Mrs Brown presents to the hospital in preparation for her wound dressing change. When asked to come into the procedure room, Mrs Brown walks slowly but independently to the door and then sits on the examination bed. The nurse notes the following observations. Vital Observations: BP 105 / 70 mmHg HR 110 bpm (irregular pulse) RR 24 bpm Temp 37.7°C Sats: 96% (RA) Alert Complaining of 3/10 ‘throbbing’ pain around the wound area (at rest) While the vital signs are being collected, Mrs Brown mentions that she forgets to take her medications once or twice a week. Her voice is clear and her breathing appears unlaboured. Mrs Brown comments that she likes the new paint colour of the walls (the department had been painted the previous week) and asks the receptionist if she was a new staff member as she was not here on previous visits. When offered a coffee or tea, Mrs Brown declines, stating ‘I am not drinking a lot at the moment as I just have to go to the bathroom all the time’. Physical Assessment: Height: 162cm Weight: 71kg BGL: 10.2mmol/L Bilateral pedal pulses present Capillary refill 2 seconds on all limbs Equal air entry on lung auscultation, nil adventitious breath sounds detected Abdomen soft and palpable, nil complaints of abdominal discomfort Skin turgor on back of the hand 2-3 seconds Dry oral mucosa Mrs Brown states she ate her breakfast this morning at 08.30am and had toast with jam, and a cup of tea with two sugars. She explains she has ‘been a bit naughty with the diet’, consuming a lot of sugary foods and drinks, not eating much meat or vegetables, and skipping a lot of meals. While she normally opens her bowels once or twice per day, over the last few weeks she has been opening her bowels every four or five days, commenting ‘I feel uncomfortable sometimes in my belly and my stools have been quite hard’.
Question : Provide a brief description of the context of this scenario and enter relevant assessment data into the collecting cues section of the template. You should use the primary/secondary survey framework to undertake this activity.
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