitus is characterized by the patient's blood glucose levels are controlled.

5. CLOSING 5.1Conclusion

Based on the results of research and discussion of the conclusions of this study are as follows.

1. The level of stress on the client type 2 diabetes mellitus in Surakarta Jayengan Primary Health Center working area was largely moderate stress.

2. Blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta largely normal.

3. There was a relationship stress levels with blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta.

5.2Suggestion

1. For Health Center

For health center should improve efforts to the clients knowledge about stress management by conducting health education on stress management. Remind clients about the compliance of diabetes mellitus diet, so it can control blood glucose levels and can prevent complications of diabetes. The measures undertaken include conducting health education to the public or distributing pamphlets about the diabetes mellitus to the public.

2. For clients with type 2 diabetes

Clients type 2 diabetes mellitus should undertake a diet to control blood glucose levels. Improving knowledge about the prevention of diabetes mellitus complications is by asking health workers health centers or through pamphlets, so as to minimize the incidence of complications of diabetes at the same time also reduce the stressors of client type 2 diabetes mellitus. Client should learn to conduct stress management so that they can control their stress levels and able to maintain their blood glucose levels.

3. For Further Research

Researchers should further improve the quality of research by performing a multivariate analysis, transform research into experimental research, it is recommended for future studies which measure blood glucose levels do not use clinical trials with glucometers but it is recommended to use a hematological laboratory examination results to get more accurate results.

13 BIBLIOGRAPHY

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Hawari, D. 2010. Psikologi Keperawatan. Jakarta: EGC.

Inzucchi, SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck N, Peters AL, Tsapas A, Wender R,9, and Matthews DR. 2015. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Clients- Centered Approach Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Journal of Diabetes. Diabetes Care Volume 38, January 2015.

Jelantik, G.M.G. 2014. Hubungan Faktor Resiko Umur, Jenis Kelamin, Kegemukan dan Hipertensi dengan Kejadian Diabetes Mellitus tipe II di Wilayah Kerja Primary Health Center Mataram. Jurnal Kesehatan. Denpasar. Media Bina Ilmiah. Volume 8, No 1, Februari 2014. Katon. 2008. Faktor-faktor Risiko Ulkus Diabetika Pada Penderita Diabetes Melitus Studi Kasus di

RSUD Dr. Moewardi Surakarta. Publikasi Penelitian. Universitas Diponegoro. Maghfirah, S. 2013. Optimisme dan Stres pada Pasien Diabetes Melitus. Jurnal Florence, 1(2). Niven, N. 2002. Psikologi Kesehatan. Jakarta: Penerbit Buku Kesehatan EGC

Nurkhalim. 2012. Gambaran Faktor Resiko Pasien Diabetes MelitusTipe II di Poliklinik Endokrin Bagian/SMF FK Unsrat RSU Prof. Dr. R.D Kandou Manado Periode Mei 2011 - Oktober2011. e-Biomedik (eBM), 1(1), pp. 45-49

Omar M.L and San K.L. 2014. Diabetes Knowledge and Medication Adherence Among Geriatric Clients With Type 2 Diabetes Mellitus. International Journal of Pharmacy and Pharmaceutical Sciences. Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz 53000 Kuala Lumpur Malaysia. Email: marhanis@pharmacy.ukm.my Potter and Perry. 2010. Buku Ajar Fundamental Keperawatan : Konsep, Proses, dan Praktik. Edisi

4.Volume 2.Alih Bahasa : Renata Komalasari, dkk. Jakarta: EGC.

Price, A. S., & Wilson, L. M. 2005. Patofisiologi : Konsep Klinis Proses- proses Penyakit (Vol. 2). Jakarta: EGC.

Sara, J.C. 2015. Glucose Levels can Fluctuate for Variety of Reasons. Journal of Diabetes. Mayo Clinic. Health System Location. Florida and Minessota.

Sherwood, L. 2001. Fisiologi Manusia dari Sel ke Sistem. Penerbit Buku Kedokteran EGC : Jakarta Suyono, S. 2007. Penatalaksanaan Diabetes Melitus Terpadu. Edisi kedua. Jakarta: Departemen

Ilmu Penyakit Dalam FKUI

Tandra, H. 2008. Segala Sesuatu Yang Harus Anda Ketahui Tentang Diabetes: Panduan lengkap Mengenal dan Mengatasi Diabetes dengan Cepat dan Mudah. Jakarta: PT Gramedia Pustaka Utama.

Widayati. 2008. Pengaruh Meditasi Relaksasi Dalam Gerak Terhadap Penurunan Tingkat Stres Dan Kadar Gula Darah Pada Penderita Diabetes Mellitus Tipe 2. Publikasi Penelitian. Surabaya: Universitas Airlangga

Wilda, T Dkk. 2011. Hubungan Tingkat Stress dengan Proses Penyembuhan Luka Gangren pada Pasien Diabetes Mellitus di RSD Sidoarjo. Jurnal Penelitian. Sidoarjo: Prodi Keperawatan Kampus Sidoarjo

Wohpa, N. 2015. Gambaran Dan Manajemen Stres Pada Penderita Diabetes Melitus Di Poliklinik Penyakit Dalam RSUD Dr. Moewardi Surakarta. Jurnal Penelitian. Surakarta: : eprint.ums.ac

Wulandari, A.F. 2011. Kejadian dan Tingkat Depresi pada Lanjut Usia Diabetes Mellitus: Studi Perbandingan di Panti Wredha dan Komunitas. Jurnal Penelitian. Semarang: Universitas Diponegoro.

Yusra, A. 2011. Hubungan antara Dukungan Keluarga dengan Kualitas Hidup Pasien Diabetes Melitus tipe 2 di Poliklinik Penyakit Dalam Rumah Sakit Umum Pusat Fatmawati Jakarta. Publikasi Tesis. Jakarta: Fakultas Ilmu Keperawatan Universitas Indonesia.

4.2Level of Stress Clients

Based on the results of the study stress levels of clients indicated that the majority of moderate stress. Illness suffered by a person can be a source of stress, this could be caused by the level of understanding about the disease, so that people who suffer from fear and stress eventually arise. Disease was a life threatening condition and it has been known that, in normal circumstances before someone dies will get sick in advance or death caused by accidents and others. For that diseases are a common source of stress was very high, and people who are suffering from an illness that do not understand what was experienced and treatment (Eom, et al., 2011).

This study indicates that clients largely stress levels are moderate stress because it was caused by a large majority of clients experienced a diabetes mellitus of less than 10 years and most do not experience complications of diabetes mellitus. By sex in this study found that women with type 2 diabetes mellitus client more stress than type 2 diabetes mellitus client men. Similar results were also found in the study Galveia, Cruz & Deep (2012). The study concluded that women with diabetes clients generally have high levels of stress; anxiety and depression were higher than men.

Age distribution of clients showed most clients aged less than 60 years. Sociodemographic risk factors that are important associated with depression in type 2 diabetes mellitus client was a younger age, lower socioeconomic status, lack of education, unmarried, poor social support, and female gender (Katon, 2008). The highest level of depression occurs on the client with type 2 diabetes aged less than 60 years. The high stressors on the client type 2 diabetes under the age of 60 years due to their fears of livelihood in the future was uncertain and the decline in the health of the body, while on the client type 2 diabetes over the age of 60 years have had a sense of resignation so as to decrease the stressors receipt as a result of the diabetes mellitus disease (Wulandari, 2011).

Long suffering from diabetes experienced by respondents in this study the majority of clients had long diabetes mellitus less than 10 years. Factors old diabetes mellitus experienced by clients were also related to stress levels of clients. Factors affecting stress was a factor psikoedukatif / socio-cultural consisting of the development of personality, experience, and other conditions affecting (Maghfirah, 2013). Some of the factors affecting the level of stress on the client type 2 diabetes mellitus was a client there was information that the disease was refractory and the clients should be able to change his lifestyle by doing a strict diet if you want to heal, the clients will feel his suffering never broke and always pictured a bleak future , the client will feel that life with diabetes can be difficult in the face

of a complex, demanding, and often confusing in self-care, the client may be disappointed, angry, overwhelmed, and despair (Widayati, 2008).

4.3Blood Glucose Levels

The frequency distribution of blood glucose levels clients showed the highest distribution was not normal that has a fasting blood glucose of> 110 mg / dL and blood glucose 2 hours post prandial> 140 mg / dl. Suyono (2007) that diabetes mellitus was a syndrome that was characterized by elevated blood glucose levels caused by abnormalities of the islets of Langerhans beta cells of the pancreas gland. In type 2 diabetes blood glucose levels rise because of insulin resistance due to wrong lifestyle. Diabetes Mellitus was a group of metabolic diseases with characteristic hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. Inzucchi, et.al (2015) revealed that client type 2 diabetes tends to increase blood glucose levels due to the decreased ability of the pancreas to produce insulin.

4.4Relationship Level of Stress with Blood Glucose Level in Diabetes Mellitus type 2 clients

The result of Chi Square test was concluded there is a relationship between the level of stress in blood glucose levels (fasting blood glucose) on the type 2 diabetes mellitus clients in Primary Health Center Jayengan Surakarta, is the higher levels of stress client type 2 diabetes, the blood glucose levels (fasting blood glucose) higher or abnormal ((2obs = 15.467 with p-value = 0.000). The results of Chi Square test also concluded that

there is a relationship between the level of stress in blood glucose levels (blood glucose 2 hours post prandial) on the type 2 diabetes mellitus clients in Primary Health Center Jayengan Surakarta, is the higher level of stress client type 2 diabetes, the blood sugar levels (blood glucose 2 hours post prandial) higher or abnormal ((2obs = 19.779 with

p-value = 0.000).

Stress is a factor that affects important for people with diabetes mellitus, due to increased production of stress hormones can cause blood glucose levels to be increased. Conditions to relax can control counterproductive hormonal regulation of stress and allows the body to use insulin more effectively. Effect of stress on the increase in blood glucose levels associated with a bunch of the neuroendocrine system, namely through the Hypothalamic-Pituitary-Adrenal (Dewi, 2014). The hypothalamus secretes corticotropin-releasing-factor, which will stimulate the anterior pituitary to produce adrenocorticotropic hormone (ACTH). Then ACTH stimulates the anterior pituitary to produce glucocorticoids, especially cortisol. Cortisol stimulates catabolism of protein, releasing amino acids, stimulates the uptake of amino acids by the liver and its conversion into

glucose (gluconeogenesis) and inhibits glucose uptake (anti-insulin action) by various cells of the body other than the brain and heart. Induced metabolic effects of cortisol will provide a ready source of energy during times of stress. There are various important implications to this effect that people suffering from diabetes when experiencing stress, as a result of infection, will need more insulin than usual. Every client who experience stress (disease, surgery, prolonged psychological stress) will mengkatabolisme body that require additional protein. (Potter & Perry, 2010)

Diabetes Mellitus and stress are the two things that affect each other both directly and indirectly. Less control on Blood Glucose lead to feelings of stress and vice versa. The same thing also as expressed by Hawari (2010), that stress has become one of the factors that appears on the client with diabetes mellitus. Sara (2015) echoed that physical or emotional stress triggers the release of hormones called catecholamines, which often leads to hyperglycemia (high blood sugar). Research Faulenbach, et al (2011) on the effects of psychological stress on blood glucose control in patients with diabetes mellitus type 2. This study concluded that acute stress affects the increase in blood glucose concentrations in patients with type 2 mellitus diatebes.The results also supported by research conducted Wilda (2011), revealed no association with Blood Glucose Stress.

Research shows that higher levels of stress, the blood glucose levels of clients increased. However, in this study there were 16 clients who do not stress or mild stress but fasting blood glucose levels are abnormal, and clients who experience stress but normal fasting blood glucose levels. Similarly, the blood glucose levels two hours post prandial there are 12 clients who do not stress or mild stress but not normal blood glucose levels and one person who had a severe stress levels but normal blood glucose levels. Irregularities or differing conditions of the conclusions of this research possible because of other factors associated with blood glucose levels of patients with type 2 diabetes mellitus eg behavioral factors exercise, consumption of drugs and dietary or diet. This research shows the majority of clients who have abnormal blood glucose levels are not taking good diabetes medications from health workers or traditional medicine. Relationships compliance diabetes drugs with blood glucose levels, as concluded in the study Hapsari (2014) about the relationship between compliance of drug use and the success of therapy in patients with diabetes mellitus. The study concluded that there is a relationship of compliance of drug use with the success of the treatment of patients with diabetes mellitus is characterized by the patient's blood glucose levels are controlled.

5. CLOSING 5.1Conclusion

Based on the results of research and discussion of the conclusions of this study are as follows.

1. The level of stress on the client type 2 diabetes mellitus in Surakarta Jayengan Primary Health Center working area was largely moderate stress.

2. Blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta largely normal.

3. There was a relationship stress levels with blood glucose levels in type 2 diabetes mellitus clients in the region work of Primary Health Center Jayengan Surakarta.

5.2Suggestion

1. For Health Center

For health center should improve efforts to the clients knowledge about stress management by conducting health education on stress management. Remind clients about the compliance of diabetes mellitus diet, so it can control blood glucose levels and can prevent complications of diabetes. The measures undertaken include conducting health education to the public or distributing pamphlets about the diabetes mellitus to the public.

2. For clients with type 2 diabetes

Clients type 2 diabetes mellitus should undertake a diet to control blood glucose levels. Improving knowledge about the prevention of diabetes mellitus complications is by asking health workers health centers or through pamphlets, so as to minimize the incidence of complications of diabetes at the same time also reduce the stressors of client type 2 diabetes mellitus. Client should learn to conduct stress management so that they can control their stress levels and able to maintain their blood glucose levels.

3. For Further Research

Researchers should further improve the quality of research by performing a multivariate analysis, transform research into experimental research, it is recommended for future studies which measure blood glucose levels do not use clinical trials with glucometers but it is recommended to use a hematological laboratory examination results to get more accurate results.

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Omar M.L and San K.L. 2014. Diabetes Knowledge and Medication Adherence Among Geriatric Clients With Type 2 Diabetes Mellitus. International Journal of Pharmacy and Pharmaceutical Sciences. Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz 53000 Kuala Lumpur Malaysia. Email: marhanis@pharmacy.ukm.my Potter and Perry. 2010. Buku Ajar Fundamental Keperawatan : Konsep, Proses, dan Praktik. Edisi

4.Volume 2.Alih Bahasa : Renata Komalasari, dkk. Jakarta: EGC.

Price, A. S., & Wilson, L. M. 2005. Patofisiologi : Konsep Klinis Proses- proses Penyakit (Vol. 2). Jakarta: EGC.

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Sherwood, L. 2001. Fisiologi Manusia dari Sel ke Sistem. Penerbit Buku Kedokteran EGC : Jakarta Suyono, S. 2007. Penatalaksanaan Diabetes Melitus Terpadu. Edisi kedua. Jakarta: Departemen

Ilmu Penyakit Dalam FKUI

Tandra, H. 2008. Segala Sesuatu Yang Harus Anda Ketahui Tentang Diabetes: Panduan lengkap Mengenal dan Mengatasi Diabetes dengan Cepat dan Mudah. Jakarta: PT Gramedia Pustaka Utama.

Widayati. 2008. Pengaruh Meditasi Relaksasi Dalam Gerak Terhadap Penurunan Tingkat Stres Dan Kadar Gula Darah Pada Penderita Diabetes Mellitus Tipe 2. Publikasi Penelitian. Surabaya: Universitas Airlangga

Wilda, T Dkk. 2011. Hubungan Tingkat Stress dengan Proses Penyembuhan Luka Gangren pada Pasien Diabetes Mellitus di RSD Sidoarjo. Jurnal Penelitian. Sidoarjo: Prodi Keperawatan Kampus Sidoarjo

Wohpa, N. 2015. Gambaran Dan Manajemen Stres Pada Penderita Diabetes Melitus Di Poliklinik Penyakit Dalam RSUD Dr. Moewardi Surakarta. Jurnal Penelitian. Surakarta: : eprint.ums.ac

Wulandari, A.F. 2011. Kejadian dan Tingkat Depresi pada Lanjut Usia Diabetes Mellitus: Studi Perbandingan di Panti Wredha dan Komunitas. Jurnal Penelitian. Semarang: Universitas Diponegoro.

Yusra, A. 2011. Hubungan antara Dukungan Keluarga dengan Kualitas Hidup Pasien Diabetes Melitus tipe 2 di Poliklinik Penyakit Dalam Rumah Sakit Umum Pusat Fatmawati Jakarta.