Patient Case Study: Jonathan's Hyperthermia

This assignment presents a clinical case study of a patient named Jonathan Yung who exhibits signs of hyperthermia following a game of bubble soccer. A student nurse analyzes Jonathan's vital signs, including elevated temperature, rapid heart and respiratory rates, and flushed skin, identifying potential risks associated with his condition. The analysis emphasizes the importance of monitoring Jonathan's temperature, recognizing triggering factors, and implementing appropriate interventions to prevent complications.

CLINICAL REASONING REPORT

TABLE OF CONTENTS
INTRODUCTION...................................................................................................................................3
MAIN BODY..........................................................................................................................................3
1 Summary of Jonathan’s Situation.....................................................................................................3
2 List of Objective and Subjective data...............................................................................................3
3a) Identification of normal and abnormal elements of objective and subjective data.......................3
3b) Comparison of current situation and vital signs of health information of patient.........................4
3c) Application of knowledge of anatomy and principles of physiology............................................4
4. Collection of further cues and why those are important relevant to patient’s situation..................5
CONCLUSION........................................................................................................................................5
REFERENCES........................................................................................................................................6

INTRODUCTION
Clinical reasoning report is a process performed by health care provider or other
clinicians who are responsible for collecting cues, process information and problem of
patient. This is prepared with the motive of planning, implementing intervention and
evaluating outcomes. The present assessment is based on 16 years old patient Jonathan Yung
whose vital signs at the time of health assessment after playing bubble soccer match was odd.
MAIN BODY
1 Summary of Jonathan’s Situation
In accordance with observations record of 2nd April Blood pressure of Jonathan was
recorded at 110/60, pulse 70, respiratory rate was 14 and temperature was 36.8. However, on
2nd April record of observation was low where his body temperature of Jonathan was low that
is 36.6, RR was 12 and pulse was 74. Further, He had flushed skin and his shirt was soaked
with sweat. Also, behaviour of Jonathan was curious as he was feeling very hot and his heart
was feeling very fast. In accordance with clinical chart and behaviour of service user it can be
said that the patient is suffering from Hyperthermia. According to Simon, (2016),
Hypothermia occurs when body temperature of body falls below 35-degree C. It occurs when
the body of person is losing more heat to environment than it is generating.
2 List of Objective and Subjective data
3a) Identification of normal and abnormal elements of objective and subjective data
Assessment 3a) Diagnosis
Subjective Data
Drawing off heat in form of liquid which flows
across body
Burning sensations like steam comes out
(Hypothermia. 2018)
Objective data
Flushed skin with 36.6 temperature
12 breaths per minute respiratory rate
Fluctuating blood pressure
In this condition a person's body loses
heat faster than it can produce heat that
causes very low body temperature
which is very dangerous. It can be
controlled by increasing intake of
fluids.
Hyperthermia is related to cerebral
Edema and infectious process
Breathing is normal, under 12 and

74 per minute pulse rate above 25 breaths in a minute is
considered to be abnormal.
Pulse rate is slow but can be considered
as normal.
Fluctuation blood pressure is normal as
it can lead to imbalance in body
temperature and respiratory rates.
3b) Comparison of current situation and vital signs of health information of patient
Vital signs of Jonathan’s after a match of bubble soccer at 3 pm were dangerous as his
temperature was 38.5 degree C whereas pulse rate was beating at 140 per minute which is life
thr4eatining as well as abnormal. However, in accordance with clinical records on 2nd April
body temperature of patient was 36.8 and pulse rate was 70 per minute. According to El-
Radhi, 2018, continuous decrease in body temperature is sign of hyperthermia which is
supported by flushed skin and soak body. As per the views of author it can be argued that
tremendous de crease in vital signs of Jonathan can be dangerous because apart from current
situation when he was enrolled in school his behaviour was different and he was feeling very
hot and his heart was beating very fast and therefore he asked for a chair and cold water.
3c) Application of knowledge of anatomy and principles of physiology
According to Caldwell and et.al., 2018, slow or weak pulse, absent respiration is the
second stage of Hyperthermia which is followed by reduced circulation and decrease in body
temperature. This is the condition which body temperature of in human body is elevated
belong normal because of failed thermoregulations. There are 2 types of hyperthermia in
which one leads to exhaustion of heat and is not much threatening. However, in this service
user experiences high level of perspiration which leads to drenched clothing. The condition is
risky because it can cause collapse of circulatory. The analysis is similar to Jonathan’s
observation record according to this, he has flushed skin and liquid flowing on body.
According to Maheshwari and et.al., 2018, when body of a person starts experiencing high
temperature, the body starts restoring homeostasis. The person sweats because of evaporative
cooling where blood vessels dilate to release excess heat. Symptoms of hyperthermia which
comprise cold, clammy or pale skin with liquid flowing on body which act as core principles
of physiology which assist nurse in making decision regarding change in medication and for
emergency of the situation. Duff and et.al., 2018, stated that normal human body function
depends on ability of body to maintain thermal homeostasis where body has two thermal

compartments where one comprises head and trunk which is regulated by 37 degree C
temperature. On the other hand, there is peripheral compartment which comprise extremities
and skin which has low temperature as per core temperature. Hypothermia induces before
neurosurgical or cardiosurgical procedures with decrease in tissue oxygen demand which can
lead to risks of cardiac ischemic or cerebral damage.
4. Collection of further cues and why those are important relevant to patient’s situation
In accordance with overall analysis it can be said that it is important for the student
nurse to focus on other cues like metabolic rate and vigorous activity of Jonathan. To manage
cues, it is important for the nurse to identify triggering factors by managing underlying cause
which is necessary for recovery which can be attained be regularly monitoring heart rate,
blood pressure and rectal temperature (Temperature Management, 2014). According to El-
Radhi, 2018, it is important for the student nurse to focus on eliminating cloths and covers
which will help in exposing skin to room temperature which lead to decrease on warmth and
increase in evaporative cooling. As per the views of Duff and et.al., 2018, mild hyperthermia
is when body temperature is 32 to 35 degree C and is easy to treat. Signs and symptoms of
Jonathan denotes decreasing body temperature and therefore incorporating intervention to
treat his condition is necessary because the situation can lead to no pupil, very cold to touch,
no breathing, etc. As per the views of Maheshwari and et.al., 2018, dry mucus membrane,
fluctuating BP, shallow breathing, loss of reasoning, confusion, unconsciousness can be
future cues with regard to condition of Jonathan.
CONCLUSION
The report summarized clinical reasoning of the patient Jonathan Yung whose vital
sign at 3 pm af6tr playing Bubble soccer match was critical like his temperature was 38. 5
degree C and there was rapid fluctuation in it respiratory, heart and pulse rate. In accordance
with subjective and objective data it is been outlined that patient might be suffering from
Hyperthermia as he had flushed skin and his shirt was soaked. Thus, the study outlined cues
which can be risks in future as per his current situation and observation records.

REFERENCES
Books and Journals
Caldwell, J.N. and et.al., 2018. A vascular mechanism to explain thermally mediated
variations in deep‐body cooling rates during the immersion of profoundly
hyperthermia individuals. Experimental physiology. 103(4). pp.512-522.
Duff, J. and et.al., 2018. Effect of a thermal care bundle on the prevention, detection and
treatment of perioperative inadvertent hypothermia. Journal of clinical nursing. 27(5-
6). pp.1239-1249.
El-Radhi, A.S., 2018. Hyperthermia. In Clinical manual of fever in children (pp. 29-51).
Springer, Cham.
Maheshwari, R. and et.al., 2018. A Retrospective Study of Therapeutic Hypothermia in
Neonatal Hypoxic Ischemic Encephalopathy. Journal of Neonatology. 32(1). pp.15-
21.
Simon, H.B., 2016. Hyperthermia. New England Journal of Medicine. 329(7). pp.483-487.
Online
Hypothermia. 2018. [Online]. Available through:
<https://www.betterhealth.vic.gov.au/health/healthyliving/hypothermia>.
Temperature Management. 2014. [Online]. Available through: <
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Temperature_Mana
gement/ >