Assessment Task 2A: Clinical Reasoning Report (Patient 1)

Clinical Reasoning Report

This assessment task aims to develop your ability to apply the first three phases of the clinical reasoning process, at an introductory level, to the patient scenario below.

Patient Scenario - Jessie Lin

You are a student nurse working with a school nurse (registered nurse) in a secondary school. You and your mentor are supervising a bubble soccer match this afternoon (26th March) which commenced at 1400 hrs. The match goes for 40 minutes with a 5 minute break in between the two halves. It is a hot and sunny day, the air temperature is 32 °C and the humidity is 45%.

Jessie Lin is 16 years old and in Year 11

It is now 1450 hours. You assess Jessie's vital signs and record the following results:

• Temperature (tympanic) 38.5°C

• Pulse rate 140 beats/min

• Respiratory rate (RR) 29 breaths/min

• Blood pressure (BP) 130/70mmHg

Jessie has flushed skin (see picture above) and her t-shirt is soaked. Her past medical history has not yet been documented in the school record as she is a new student and only enrolled in the school last week after moving from another state. She informs you that her mother is waiting for her in the car park, but she feels very hot and that her heart feels like it is beating very fast. She asks you for a bottle of cold water and a chair. 

Jessie's previous observation records (on a clinical chart) are:

What you need to do in your clinical reasoning report.