Health Assessment 

Introduction to Jessie Lin

Jessie Lin is a sixteen-year-old year eleven student. There is no past health history recorded in the school as he is a new student. She was playing bubble soccer on a hot and sunny day. She started feeling extremely hot and experiencing increased heartbeat. Her skin appeared to be flushed and her t-shirt is soaked. She immediately asked for cold water to drink and chair to be seated.

Data Collection of Jessie Lin

These are some subjective and objective cues collected from reviewing the information provided.

Subjective

Objective

· Feeling very hot

· Racing heart beat

· Severe fatigue fatigued

· Shortness of breath

· Flushed skin

· Soaked shirts by sweat

· Vital signs as follows:

· Temperature: 38.5°C

· Pulse rate: 140 beats/min

· Respiratory rate: 29 breaths/min

· Blood pressure: 130/70 mmHg

Data Analysis of Jessie Lin

According to the collected cues following is found to be normal and abnormal

Normal

Abnormal

· Blood pressure: 130/70 mmHg

· Temperature: 38.5°c

· Pulse rate: 140 beats/min

· Respiratory rate: 29 breaths

· Flushed skin

· Soaked shirt and sweating face

As per the provided data, it is found that Jessie’s current blood pressure measurement is 130/70 mmHg, which is slightly high. Which could be dude to affected of prolonged the exercise, high level of stress, and increased temperature.

Jessie’s body temperature is 38.5°c which is indicative of fever of low grade (37.5- 38.5°c) The reason contributing to hypothermia is due to substantial exercise in the hot atmospheric conditions During heavy exercise, core body temperature of the body temperature by 1 to 1.5°C According to his earlier records, it has risen by 1.7°C. This will be auto-regulated by the body with rest/break and is not a factor for medical concern in this scenario.

Jessie’s respiratory rate has found to jump significantly from previous recordings of 12-14 to 29 breaths/minute.

Jessie’s current pulse rate has also rapidly increased as compared to her previous records This is a condition which requires medical attention, as it is indicative of tachycardia.

Body Mechanism of Jessie Lin

The following events took place in Jessie’s bodily functions, after playing soccer in hot climate for a prolonged period of time. Activation of negative feedback loop established homeostasis. This helps in maintenance of the body temperature. There are receptors on the skin, named thermoreceptors which are responsible for sensing the increase in the heat and carrying this vital information to the hypothalamus, which is the command center of the brain. The information is perceived and transmitted further via motor neurons arising from the brains to the blood supply of the muscles, skin and the sweat glands who in react to the message by increasing dilatation of the vessels, causing the skin to appear flushed. The sweat glands produce sweat which is a defense mechanism of the body to cool the heated surface of the skin when it evaporates (Levett-Jones, 2013).

Increase rate of respiration caused by the operating system of the brain, Medulla Oblongata. It is induced by the lack of energy and nutrition which is exhausted during intense exercise. The lack of energy is the cue to the brain to increase the breathing so that there is adequate oxygen supply reaching to the brain as a protective mechanism for survival. This in turn raises the breathing.

This also causes pressure on the heart to pump faster to deliver the amount of the oxygen to the blood vessels and the body organs, this increases the heart rate (Amerman, 2019).

Further Cues Collection

After completely analysing Jessie’s situation, I was concerned about her medical health. She had symptoms of tachycardia and tachypnoea. I made her sit comfortably on the chair with head in forward position to reduce the effort of breathing and to cool her down. Meanwhile, I sent one of her colleagues to inform her mother. There was no prior medical record comprising her past medical history, which I will obtain from her mother. Also, I started taking her vital signs. I also realized that it is important to record her vitals again after one hour, to check if her vitals are stabilized. In view of her condition, the following must be collected:

  • Blood pressure, heart rate, respiratory rate.
  • Past medical history related to respiratory illnesses, if any
  • Family history
  • Social history
  • Any infection Jessie’s suffering from (for example UTI or urinary tract infection or any other underlying infection)

It is important to assess the Jessie’s vital signs to evaluate and determine her current physical and psychological status (RPA policy directive, 2010). It is also necessary to social and family history to rule out whether her condition is due to genetic or hereditary root cause or only conditional, and shall subside the with rest (Sawka, Cheuvront, & Kenefick, 2012).

Management of other vital signs such as fever and severe fatigue

I counselled Jessie related her medical condition and assured her that she will feel normal after thirty minutes to one hour when the body has rested (Ely et al., 2010) I explained her that fever is only the response of the body due to an underlying infection; or as a response to playing for prolonged period in hot conditions in order to maintain the homeostasis in the body. She was advised to increase her fluid/water intake. Fluid is responsible for moving the waste material from the body such as metabolic waste, lactic acid and it also simultaneously provides nutrition to vital body organs. During excessive exercise, a significant amount of water is oozed out from the body in the form of sweat, which leads to dehydration (Cheuvront et al., 2010). Therefore, it is vital to have the knowledge of Jessie’s fluid intake in the past and ask to her maintain optimal fluid intake to avoid future relapses.

References for Clinical Reasoning Report

Amerman, E 2019, Human anatomy and physiology, 2nd global edition, Pearson education limited, United Kingdom. 

Cheuvront, S. N., Kenefick, R. W., Montain, S. J., & Sawka, M. N. (2010). Mechanisms of aerobic performance impairment with heat stress and dehydration. Journal of Applied Physiology109(6), 1989-1995.. doi.org/10.1152/japplphysiol.00367.2010

Ely, B. R., Cheuvront, S. N., Kenefick, R. W., & Sawka, M. N. (2010). Aerobic performance is degraded, despite modest hyperthermia, in hot environments. Medicine & Science in Sports & Exercise42(1), 135-141.

Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse.

NSW Government Health (2013), Standard Adult General Observation chart, NSW Health

Sawka, M. N., Cheuvront, S. N., & Kenefick, R. W. (2012). High skin temperature and hypohydration impair aerobic performance. Experimental physiology97(3), 327-332. doi.org/10.1113/expphysiol.2011.061002

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