Patient Health Assessment Project Report

Clinical Reasoning Report 1000 words please find attached file for all the detailed information and also a guide to Harvard referencing style. Scholarly sources of information.

Running head: HEALTH ASSESSMENT 1
Health Assessment
Student name
Institutional Affiliation

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Patient situation
The patient, Jessie Lin, is a 16-year-old girl who is from playing in a bubble football game for
forty minutes on a hot sunny day with humidity is 45% and external temperature at 32⁰C. After
the match, vital signs were taken to assess the patient condition. The temperature is 38.5⁰C,
respiratory rate at 29 breaths/min, rate of the pulse at 140 beats/min with blood pressure (BP)
measuring 130/70 mmHg. The patient has flushed skin and a soaked t-shirt. She reports to be
feeling very hot, thirsty and asks for a chair to sit on.
Cue collection
Subjective data Objective data
 Jessie reports being feeling very hot,
which is normal due to the hot weather.
 The patient feels a fast-beating heart
which is expected after an activity.
 The patient reports feeling thirsty and
fatigued, which is normal after physical
exertion.
 Temperature (Temp) is 38.5⁰c which is
abnormal (standard range 36.5-37.5⁰C).
 Rate of respiration (RR) is 29
breaths/min, which is deranged (normal
range according to Hill and Annesley
(2020, p.12-16) is 12-20 breaths/min).
 Pulse rate (PR) is 140 beats/min that
are not normal (standard range is 60-
100 beats/min).
 Blood pressure (BP) is at 130/70
mmHg, a standard reading.
 The patient has a flushed skin which is
abnormal.

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 The patient’s t-shirt is soaked probably
with sweat which is normal after the
physical activity.
Processing information
From the above cues collected; it is depicted that vital signs are deranged. Temperature,
pulse rate, respiratory rate and BP are abnormal. The patient is thirsty and complains of fatigue.
The finding in this assessment is different from the previous health assessment done. On 23rd
march; the temperature was 36.8, BP 110/60 mmHg, RR of 14 breaths/min and a PR of 70
beats/min while on 24th march, temp -36.6, PR – 74 b/min, respirations- 12 breaths/min and BP-
112/60 mmHg. Regarding the previous vital signs, Jessie seems to be healthy, and the increase in
the essential sign reading is a result of a body function to maintain homeostasis.
During an activity, the body requires more energy than usual to be able to keep up; hence
there is increased muscle breakdown. Breakdown of muscles and fat to provide energy requires
more oxygen. Blood is the medium for transport of oxygen bound to haemoglobin from the lungs
to the muscle. Due to increased demand of oxygen by the muscles, the heart pounds at a higher
rate to deliver more blood and oxygen into the tissues for metabolism (Belzile et al., 2019,
pp.A11806-A11806) The rise in heart rate is directly proportionate to the intensity of the
exercise, and it increases more on individuals who are non-athletes. Due to the increasing force
left ventricle to pump blood to muscles, more blood is drained into blood vessels, and this
increases blood pressure during physical activity: both heart rate and pressure return to a
standard few minutes after exercise.

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Respiration is affected during exercise since it's the process by which oxygen is delivered
into the body with the elimination of carbon iv oxide. Due to increased muscle oxygen demand,
the individual breaths faster and more profound. Gaseous exchange occurs at the lung alveoli,
and increases in the rate of breathing maintain a high concentration gradient in the alveoli
maximizing uptake of oxygen and elimination of carbon iv oxide (Yang, Cao, and Liu, 2019, pp
1-24). Core body temperature rises during exercise due to the increased metabolism, which
produces energy that is converted to heat. The humidity is high (45%), and this inhibits the
evaporation of sweat to cool the body; hence the skin temperature remains high. Jessie's shirt is
soaked due to the low rate of evaporation of sweat in the high humidity environment (Abellán-
Aynés et al., 2019, pp. 260-267). She has a flushed skin due to increased blood flow to the skin
surface as a result of generalized vasodilation. When core temperature exceeds the normal range,
the hypothalamus sends signals to blood vessels initiating vasodilation (Vieira, 2016, pp. 33-
38)> Feeling of thirst is normal after exercise due to excessive loss of water through sweating,
and the patient is fatigued from the activity that depleted energy in the body.
Further cues
A repeat of vital signs is necessary after immediate interventions to retain homeostasis.
Due to the high humidity and hot weather, Jessie’s temperature lowering mechanism is
compromised. I would advise the patient to remove extra clothing and apply cold towels on her
neck to cool the body drinking of fluids is necessary to prevent dehydration and to ensure fluid
volume is kept normal (Rojas-Valverde et al., 2019, p. 569-570). Repeating the vital signs is
essential to confirm the presence of any pathology.

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Body mass index (BMI) is another cue to be calculated regarding the patient vital sign
measurement after the exercise. After the interventions, I will measure the client's height and
weight to calculate the BMI. In individuals with a higher BMI, the body requires more energy for
the activity; hence there is increased muscle work. The increased muscle work requires more
oxygen than for individuals with healthy BMI (Zou and Gao, 2018, pp. 902-906). This relation
facilitates the increased heart function to pump blood to the overly exerted muscles. This further
increases the pulse rate and blood pressure to supply oxygen for the breakdown of the fatty tissue
to produce energy. Jessie's vital signs have increased exponentially after the match and maybe a
result of a higher BMI.
I prefer to perform an arterial blood gas analysis for the patient. The test is used to
confirm the capability of the lungs to provide oxygen into circulation and eliminate carbon iv
oxide from the body. The ability of the lungs to supply enough oxygen for the body tissues is
essential in physical activity to ensure the body can quickly return to homeostasis after the
exercise (Bosco et al., 2018, p. 1158). The vital signs are extraordinarily elevated and may
indicate ineffective perfusion hence compensatory mechanisms of increased heart rate and
respiratory rate.

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References
Abellán-Aynés, O., López-Plaza, D., Alacid, F., Naranjo-Orellana, J. and Manonelles, P., 2019.
Recovery of Heart Rate Variability After Exercise Under Hot Conditions: The Effect of
Relative Humidity. Wilderness & environmental medicine, 30(3), pp.260-267. Doi
10.1016/j.wem.2019.04.009.
Belzile, D., Lebel, A., Auclair, A., Pettigrew, M., Biertho, L., Marceau, S. and Poirier, P., 2019.
The Modulating Effect of Exercise on Heart Rate Variability After Bariatric
Surgery. Circulation, 140(Suppl_1), pp.A11806-A11806. Doi
10.1016/j.cjca.2019.07.480.
Bosco, G., Rizzato, A., Martani, L., Schiavo, S., Talamonti, E., Garetto, G., Paganini, M.,
Camporesi, E.M. and Moon, R.E., 2018. Arterial blood gas analysis in breath-hold divers
at depth. Frontiers in physiology, 9, p.1558. Doi 10.3389/fphys.2018.01558.
Hill, B. and Annesley, S.H., 2020. Monitoring respiratory rate in adults. British Journal of
Nursing, 29(1), pp.12-16. Doi 10.12968/bjon.2020.29.1.12.
Rojas-Valverde, D., Gutiérrez-Vargas, R., Sánchez-Ureña, B. and Mjaanes, J.M., 2019. Effects
On Skin Temperature of Marathon Running in a Hot Humid Environment: 2094: Board#
250 May 30 2: 00 PM-3: 30 PM. Medicine & Science in Sports & Exercise, 51(6),
pp.569-570. Doi 10.1249/01.mss.0000562212.76160.ff.
Vieira, T., 2016, May. Parameterized skin for rendering flushing due to exertion. In Proceedings
of the Joint Symposium on Computational Aesthetics and Sketch-Based Interfaces and

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Modeling and Non-Photorealistic Animation and Rendering (pp. 33-38). Doi
10.1002/cav.1725.
Yang, Y., Cao, J. and Liu, X., 2019. ER-Rhythm: Coupling Exercise and Respiration Rhythm
Using Lightweight COTS RFID. Proceedings of the ACM on Interactive, Mobile,
Wearable and Ubiquitous Technologies, 3(4), pp.1-24. Doi 10.1145/3369808.
Zou, X. and Gao, J., 2018. A Study of Exercise Intensity Based on Individual’s BMI and Heart
Rate. Health, 10(7), pp.902-906. Doi 10.4236/health.2018.107066.