PAMANTASAN NG LUNGSOD NG PASIG

A. Jose St., Kapasigan Pasig City

COLLEGE OF NURSING

Case Study On

Left-Sided Hemothorax secondary to

Gunshot Wound

Introduction
Hemothorax is the presence of blood in the pleural space. The source of blood may be
the chest wall, lung parenchyma, heart, or great vessels. Although some authors state that a
hematocrit value of at least 50% is necessary to differentiate a hemothorax from a bloody pleural
effusion, most do not agree on any specific distinction.
Hemothorax is usually a consequence of blunt or penetrating trauma. The trauma from a
gunshot wound or a stab wound is the most common cause of hemothorax. Much less commonly,
it may be a complication of disease, may be iatrogenically induced, or may develop
spontaneously.
Prompt identification and treatment of traumatic hemothorax is an essential part of the
care of the injured patient. The upright chest radiograph is the ideal primary diagnostic study in
the evaluation of hemothorax. In cases of hemothorax unrelated to trauma, a careful investigation
for the underlying source must be performed while treatment is provided.
In this study, we will know how the patient got the condition, the condition itself, and her
course in the hospital. We also aim to further understand the treatment, manifestations, and
nursing actions in patients with hemothorax.
Demographic Data
Name: V, E A.
Sex : Female
Age : 34 years old
Birthdate: June 3, 1983
Birth place: Quezon City
Civil status: Single
Race/ Nationality: Filipino
Educational Background: High School Graduate
Address: Upper Bicutan, Taguig City
Occupation: Unemployed
Source of Income: Salary of Husband (Dealer)
Admission Diagnosis: Left-Sided Hemothorax secondary to gunshot wound
Final Diagnosis: s/p Posterolateral Thoracotomy
Date Admitted: May 14, 2017
Time Admitted: 6:00 AM
Information Source and Reliability of Information
The data in this paper was primarily taken from the patient herself, and some of the
information in this case presentation was taken from the patient’s chart. The patient is known to
have taken illicit substances outside the hospital. However, the data given by the patient is reliable
because when asked, the patient is not withdrawn and the patient answers the nurse’s questions
with confidence and honesty.
Chief Complaint
The patient came to the hospital because of a gunshot wound at May 14, 2017 at about 4
AM. She complains of pain in the left chest and left arm, bleeding, and difficulty of breathing.

History of Present Illness

 An hour prior to confinement, the patient was allegedly shot twice in her house by an
unknown assailant. The first shot was a missed shot, but the bullet penetrated her left arm. The
second shot landed on her chest and the assailant escaped. She sought for help and was brought
to a hospital in Pateros, but she was not accepted because they lack bed capacity. She was
admitted at PCGH at about 5:30 AM.
Past Medical History
The patient said has no history of hospitalization because her illnesses are just cured at
home. She said that she does not consult the doctor and she just self-medicates to heal. She has
no history of hypertension, or DM. Her father died of cancer of the throat, and her mother has
hypertension.
Physical Assessment

SKIN
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
GENERAL COLOR (+) Normal (+) Normal
Normal (-) Pallor (-) Pallor Normal
Pallor (-) Jaundice (-) Jaundice
Jaundice (-) Redness (-) Redness
Redness
MOISTURE
Moist (+) Moist (+) Moist Normal
Dry (-) Dryness
Wet/Clammy (-) Clammy skin
Oily (-) Oily skin
TEXTURE
Smooth (-) Scaly skin (+) generalized Normal
Scaly (-) Rough skin smooth skin
Rough
Palpation:
TEMPERATURE (+) Warm (+) Warm Normal
Warm (-) Cool
Cool
TURGOR
Good (+) Good (+)Good skin turgor Normal
Fair
Poor
EDEMA
No edema (-) Edema (-) Edema Normal
Pitting
Non pitting
Pedal R/L
Others:
 Petechiae (-) Petechiae (-) Petechiae Normal
Ecchymosis (-) Ecchymosis (-) Ecchymosis
Lesions/ (-) Lesions (-) Lesions
Rashes (-) Rashes (-) Rashes

HEAD
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
SCALP (+) Clean (-) Dandruff Normal
Clean (-) Dandruff
Dandruff (-) Lice
Lice (-) Wounds/ Scars
Wounds/ Scars/ (-) Lesions
Lesions
HAIR
Normal/ Even (+) Even distribution (+) Black, shiny, Normal
distribution (-) Fine texture evenly distributed
Fine (-) Coarse texture with average
Coarse (-) Dry texture
Dry (-) Alopecia
Alopecia
Palpation:
CONFIGURATION (+) Normocephalic (+) Normocephalic Normal
Normocephalic (-) Masses (-) Masses
Masses
FONTANELS
Closed Not applicable Not applicable
Open
Sunken
Bulging

EYES
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
LIDS (+) Symmetrical (+) Edema Allergic
Symmetrical (-) Edema Reaction to
Edema/ Swelling (-) Swelling Ketorolac
PERIORBITAL
REGION (+) Normal (+) Edema Allergic
Normal (-) Edema Reaction to
Edema (-) Sunken Ketorolac
Sunken (-) Discoloration
 Discoloration
CONJUNCTIVA
Pinkish (+) Pinkish (+) Pinkish Normal
Pale (-)Pale palpebral
Lesion (-) Lesion conjunctiva
Discharge (-) Discharge
SCLERA
Anicteric (+) Anicteric (+) White, anicteric Normal
Sub icteric (-) Hemorrhages sclera
Icteric
Hemorrhages
CORNEA
Smooth (+) Smooth (+) Smooth and Normal
Clear (+) Clear clear with no
Lesions (-) Lesions opacity nor scratch
Opacity (-) Opacity
Arcus Senilis (-) Arcus Senilis
PUPILS (+) Equal in size,
Equal (+) Equal round and regular in Normal
Unequal shape.
Diameter (R) 2-4 mm (light) Pupil is 4mm
Diameter (L) 4-8 mm (dark) constricting to 2mm
REACTION TO Pupil equally
ACCOMODATION reactive to light and
Uniform (+) Uniform accommodation Normal
Constriction constriction
Unequal
Constriction
CONVERGENCE (+) Uniform Pupil equally
Uniform convergence reactive to light and Normal
Convergence accommodation
Unequal
Convergence
VISUAL ACUITY
Grossly Normal (+) Grossly normal Can read signages Normal
Wears eye-
glasses
Other findings: (+) Blink reflex Normal

EARS
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
EAR PINNAE (+) Symmetrical (+) Symmetrical, Normal
Symmetrical (-) Abnormalities color same as skin,
Gross mobile, firm and
Abnormalities non-tender
EAR CANAL
Normal (+) Normal Left canal clear Normal
Impacted (-) Impacted cerumen Right canal clear
cerumen (-) discharge No discharge
Discharge
Foul smell
Mucoid
Serous
Purulent
GROSS HEARING Acuity good to
Symmetrical (+) Symmetrical whispered voice on Normal
Deafness on L/R (-) Deafness on L/R both L and R side

NOSE
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
NASOLABIAL (+) Symmetrical (+) Symmetrical Normal
Symmetrical No nasal flaring
Shallow
nasolabial fold L/R
SEPTUM
Midline (+) Midline (+) Midline Normal
Deviated to L/R (-) Deviation
Perforated (-) Perforation
MUCOSA
Pinkish (+) Pinkish (+) Pinkish nasal Normal
Pale (-) Pale mucosa, no
Reddish (-) Reddish congestion
DISCHARGE
No discharge (-) Discharge No nasal discharge Normal
Serous
Mucoid
Purulent
Bloody
PATENCY
Both patent (+) Both patent Patent nares with
Obstructed L/R (-) Obstructed L/R good air entry
Masses/ Lesions (-)Masses/ Lesions
GROSS SMELL
 Symmetrical (+) Symmetrical (+) Symmetrical Normal
Olfactory
Deficiency L/R
SINUSES No tenderness on
Non-tender Non-tender Frontal and Normal
Tender Maxillary sinuses

MOUTH
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
LIPS
Normal (+) Normal (-) Pallor Normal
Pallor (-) Pallor
Cyanosis (-) Cyanosis
Dryness/ Crack (-) Dryness
Lesions (-) Lesions
Swelling (-) Swelling
TONGUE
Midline (+) Midline (+) Midline Normal
Deviation to L/R (-) Deviation
Atrophy (-) Atrophy
Fasciculation (-) Fasciculation
Lesions (-) Lesions
TEETH
Complete (+) Complete 6 upper teeth Lack of Dental
Missing Teeth (-) Missing teeth 3 bottom teeth hygiene
Caries (-) Caries (+) caries
Dentures
Braces/ Retainers
GUMS
Pinkish (+) Pinkish (+) Darkened Smoking
Pale
Bleeding
Tenderness
BUCCAL MUCOSA
Pinkish (+) Pinkish Pinkish buccal
Pale mucosa Normal
Cyanotic
Stenson’s Duct
SPEECH Due to missing
Intact (+) intact (+) slurred speech teeth
Slurred
 Aphasia

PHARYNX
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
UVULA (+) Midline (+) Midline, No Normal
Midline deviation
Deviation to L/R
MUCOSA
Pinkish (+) Pinkish (+) Dull red color Normal
Pale
Reddish
TONSILS
Not inflamed Not inflamed Pink and smooth, Normal
Slightly inflamed not inflamed with no
Exudate exudate

NECK
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
TRACHEA (+) Midline (+) Midline Normal
Midline (-)Deviation to L/R
Deviated to L/R
Palpation:
CERVICAL LYMPH Non-palpable No cervical Normal
NODES Non-Tender lymphadenopathy
Non-palpable
Palpable
Tender
THYROID GLAND
Non-palpable Non-palpable Non-palpable Normal
Enlarged
RANGE OF MOTION
Normal (+) Normal Supple, Erect, No Normal
Neck Rigidity (-) Neck rigidity neck rigidity
Others:
Masses (-) Masses No mass noted no Normal
Neck vein (-) Neck vein neck vein
engorgement engorgement engorgement

BREAST AND AXILLA

CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection: Equally pendulous
SIZE AND SYMMETRY (+) Equal extending from 2nd Normal
Equal rib down to the 6th
Unequal rib.
SKIN
Normal Redness (+) Normal (+) Normal Normal
Venous
prominence
Edema
CONTOUR
Normal (+) Normal (+) Normal Normal
Masses (-) Masses
Dimpling (-) Dimpling
NIPPLE AND AREOLA
Normal (+) Normal Nipples and areola Normal
Inversion are dark
Flattening or
Retraction
Edema
Discharge
Deviation

LUNGS
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
BREATHING (+) Effortless Pain on breathing Pain on
PATTERN (-) Hyperventilation incision and
Effortless (-)Use of accessory inserted
(Eupnea) muscles thoracic
Hyperventilation catheter
Use of accessory
muscles
SHAPE OF CHEST
Anterior- Normal
Posterior-Lateral
Ratio
AP___L____
Barrel Chest
Funnel
Pigeon
Other
CHEST EXPANSION (+) Symmetrical
Symmetrical (+) Symmetrical lung expansion Normal
Decreased L/R
Percussion:
Resonant (+) Resonant (+) Dullness on left Expected
Dullness lung base findings on
Hyperresonant pleural
Tympany effusion or
Flatness hemothorax
Vocal/Tactile
Symmetrical (+) Symmetrical (+) Decreased on Expected
Decreased/ left lung base findings on
Increased pleural
effusion or
hemothorax
Breath Sounds
Normal (+) Normal (+) Decreased on Expected
Abnormal (+) Vesicular left lung base findings on
Bronchovesicular pleural
Vesicular effusion or
Bronchial hemothorax
Wheezes
Rhonchi
Rales
Pleural Friction
Other findings: >Placement of a chest tube connected to a one-way bottle;
inserted at left 9th intercostal space
>Visible scar on the left side of the chest due to gunshot
wound

HEART
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
PERICORDIAL AREA (+) Adynamic Adynamic Normal;
Flat precordium precordium; No
Normodynamic (-) Bulging heave, no thrills.
Precordial (-) Tenderness PMI: 5th Intercostal
Hyperdynamic (-) Heave Space (ICS) on the
Precordial (-) Thrill left mid-clavicular
Bulging line
Tenderness
Heave
Thrill
 Point of Maximal
Impulse (PMI)
Apical Beat (AB)
Auscultation:
HEART SOUNDS (+) Distinct heart S1 louder than S2 at Normal
Distinct sounds the apex
Faint S2 louder than S1 at
S1S2 at base the base
S1S2 at apex
EXTRA SOUNDS
S3 Normal
S4
Murmur, grade
Best heard at

ABDOMEN
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
SKIN
Normal (+) Normal Normal skin with Normal
Dilated vein (-) Dilated veins linea nigra
Scars
Rashes
Striae
Lesion
CONFIGURATION
Flat Protuberant Poor abdomen
Globular abdomen muscle tone
Protruberant
Scaphoid
UMBILICUS
Normal/ Sunken (+) Normal (+) Normal/Sunken Normal
Bulging
Hernia
Palpation:
Normal (+) Normal Flabby, no muscle Normal
Muscle guarding (-) Muscle guarding guarding, Non-
Direct tenderness (-) Tenderness tender
Rebound
tenderness
Percussion:
Resonant (+) Tympanitic (+) Tympanitic Normal
Tympanic
 Hypertympanic
Fluid wave
Shifting dullness
Auscultation:
BRUIT (-) Absent (-) Absent Normal
Present
Absent
BOWEL SOUNDS
Normoactive (+) Normoactive (+) Normoactive Normal
Hyperactive
Hypoactive
Absent

GENITOURINARY
CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
Inspection:
LABIA (+) Symmetrical Patient refused
Normal (+) Pinkish genital examination
Symmetrical No discoloration
Asymmetrical
Lesion
Pinkish
Discoloration
Edema
VAGINAL ORIFICE
Normal (+) Normal Patient refused
Discharge (-) Discharge genital examination
Purulent
Bloody
Foul smelling
INGUINAL
Normal size (+) Normal size Patient refused
Enlarged genital examination
BARTHOLINS GLAND
Normal (+) Normal Patient refused
Swelling genital examination
Discharge
Tenderness

BACK AND EXTREMITIES

CHARACTERISTICS: NORMAL ACTUAL INTERPRETA
FINDINGS: FINDINGS: TION:
PERIPHERAL PULSES
 Inspection: (+) Symmetrical Present, Normal
Symmetrical Symmetrical
Absent
Palpation:
Normal Normal
Warm
Bounding
NAILS & NAIL BEDS
Inspection: (+) Normal Pallor Recent blood
Normal loss
Redness
Swelling
Pain
Palpation:
Normal No tenderness No tenderness Normal
Tenderness
Auscultation:
Normal No crepitation No crepitation Normal
Crepitation
JOINTS
Inspection: No joint deformities.
Normal (+) Normal With good range of Normal
Redness motion. No swelling,
Swelling no redness, no pain
Pain
Palpation:
Normal No tenderness No tenderness Normal
Tenderness
Auscultation:
Normal No crepitation No crepitation Normal
Crepitation
MUSCLE TONE &
STRENGTH (+) Symmetrical Patient can’t raise Comminuted
Inspection: her left arm fracture on left
Symmetrical humerus
Normal Tone
Tics
Tremors
Palpation:
Normal (+) Normal Normal, non-tender Normal
Fasciculation
SPINE The shoulder is
Inspection: (+) Midline tilted to left side Normal in
Midline patients with
Kyphosis CTT
 Lordosis
Scoliosis
COSTOVERTEBRAL
ANGLE No tenderness No tenderness Normal
Palpation:
Normal
Tenderness
Other findings: >Left arm deformity and tenderness
>Visible scar on left arm

Family History: Genogram

Gordon’s Functional Health Pattern
A. Health Perception and Health Management Pattern
Before confinement
According to the patient, the
patient loved walking at night.
She considers this as an
exercise. When she felt sick,
she just stayed at home and
self-medicate. Outside the
hospital, she claims to have
used drugs from 1995 up to the
present, before her
confinement, and she also
drinks a cup of coffee everyday.
She said that she want to leave
the hospital as soon as the
procedures are finished. She
doesn’t believe in faith healers.
B. Nutritional and Metabolic Pattern
Before confinement
Before confinement, the patient
claims to have wanted food that
she cooks at home. She said
that she doesn’t like buying food
from vendors. She also said that
she can eat all sorts of food like
vegetables and meat and she
isn’t a picky eater.
C. Elimination Pattern
Before Confinement
Before the confinement, the
patient said that she was
defecating at least once a day,
and the patient never had a
history of urinary difficulties and
urinary infections.
During Confinement Identified Nursing
Diagnosis
During the hospital stay, the Readiness for enhanced
patient was able to care for health management
herself. She could bathe and
eat alone as long as food is
present. She is not taking the
illicit drugs during the hospital
stay, but claims to have drank
more coffee now that she is
inside the hospital. She said
that she is drinking up to 3 cups
of coffee.
During confinement Identified Nursing
Diagnosis
In the patient’s confinement Imbalanced nutrition: less
period, she said that the she than bodily requirements
only eats what the hospital is
giving and if she wants, she
eats cup noodles.
During Confinement Identified Nursing
Diagnosis
During the hospital stay, she is Risk for constipation
able to go in and out of the
bathroom whenever she feels
the urge. She also defecates
everyday, and she doesn’t have
any difficulties urinating too.
D. Activity and Exercise Pattern
Before confinement
The patient did not participate in
any exercise program outside
the hospital. She says that she
was only sleeping during the
day, but sometimes, she does
house chores like cooking and
she has no trouble doing it. She
says that she is more active at
night, and when she is under
the influence of drugs, she says
that she loves to walk.
E. Sleep and Rest Pattern
Before confinement
The patient said that she was
not sleeping at night. She was
resting during the day because
she said that she was taking
drugs during night, and the
drugs keep her awake. There
were also times that she isn’t
sleeping for 2 days. If sleepy,
she would sleep in the day for 6
hours.
F. Cognitive Perceptual Pattern
Before confinement
Before confinement, the patient
wasn’t having any hearing,
sight, or memory difficulty. She
said that the last time that her
vision was checked was 2007.
Even though she takes drugs,
she said that nothing have
changed, but if she takes drugs,
it is like her thinking is enhanced
During confinement Identified Nursing
Diagnosis
Now that she is confined, she Readiness for enhanced
said that she misses walking, so health management
she is commonly seen walking
in and out with her bottle. While
at the hospital, she can take
care of himself. She can take a
bath and take herself to the
bathroom without any trouble.
During confinement Identified Nursing
Diagnosis
Now that the patient is confined, Disturbed sleep pattern
if she isn’t talking to the patients
of the ward, she is seen
napping or her eyes are closed.
She said that she can rest well
and sleep up to 8 hours.
During confinement Identified Nursing
Diagnosis
Now that she is confined, she Readiness for enhanced
says that she doesn’t feel that knowledge
anything have changed. She
can read the signage in the
ward.
G. Self-Perception and Self-Concept Pattern
Before confinement
Before confinement, the patient
said that she was confident with
herself. She says that she was
always happy outside the
hospital because she talks to
everyone and that everyone in
their neighborhood is her friend.
H. Role Relationship Pattern
Before confinement
She was separated with her
family. She was living with her
live-in partner in the time that
the incident happened. She has
two sons, the one is in college,
and the other is in high school.
She said that her sons just
depend on her for problems
other than finances, because
finances are handled by their
father. She said that they are
not a problem at all because
they have contact and they
meet at Fridays. Her mother
goes to stay with her at the
hospital sometimes. During
stress, the patient just relies on
herself because she doesn’t
want to add to anyone’s stress.
During confinement Identified Nursing
Diagnosis
Now that she is confined, the Readiness for enhanced
patient said that she sees health management
herself the same way before
she was confined. She said that
her arm injury would be
bothering because it would be
harder to move around, but it
won’t change the way she looks
at herself. She feels a bit angry
at the person that is responsible
why she was shot.
During confinement Identified Nursing
Diagnosis
During the confinement, her Readiness for enhanced
sons come to visit her on relationship
Fridays, and some of her
relatives have come to check on
her condition. Her live-in partner
did not have the chance to visit
her because he went back to
Mindanao for his safety. The
patient that this incident have
become a burden for her
brother and sister because they
have their own lives but they
worry for the patient’s hospital
bills. During stress, she
sometimes talks to her mother
because she is present
I. Sexuality-Reproductive Pattern
Before confinement
Her present relationship is her
2nd live-in partner. She admits
that they have a sexual
relationship and there is no
problem with regards to sexual
patterns. She admitted that she
didn’t use any contraceptives of
some sort. She said that she
had regular menstruation and
her menarche was when she
was 12.
J. Coping Stress Pattern
Before confinement
The before the patient was
confined, she said that she was
very confident. She doesn’t
care who she talks to because
her treatment to people are all
the same, She said that she
doesn’t let herself feel stressed
because if she does, she
handles it alone because she
doesn’t want to seek help from
other people. Sometimes, she
uses drugs to relieve her
stress.
K. Value and Belief Pattern
Before confinement
The client’s religion is Islam.
She isn’t a devoted worshiper
and she sometimes eats pork
which goes against her current
religion. She said that she
values her god because of the
second chance that she got in
life. She said that her family is
her strength.
During confinement Identified Nursing
Diagnosis
Now that the patient is confined, Knowledge deficit
she said that her live-in partner
is now in Mindanao for his
safety. She said that it is alright
because they have
communication.
During confinement Identified Nursing
Diagnosis
Now that she is confined, she Knowledge deficit
said that it was very stressful for
her to be confined because she
knows who is behind the incident
that caused her hospitalization.
She said that she wants to take
revenge to vent her stress out
but in the hospital, she is happy
because there are happy
patients with her in the ward.
During confinement Identified Nursing
Diagnosis
The patient said that she still Readiness for enhanced
believes in her god and that spiritual well-being
hope haven’t left her because
she have been saved in the
hospital. She said that her
family will be of help to give her
strength.
Anatomy and Physiology

 Nasal Cavity (Filters and moistens the inhaled air)

 Pharynx (Passageway of food and air)
 Larynx (Also known as the “voice box”; produces voice)
 Trachea (ciliated cartilaginous tube that is a passageway of air)
 Bronchus (passageway of air after trachea)
 Lungs (Houses the bronchus, bronchioles, and alveoli)
 Alveoli (Primary unit of gas exchange)
 Diaphragm (Major muscle that is responsible for the expansion and compression of the
lungs)
 Pleural Cavity (Cavity that covers the lungs)
The respiratory system has four main functions. They are:

1. BREATHING or ventilation
2. EXTERNAL RESPIRATION, which is the exchange of gases (oxygen and carbon dioxide)
between inhaled air and the blood.
3. INTERNAL RESPIRATION, which is the exchange of gases between the blood and tissue
fluids.
4. CELLULAR RESPIRATION
In addition to these main processes, the respiratory system serves for:

 REGULATION OF BLOOD pH, which occurs in coordination with the kidneys, and as a
 DEFENSE AGAINST MICROBES
 Control of body temperature due to loss of evaporate during expiration

External Respiration

Breathing is an active process - requiring the contraction of skeletal muscles. The primary
muscles of respiration include the external intercostal muscles (located between the ribs) and the
diaphragm (a sheet of muscle located between the thoracic & abdominal cavities).

The external intercostals plus the diaphragm contract to bring about inspiration:

 Contraction of external intercostal muscles > elevation of ribs & sternum > increased front-
to-back dimension of thoracic cavity > lowers air pressure in lungs > air moves into lungs
 Contraction of diaphragm > diaphragm moves downward > increases vertical dimension
of thoracic cavity > lowers air pressure in lungs > air moves into lungs

To exhale:

 relaxation of external intercostal muscles & diaphragm > return of diaphragm, ribs, &
sternum to resting position > restores thoracic cavity to preinspiratory volume > increases
pressure in lungs > air is exhaled

Pathophysiology
Theoretical Pathophysiology
Client-based Pathophysiology
Diagnostic and Laboratory Results
Radiographic Imaging
CXR AP/LAT (5/14/17)
CXR AP/LAT (5/15/17)
CXR AP/LAT (5/17/17)
CXR AP/LAT (5/21/17)
CXR AP/LAT (5/24/17)
Arm/Humerus AP/LAT (5/30/17)
Arm/Humerus AP/LAT (6/7/17)
CXR AP/LAT (7/3/17)
Significant Results
Patches of opacities in the left lung; Left-sided
CTT is noted
Progression of confluent opacities; indicative
of hemothorax or pulmonary contusion
Hazy opacity in the left lower lung
Partial clearing of the haziness in the left lower
lung
No significant changes
Comminuted fracture on the left mid-humeral
diaphysis; soft tissue swelling
Comminuted fracture on the left mid-humeral
diaphysis
Haziness in the left lower lung field
CT SCAN (5/30/17)

Result

1. Reticulonodular density noted at the right apex

2. Moderate left pleural effusion noted with compression atelectasis of the left lower lobe.
Left-sided CTT is noted with tip at the level of the superior segment of the left lower lobe
3. No evident enlarged lymph nodes seen
4. The heart and blood vessels are non-remarkable
5. The trachea-bronchial tree is patent, with no intraluminal lesions evident
6. The rest of the soft tissues and osseous structures are intact

Impression

1. PTB, right apex

2. Moderate pleural effusion with compressive atelectasis of the left lower tube

HEMATOLOGY

Complete Blood Count

Examination May 14 May 17 June 7 July 12 Units Normal
Hemoglobin 77 90 98 116 g/L 135 – 180
Hematocrit 0.24 0.29 0.32 0.37 % 40 – 54
RBC Count --- --- --- --- x1012/L 4.5 – 6.0
Platelet 354 --- 130 479 x109/L 150 – 400
Count
WBC Count 17.7 --- 7.6 6..0 x109/L 4.5 – 11.0
Band Cells --- --- --- --- --- 0.00 – 0.05
Neutrophils 0.89 --- 0.53 0.45 --- 0.35 – 0.65
Lymphocytes 0.05 --- 0.37 0.46 --- 0.20 – 0.40
Monocytes 0.04 --- 0.05 --- --- 0.02 – 0.08
Eosinophils 0.01 --- 0.05 0.09 --- 0.00 – 0.05
Basophils --- --- --- --- --- 0.00 – 0.01

 Hematocrit is decreased in severe anemias, anemia of pregnancy, acute massive blood

loss
 Hemoglobin is decreased in various anemias, pregnancy, severe or prolonged
hemorrhage and with excessive fluid intake
 Platelet count is increased in malignancy, myeloproliferative disease, rheumatoid arthritis,
and postoperatively; about 50% of patients with unexpected increase of platelet count will
be found to have a malignancy; decreased in thrombocytopenic purpura, acute leukemia,
aplastic anemia, and during cancer chemotherapy.
 WBC Count is increased in patients that have infections
 High neutrophils and low lymphocyte count signifies bacterial infection
POCT Electrolytes
Examination June 7 July 12 Normal Values
Sodium 138.8 135.1 136.00 – 145.00
mmol/L
Potassium 3.85 3.93 3.50 – 5.10 mmol/L

APTT, PTT
PT June 8 July 12 Normal Values
Time 13.4 secs 12.8 secs 11.0 – 14.0 secs
INR 1.12 INR 1.07 INR 0.80 – 1.2
%Activity 74.9% 73.4% >70.0%
APTT June 8 July 12
Time 48.0 secs 27.9 secs 25.0 – 35.0 secs

 An elevated APTT signifies that bleeding is present

Clinical Chemistry (June 12, 2017)

Examination Result Normal Values
Creatinine 67.88 53.04 – 106.08 umol/L
Chloride 101.3 98 – 106 mmol/L
Ionized Calcium 1.12 1.13 – 1.32 mmol/L

Clinical Chemistry
Examination May 29 June 8 Normal Values
BUN 3.62 3.32 2.5 – 7.14 mmol/L
Creatinine 54 61 46 – 110 umol/L
Albumin --- 25 35-51 g/L

 Low albumin count signifies malnutrition or hemorrhage

Drug Study
Azithromycin
Indications Acute bacterial worsening of COP cause by
Haemophillus influenza, Moraxella catarhallis,
or Streptococcus pneumonia, community-
acquired pneumonia from chalmydia
pneumonia, H. influenza, Mycoplasma
pneumoniae, or S. pneumoniae, chancroid,
mild to moderate bacterial sinusitis,
Nongococcal urethritis or cervitis caused by
C.trachomatis
Contraindications Patients hypersensitive to the drug,
erythromycin, or other macrolide or ketolide
anitbiotics, patients with impaired hepatic
function
Dosage 1 tablet (500 mg) OD oral (5/17/17 – 5/24/17)
Nursing Consideration Obtain specimen for culture and sensitivity
tests before giving first dose, monitor patient
for superinfection, don’t give with antacids
Health Teaching Tell patient that drug may be taken with or
without food; patient should follow the
prescribed antibiotic therapy to avoid
superinfection and drug resistance

Paracetamol
Indications Mild pain or fever
Contraindications Contraindicated in patients hypersensitive to
the drug or its components, patients with long-
term alcohol use because therapeutic doses
could cause hepatotoxicity in these patients
Dosage 1 ampule (150 mg) q4 SIVP RTC (7/17/17 –
present)
Nursing Consideration Check IV line patency as drug is oil-based and
irritating to the vein, dilute drug in sterile water
for patient’s comfort, flush IV line before and
after administration
Health Teaching Tell patient to report if pain or fever is still
present because paracetamol is hepatotoxic.

Celecoxib
Indications Relieve signs and symptoms of osteoarthritis,
rheumatoid arthritis, and ankylosing
spondylitis, adjunctive treatment for familial
adenomatous polyposis to reduce the number
of adenomatous colorectal polyps, acute pain
and primary dysmenorrhea
Contraindications Patients hypersensitive to the drug,
sulfonamides, aspirin, or other NSAIDs,
severe hepatic impairment, and in the
treatment of perioperative pain after coronary
artery bypass graft surgery, third trimester of
pregnancy, elderly or debilitated patients,
ulcers, GI bleeding, advanced renal disease,
dehydration, anemia, symptomatic liver
disease, hypertension, edema, heart failure or
asthma
Dosage 1 capsule (400 mg) OD oral (5/17/17 –
6/12/17)
Nursing Consideration
Health Teaching
Patients allergic to or with a history of
anaphylactic reactions to sulfonamides,
aspirin, or other NSAIDs may be allergic to this
drug, NSAIDs may increase the risk of serious
thrombotic events, MI, or stroke, WOF occult
or overt bleeding, assess patient for CV risk
factors before therapy
Tell patient to report history of allergic
reactions to sulfonamides, aspirin, or other
NSAIDs before therapy; instruct patient to
promptly report signs of GI bleeding such as
blood in vomit, urine or stool; advise patient to
immediately report rash, unexplained weight
gain, or swelling

Acetylcysteine
Indications Adjunct therapy for abnormal cricoid or
thickened mucous secretions in patient, with
pneumonia, bronchitis, bronchiectasis,
pulmonary complications of thoracic surgery,
primary amyloidosis of the lung, tuberculosis,
cystic fibrosis, emphysema, atelectasis,
acetaminophen toxicity
Contraindications Patients hypersensitive to the drug, elderly or
debilitated patient with severe respiratory
insufficiency
Dosage 1 sachet (200 mg) PO TID (5/17/17 – 5/28/17)
Nursing Consideration Mix in juice or cola to mask the sulfur-taste of
the medication; monitor cough type and
frequency; monitor patient for bronchospasm
Health Teaching Instruct patient that medication is to be diluted
in water and is mixed like juice; instruct patient
to cough to expel secretions

Omeprazole/Omeprazole Magnesium
Indications
Symptomatic gastroesophageal reflux disease
(GERD) without esophageal lesions, erosive
esophagitis and accompanying symptoms
caused by GERD, maintenance of healing
erosive esophagitis, pathologic
hypersecretory conditions such as Zollinger-
Elison Syndrome, duodenal ulcer,
Helicobacter pylori infection and duodenal
ulcer disease, short-term treatment of acute
benign gastric ulcer, frequent heartburn
Contraindications Patients hypersensitive to the drug or its
components, metabolic alkalosis and
hypocalcemia, patients with Bartter syndrome,
hypokalemia, and respiratory alkalosis, long-
term administration of sodium bicarbonate
with calcium or milk can cause milk-alkali
syndrome
Dosage 40 mg TIV OD (5/14/17, 5/15/17, 6/15/17)
Nursing Consideration Dosage adjustments may be necessary in
Asians and patients with hepatic impairment;
drug increases its own bioavailability with
repeated doses, unstable in gastric acid,
gastrin level increases in most patients during
the first 2 weeks of therapy
Health Teaching Tell patient to swallow tablets whole and not to
open them; instruct patients to take drug 30
minutes before meals, avoid hazardous
activities if he gets dizzy

Tramadol
Indications Management of pain severe enough to require
an opioid analgesic and for which alternative
treatments are inadequate
Contraindications Significant respiratory depression, acute or
severe bronchial asthma in an unmonitored
setting or in the absence of resuscitative
equipment, known or suspected GI
obstruction, including paralytic ileus, during or
within 14 days of MAOIs
Dosage 50 mg TIV RTC (5/14/17 – 5/17/17, 6/15/17)
Nursing Consideration Ready an emesis basin because tramadol
causes nausea and vomiting for some
patients, constantly communicate with the
doctors because tramadol is an opioid drug ,
patient may experience addiction and
tolerance to the drug
Health Teaching Tell the patient that the drug is a pain reliever,
and it will be taken on a limited period only.
Instruct patient to report feelings of nausea
and vomiting, and assure them that this is a
normal reaction.

Ibuprofen + Arginine
Indications Management of mild to moderate pain &
inflammation in conditions like dysmenorrhea,
headache including migraine, post-op pain,
dental pain, musculoskeletal & joint disorders
 like ankylosing spondylitis, juvenile arthritis,
peri-articular disorders like bursitis,
tenosynovitis, and soft tissue disorders like
sprains and strains, antipyretic
Contraindications Known or history of hypersensitivity to arginine
or other NSAIDs, patient with previous or
active peptic ulceration; cardiac, liver & renal
disease; asthma, urticarial, angioneurotic
edema or other allergic reactions, GI bleeding,
intestinal inflammatory disease; sever hepatic
& renal failure, SLE & collagen disease,
hemorrhagic diathesis or other coagulation
alterations
Dosage 400 mg 1 tablet PO OD (5/17/17 – 6/12/17,
6/20/17)
Nursing Consideration Check renal and hepatic function periodically
in patients on long-term therapy, stop drug if
abnormalities occur and notify prescriber;
blurred or diminished vision and color changes
may occur; drug may cause stomach bleeding
Health Teaching Tell patient to take with meals or milk to reduce
adverse GI reactions; tell patient that full
therapeutic effect for arthritis may be delayed
for 2 to 4 weeks; caution patient that use with
aspirin, alcohol, or corticosteroids may
increase the risk of GI adverse reactions

Combivent (Ipratropium + Albuterol)

Indications For the management of bronchospasm in
patients suffering from chronic obstructive
pulmonary disease who require regular
treatment with both ipratropium and albuterol
Contraindications Patients with hypertrophic obstructive
cardiomyopathy or tachyarrhythmia,
contraindicated in patients with a history of
hypersensitivity to ipratropium bromide,
salbutamol sulphate or to atropine or its
derivatives
Dosage Nebulize every 6 hours (5/28/17 – 6/12/17)
Nursing Consideration Ensure that patients are able to correctly use
the nebulizer; use a mouthpiece during
nebulization.
Health Teaching Avoid getting medication in the eyes, rinse
mouth after use, tell patient to not exceed the
prescribed dose, clean the mouthpiece after
use
Levofloxacin
Indications Acute bacterial sinusitis caused by susceptible
strains of streptococcus pneumonia,
Moraxella catarrhalis, or Haemophillus
influenzae, mild to moderate skin and skin-
structure infections cause by Staphylococcus
aureus or S. pyrogene, acute bacterial
worsening of chronic bronchitis, community
acquired pneumonia, to prevent inhalation of
anthrax, after confirmed or suspected
exposure to Bacillus anthracis, bacterial
prostitis, nosocomial pneumonia
Contraindications Patients hypersensitive to drug, its
components, or other fluoroquinoles, seizure
disorders, or other CNS disorders, renal
impairment, younger than 18
Dosage 250 mg 1 tablet PO OD (5/28/17 – 6/12/17)
Nursing Consideration If patient experiences symptoms of excessive
CNS stimulation, stop drug and notify
prescriber; patients with acute hypersensitivity
reactions may need treatment with
epinephrine, oxygen, IV fluids, antihistamines,
corticosteroids, pressor amines, and airway
management; drug may cause abnormal ECG
Health Teaching Tell patient to take drug as prescribed, even if
signs and symptoms disappear; advise patient
to take drug with plenty of fluids and to space
antacids, sucralfate, and products containing
iron or zinc; tell patient to take oral solution 1
hour before or 2 hours after eating; warn
patient to avoid excessive sunlight, use
sunscreen, and wear protective clothing when
outdoors

Ampi-Sulbactam (Ampicillin + Sulbactam)

Indications Gynecologic infections, intra-abdominal
infections, skin & skin structure infections,
orbital cellulitis, pelvic inflammatory disease,
pneumonia, urinary tract infections, acute
bacterial rhinosinusitis, endocarditis
Contraindications Patients allergic to ampicillin, sulbactam,
penicillin, beta-lactams, or its components,
clostridium difficile infection, kidney disease,
inflammation of the liver with stoppage of bile
flow
Dosage 1.5 g TIV (-) ANST prior to OR (6/17/17)
Nursing Consideration Determine previous hypersensitivity to
penicillins, cephalosporins, and other
allergens prior to therapy, obtain skin test of
the medication prior to administration, monitor
during the first 30 mins after administration
Health Teaching Report signs of hypersensitivity like chills,
wheezing, pruritus (itching), respiratory
distress, or palpitations