Patient Health Assessment Project Report

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.