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Client profile and Developmental History:

A 26-year-old, female patient who address to have a good hygiene and appears appropriately and dress for the weather. The Patient is independent without ADLs, pupils are round and equal and react to light and accommodation. Cranial nerve 1 has no deformities or deviation and is sensitive to smell. Patient skin is warm with no deformative, no bruising, teeth is white, tongue is rough moist, pink, and uvula raises for phonation. The patient has a history of type 2 diabetes mellitus, due to her age. Patient should be in Erikson’s Intimacy vs. Isolation phase, which stresses developing close relationships during this period, may be made more difficult by long-term health conditions

Health Assessment of Major Systems:

Patients appear clean, well-groomed and dressed up appropriate for the weather. She has no sign of distress. The Patients’ head is symmetrical, with no lumps or tenderness. I inspected patient’s eyes for redness and pupil reaction to light. No discharges redness or hearing ability. Her nose was intact, no discharge or deformities. Patient mouth is moist and pink, teeth is white no swelling or redness on the patient’s gums, tongue is rough and there’s no lesions. Patient neck was palpated for lymph nodes and I checked for thyroid enlargement and assessed for range of motion. Respiratory System Observe breathing patterns, chest symmetry, and use of accessory muscles. – Auscultate lung fields for breath sounds, heart sounds and any abnormalities like wheezes or crackles. I Inspect for color, temperature, and any swelling or deformities. – Palpate for pulses, capillary refill, and any tenderness. The patient is well healthy within herself.

Health Perception/Health Management Pattern:

Although she is aware of the difficulties diabetes might cause if left untreated, the patient has no pain or numbness in her body. believes her health is manageable, the patient has replied no pain. Telemedicine services have been effective because they are convenient and help reduce the impact of chronic diseases; thus, their usage to enhance self-management capacity has proved helpful in providing dependable instructions consistently while reducing the number of hospital visits (Lewinski et al., 2022). She uses prescribed insulin medication and monitors the blood glucose level as per the telemedicine course that also goes with self-management, where the patient is encouraged to participate in crucial health activities.

Nutritional Metabolic Pattern:

Patients said she wants to be healthy, that’s why she’s trying her best to decrease the symptoms she has now with her diabetes. She said she struggles with a lot of symptoms and she too young for this that’s why she eating healthier than before and excising regularly every day. She eats a light breakfast and eats some protein at lunch and eats little more at dinner. After 1900 the patient is done with all her meals except her bar depending on her blood sugar level. She stated that she drinks more water than any other beverages. The patient said that she sometimes gets tired and doesn’t want to get out of bed due to her low blood sugar. During the assessment, patient skin is clear from lesions, no deformities or bruises. Patients have no hair distribution, alopecia or cuts, hair is black. Patient height is 5’7 and weighs 156 lbs. Her BMI is 26.7 which is more than a normal range. No food allergies she stated.

Elimination Pattern:

According to the patient, who regularly uses the restroom, her last BM happened this afternoon, as is normal for her. Urinary and bowel continence are present in the patient.no symptoms of intestinal or urinary issues. has not noticed any recent changes in the appearance of their stools, asserts that their stool is brown and hard, and disputes that it has relieved their constipation. She has had no issues concerning her stomach, implying that she eats balanced meals and drinks a lot of water. It is essential to keep an eye on elimination habits when you have diabetes because changes can mean that your blood sugar control isn’t working right or that you have complications (Lewinski et al., 2022).

Activity Exercise Pattern:

Patient states, one of the weekly activities is physical exercise, which includes walking, taking care of her family and lifting weights. She works out for 30 minutes and sometimes goes for yoga once a week, which fits her schedule. She usually carries snacks because she has diabetes due to low blood sugar. She works full-time at her job and gets off work at 1530. Patients eat breakfast, lunch and dinner. The patient states she makes sure to have some bars with her because her blood sugar drops at times. She stated about her bed routine that she goes to bed at 2230 seven days a week and wakes up at 0600 every morning for work or exercise. She makes breakfast for her kids at 0630 and gets them ready for school.

Sexuality Reproduction Pattern:

A 26-year-old patient who is married regularly engages in sexual activity with her spouse. She claimed that her menstrual cycles were normal and that she had no concerns about them. Reduced sexual desire, dry vagina, and discomfort during sexual activity are all possible symptoms for women with type 2 diabetes. Danies’ secretion from the vagina. For the years she started having sex, she had no sexually transmitted infections. In her adolescence and adulthood, she has dated three individuals in her past. Patient is reportedly both partners are happy together.

Sleep-Rest Pattern:

The patient sleeps for roughly seven hours every night and keeps a consistent bedtime. However, because the patient enjoys watching movies and staying up late for other activities, their sleeping schedule varies on the weekends. She had a nice night’s sleep and didn’t require any medication. Depending on the patient’s activities, they may occasionally sleep during the day. She typically works or completes schoolwork. Regarding the patient’s sleeping patterns, there are no complaints or worries. She is content with the way she is at the moment.

Cognitive-Pattern:

In terms of cognition, the patient is oriented to person, place and time. She communicates well and understands. The patient makes her own decision with no one’s help. Her memory is intact, and she understands how to manage her ailment. As Bauer et al. (2023) say, understanding how complicated diabetes is critical to successful control, and studies show that self-management is linked with cognitive engagement. She monitors the level of glucose regularly. She knows what symptoms indicate that the level is too high or too low, thus being better prepared for fluctuations in her condition.

Role-Relationship Pattern:

The patient’s family is supportive of her diabetes management, which makes it easier for her to deal with the disease without feeling alone. Patient states that her husband is there with her during thick and thin. Her husband or mom does help with the kids when things get difficult for her. She refuses to see her daughter ask questions when she is sick. As has been said before, it is possible to increase self-efficacy and coping by engaging the family in the management of a chronic illness. Supportive relationships are significant because people with diabetes who have strong family support are more likely to stick to their treatment plans and have fewer complications linked to their diabetes (Lewinski et al., 2022 the patient goes to church once in the while but usually has devotions with her family. She plays kick ball with her friends during her free time.

Perception/Neurological Assessment:

The patient sense of smelling and tasting very well. Patient was able to look at my pen when I was doing the six carnal of gaze. The Patients doesn’t wear any glasses or contact. The patient knows how to communicate with health care provider when her blood sugar goes out of control. She said telehealth is one of the best ways she communicates with her nurses or doctors. My patient is oriented x4 to everything.

Coping-Stress Tolerance Pattern:

The patient is motivated to maintain her diabetes control by her strong personal ideals about remaining independent and healthy. Because people who have clear health ideas tend to comply better and have less problems. The patient was anxious about her time in nursing school during the COVID-19 pandemic a few years prior. She had one more quarter left to get her nursing degree, and she was in her third quarter. The patient, who was pregnant while attending nursing school, had no way to get to college since her car broke down, she never had a way to get to her final exam that day, she arrived at school 30 minutes late. She claimed that her lecturer was a cruel individual. She brought her sadly; she failed the exam with just one point. The patient claimed that after crying, she begged the professor to repeat the test, but she refused. The patient reported feeling extremely stressed till giving birth to her child two weeks early. According to her, the day her baby was born was a miracle. She was supported both physically and emotionally by her friends and family.

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Value Belief Pattern:

Patient believes her family comes first in everything she does. They help her financially, emotionally and physically. She stated after her nursing school, The going to try on making a third baby. Her other kids are all ready for a brother or sister, but she doesn’t want to interrupt her schooling right now. Upon assessment, she stated her religions and said she is Christians. The patient doesn’t go to church most of the time, but her mother usually takes her grand babies to church with her every Sunday. Patient believes someday she will return to church and bible study.

Summary:

This patient is an excellent example of how developmental, social, and psychological issues can affect how diabetes is managed. His engagements in telehealth, good nutrition, and stress alleviation suggest that he is doing everything possible to maintain his health despite T2DM’s challenges. Analyzing Gordon’s health in terms of the Functional Health Pattern approach also indicates that the client can handle/shape his health and is supported by the family and strength. His continued commitment is consistent with research highlighting that effective comprehensive and holistic care systems are necessary to manage chronic diseases (Lewinski et al., 2022).