INTRODUCTION There were many factors considered in choosing the case for this case presentation.

First, I wanted to choose a case that will show the correlation of disease entities amongst each other and showcase their relatedness to each other. Also, I have always found cardiopulmonary cases to be very interesting due to the fact that the lungs and the heart are vital organs and are important in the normal functioning of the body. It has always interested me how these two organs can affect the different organs of the body once they fail. In addition, I have a soft spot for these diseases because my grandmother died because of these diseases and my family has a history of hypertension and with this case study, I am able to enlighten myself on the things to avoid and the appropriate interventions needed if one of my family members or me is affected by these diseases. The patient was assessed on November 8, 2011 on the 18th day of hospitalization and the 5th day post operation day. During the assessment, the patient already, had stable vital signs. The pneumothorax was already resolved but difficulty of breathing was still pronounced. Concepts involved in the discussion of the case include concepts in. 1. Cardiology: most especially concepts in valvular diseases of the heart and heart failures. 2. Hematology: most especially concepts in triglyceride levels which may have precipitated the case of the patient. 3. Pumonology: most specifically concepts in lung problems such as pneumothorax. 4. Endocrinology: most specially concepts in diabetes mellitus. NURSING ASSESSMENT - Patients Profile Name: Sedi Noel Onajo Age: 76 Birthdate: April 28, 1935 Address: 3 Malaya Street, Dominican Hill, Baguio City Occupation: Retired Company Driver Marital Status: Married Spouse: Aticap Onajo Religion: Methodist Admission Details Admission Date: October 21, 2011 Ward: Coronary Ward Chief Complaint: difficulty of breathing and dyspnea Medical diagnosis: Spontaneous pneumothorax, coronary artery disease, impaired diastolic relaxation, left ventricular failure History of Present Illness: 2 weeks prior to admission, patient experienced dyspnea but with no accompanying fever. Still, patient did not consult. 1 week prior to admission, dyspnea persisted but was not acted upon. 1 day prior to admission, patient consulted at a private physician and was advised to consult to a professional. 2 hours prior to admission, patient consulted at Saint Louis University Hospital of the Sacred Heart and was advised admission. History of Past Hospitalization: Patient has no previous hospitalizations but patient has a know history of hypertension since 2009 Socio-Cultural History: The patient is an Ilocano. Upon assessment, patient expressed that he has a very strong affinity to his roots as an Ilocano and practices in marriage, death and other occasions are done following the Ilocano practices. The patients religion is Methodist. Upon assessment, patient expressed that he is actively practicing and that he has no religious concerns

M/S TOOL ACTIVITY/REST The patient is a retired driver and in the hospital, he was unable to participate in usual activities. Leisure time includes watching television, chatting with wife and with friends. The patient is not ambulatory in the hospital. Gait was not assessed. The patient is active, needing minimal help from his significant others. The muscles are flaccid and hypotonic with strength of 4/5 in all extremities. Because of the condition, the patient experienced weakness, breathlessness and inability to transfer. The patient, also, has feelings of exhaustion. Patient usually has 6-8 hours of sleep with no insomnia and is rested upon awakening. The patient usually takes 1-2 naps a day lasting for 1-2 hours. Bedtime rituals include doing hygiene needs and relaxation technique is sleep. The patient sleeps with 2 pillows and oxygen is utilized per nasal cannula at 4 LPM uses during dyspnea. There are no medications used affecting sleep. Patient was asked to sit up on bed to test his response to activities. Before the activity, heart rate was 86 beats per minute, respiratory rate was 24 cycles per minute and blood pressure was 130/80 millimeters mercury. Immediately after the activity, heart rate was 87bpm, respiratory rate was 26cpm and blood pressure was 130/80mmHg. 5 minutes after the activity, patients heart rate was 84bmp, respiratory rate was 23cpm and blood pressure was 130/80mmHg. Pulse oximetry reading was at high 80s and low 90s. Patient was alert and active, muscle was hypotonic and flaccid. There were no tremors noted and there were restrictions on range of motion in all extremities. Muscle strength was 4/5 all over. Due to this, nursing diagnosis formulated was ACTIVITY INTOLERANCE RELATED TO DECREASED ENERGY AND WEAKNESS. CIRCULATION There were no history of head injury, stroke, hemoptysis, syncope, spinal cord injury/dysreflexia, palpitations, bleeding tendencies, varicosities, thrombophlebitis, leg pain, and slow healing. On 2009, patient was diagnosed to have high blood pressure and this year, patient was diagnosed with coronary artery disease, left ventricular failure and impaired systolic relaxation. Skin assessment revealed that skin is pale, mucous membrane is pinkish, lips are dark, sclerae are non-icteric, conjunctivae are pale, nailbeds are pale, skin is moist. Blood pressure while lying down was 130/80mmHg on the right and left arm. Pulse pressure was 50mmHg. There were no auscultatory gaps. Pulse was 86bpm on all pulse points and are all strong +2. There were no cardiac thrills and heaves and heart rate was 86bpm. There was arrhythmia and quality is strong. There were also, friction rubs. At the point of maximal impulse, murmurs were noted. There were no vascular bruit and jugular vein distention. There were no adventitious breath sounds but there was a decrease breath sounds in the right lung. Extremities are 36.2C, pale, capillary refill of 2-3 secons, no homans sign, no varicosities, no nail abnormalities, no edema. Hair is thin. No lesions. Due to this, nursing diagnosis formulated was IMPAIRED TISSUE PERFUSION RELATED TO DECREASED OXYGEN CARRYING CAPACITY OF THE BLOOD. EGO INTEGRITY The patient is married. Patient did not express any concern. Stress factor was the hospitalization. Usual ways of handling stress includes verbalizing problems to the wife. Patient stated that he does not get angry too much. When anxious, patient thinks. Patient usually cries when there is grief. No other feelings such as hopelessness, helplessness and powerlessness were said. Patient is and Ilocano and religious affiliation is Methodist. He is actively practicing the religion and usually prays. There are no spiritual concerns and patient did not desire visits from clergies. No specifies expression

of sense of connectedness/harmony with self and others. Patient was calm, and patient becomes pale as a response. ELIMINATION Patient has regular bowel elimination which is usually characterized as semi formed and brownish. Last bowel movement was on November 8, 2011 and was characterized as semiformed, brownish, about 50 ml and non fowl smelling. There was no history of bleeding, no hemorrhoids, constipation, diarrhea and bowel incontinence. Hence, there is no use of laxatives nor enemas and suppositories. Patient usually voids once ever 3 hours at around 100-150 ml. there were no difficulty voiding, urgency, bladder spasm, frequency, retention and burning feeling. There was no urinary retention, history of bladder or kidney diseases. There was diuretic use after surgery with furosemide 40 mg tablet. Abdomen was soft upon palpation, non tender, non distended, size is about 34-35 inches, bowel sounds are normoactive, no costovertebral angle tenderness, bladder is nonpalpable and there are no hemorrhoids. There is usage of IFC afgter surgery. No ostomy devices. FOOD/FLUID Patient usually has 3 meals per day with 1-2 snacks eaten during the morning and late afternoon. Patients usual food intake during breakfast is coffee and bread, lunch is usually rice and a viand and snacks are usually breads and juices. Last meal consumed was rice and viand. Food preference is meat and there are no known food allergies. There are no special cultural food preparations specified. Patient consumes 80-95% of food served and after the operation, patients appetite decreased. Usual weight was 180-190lbs and there are no unexpected or undesired weight loss or gain. There are no nausea, vomiting, heartburn and indigestion. Gag and swallow reflex are intact, there are no facial injury or surgery and there are no neurological deficit. Patient was diagnosed with type II diabetes controlled with diet. There are no vitamin or food supplements. Current weight was 187lbs, height is 57, body built is endomorph and BMI is n ormal. There is good skin turgor, and mucous membrane is moist. There are no edema. Breath sounds are clear except for the decreased in breath sounds at the right lung. Gums and teeth are in good condition, there are partial dentures and absent teeth at the molars and incisors are observed. There is no sore mouth or tongue, tongue is midline and reddish and abdomen has normoactive bowel sounds all over. HYGIENE The patient's functional level is at 3 meaning that he is dependent to the caregiver to provide for the hygiene needs. The patient only requires human assistance provided by the wife and nurses. He needs help in food preparation and with eating utensils and needs help in getting supplies for hygiene, washing body parts, regulating bath water, getting in and out alone and dressing. He also needs assistance in toileting such as getting in and out of the commode. The patient's manner of dressing was not assessed because he was in a hospital gown. Still, patient was able to meet hygiene needs such as shampooing, oral care, bathing, etc. Hence, there were no body odor and vermins. Diagnosis: self care deficit related to inability to perform activities secondary to weakness. NEUROSENSORY The patient has no history of injury, trauma and stroke and the patient has no dizziness and weakness. There is tingling and numbness of upper extremities. There are not seizure episodes, hearing loss, vision changes, smell changes. There is no change in mental status and the patient is alert and oriented. There are no delusion and hallucinations and affect is euthymic. Speech is slightly soft and slurred but comprehensive. Recent and remote memory

and intact. Glasgow coma scale revealed a 15/15 score. Cranial nerves are all normal and intact. Mini mental status examination revealed a score of 23/23 since patient refused to perform some of the examination items. All deep tendon reflexes are normal scored at 2. there are no tremors or paralysis. PAIN/DISCOMFORT. There was mild pain located at the right lung and precipitated by movement with an intensity of 3, non radiating and intermittent, relieved by tramadol and relaxation. Diagnosis: Mild pain related to ongoing inflammatory process. RESPIRATION there was dyspnea related to decreased capacity of the lungs to expand precipitated by talking and movement. It is relieved by oxygen inhalation and administration of bronchodilators. Cough was non productive. Patient was a smoker with 20 pack years. There was usage of oxygen and medications used affecting respiration were bronchodilators and anti inflammatory drugs. Respiratory rate ranged from 24-26cpm and was shallow and assisted. Parameters include an IRV of 600cc. 02 inhalation was per nasal cannula at 4LPM. Chest excursion was unequal and there is decreases fremitus on the right. There was no use of accessory muscles but there was nasal flaring and decreases lung sounds on the right. Pulse oximetry read at high 80s to low 90s. Client was calm. NURSING DIAGNOSIS: impaired breathing pattern related to decreased lung expansion. SAFETY Pertinent data about safety stated that patient has altered /suppressed immune system due to corticosteroid therapy. There were 2 whole blood transfusion but with no reactions. Patient is also oriented. There is an incision site at the right thoracic region connected to a thorabottle draining to reddish, blood tinged fluid. Nursing Diagnosis: impaired skin integrity related to tissue trauma, risk for infection related to tissue trauma. *No significant findings concerning sexuality. *No significant findings in social interactions *no significant findings in teaching/learning *patient was discharged after 2 days.

LIST OF PRIORITIZED NURSING DIAGNOSES Nursing Diagnoses Actual/Potential Overt/Covert 1. Impaired breathing pattern related to decreased/inadequate lung expansion Actual Overt

Justification Latest assessment revealed that patient is suffering from difficulty of breathing with a respiratory rate ranging from 2426cpm, has shallow breathing, uses the sternocleidomastoid muscle for breathing, with nasal flaring, on oxygen inhalation at 4 LPM, and with verbalization of air hunger. The ABC's of life states that problems in breathing should be prioritized. Also, according to Abraham Maslow, oxygenation is an important part of a person's biologic needs. Fundamentally, the chief complaint of the patient must be prioritized. Latest assessment revealed that patient has pale palpebral conjunctivae, pale nail beds and skin, cold skin and obvious weakness manifested by muscle strenght of 3/5 on lower extremities and 4/5 in upper extremities and usage of soft voice. According to the abc's of life, circulation is

2. Impaired peripheral Actual tissue perfusion related to inadequate circulating oxygen and decreased oxygen carrying capacity of the blood.

Overt

prioritized after breathing. Again, abraham maslow states that oxygenation must be prioritized. The fact that the patient's problem concerns breathing more, this should be least prioritized. 3. activity intolerance related to decreased energy secondary to poor oxygenation (clustered with problem 4) Actual Overt Because of the decreased circulating 0xygen in the body, there is decreased energy due to the fact that 02 is integral in the kreb's cycle for atp production. This is least prioritized because this can be prevented with the resolution of other problems like the first two prioritzed. Because the patient cannot tolerate certain activities such as standing up and also due to the contraptions attached to the patient, the patient is unable to perform necessary self care needs in order to function as a holistic being. Also, this is least prioritized because it depends on the 3rd problems in order for this problem to be resolved. Because of the surgical procedures

4. self care deficit related to inability to perform self care needs from decreased energy.

Actual

Overt

5. impaired skin integrity related to

Actual

Overt

tissue trauma secondary to ctt insertion.

performed such as the ctt insertion and the thoracotomy, patient's skin integrity is impaired. There are no signs of infection present hence, this is least prioritized. Overt Not prioritized because the pain is mild and tolerable Because of the incisions brought about by the insertion and open thoracotomy, there is a greater chance for bacterial invasion and growth. Still, this is a risk problem and must be least prioritized. Risk problem

6. mild pain related to Actual ongoing inflammatory process 7. risk for infection related to tissue trauma Potential

Covert

8. risk for imbalanced Potential nutrition, less than body requirement related to poor oral intake. 9. risk for fall related to weakness Potential

Covert

Covert

Risk problem

DRUG STUDY

Name of Drug 1. Piperacillin + trazobactam

Indication Prophylaxis for respiratory infection

MOA Piperacillin has an antimicrobial activity against a wide range of gm-ve organisms including K. pneumoniae, P. aeruginosa, Enterobacteriacea e and against gm+ve organisms eg E. faecalis and B. fragilis. Tazobactam is a penicillanic acid sulfone derivative with beta-lactamase inhibitory properties. In combination, tazobactam enhances the activity of piperacillin against betalactamase-producing bacteria.

CEFIXIME

Prophylaxis for infection

PARACETAMOL

PRN for fever

Cefixime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat-regulating centre. Its weak antiinflammatory activity is related to inhibition of prostaglandin synthesis in the CNS Tramadol inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception and response

Nursing Responsibility Give full dose of drug Assess hematopoietic function periodically. Perform periodic electrolyte determinations in patients with low K reserves. Increased risk of fever and rash in patients with cystic fibrosis. Increased risk of bleeding manifestations. Prolonged treatment may increase risk of superinfections. Convulsions or neuromuscular excitability may occur when high doses are used, especially in renally impaired patients. Renal impairment. Give full dose of drug, History of allergy to penicillins; pregnancy, lactation; renal failure; GI disease.

Tramadol

PRN for pain

Watch out for Nausea, allergic reactions, skin rashes, acute renal tubular necrosis. Potentially Fatal: Very rare, blood dyscrasias (e.g. thrombocytopenia, leucopenia, neutropenia, agranulocytosis); liver damage. Give with food. Watch out for Sweating, dizziness, nausea, vomiting, dry mouth, fatigue,

to pain by binding to muopiate receptors in the CNS.

Levofloxacin

Prophylaxis for infection

Levofloxacin exerts antibacterial action by inhibiting bacterial topoisomerase IV and DNA gyrase, the enzymes required for DNA replication, transcription repair and recombination. It has in vitro activity against a wide range of gram-negative and grampositive microorganisms

SALBUTAMOL

For bronchospasm

Salbutamol is a direct-acting sympathomimetic with adrenergic activity and selective action on 2 receptors, producing bronchodilating effects. It also decreases uterine contractility.

AMLODIPINE

Hypertension

Amlodipine relaxes peripheral and coronary vascular smooth muscle. It produces coronary vasodilation by inhibiting the entry of Ca ions into the

asthenia, somnolence, confusion, constipation, flushing, headache, vertigo, tachycardia, palpitations, miosis, insomnia, orthostatic hypotension, seizures, CNS stimulation e.g. hallucinations. Potentially Fatal: Respiratory depression. Watch out for Nausea, diarrhoea, constipation, headache, insomnia, inj site reactions (IV). Ophthalmic: Transient decrease in vision, ocular burning, ocular pain or discomfort, foreign body sensation, headache, fever, pharyngitis, photophobia. Potentially Fatal: Anaphylaxis. Give full course of medications and give with food. Watch out for Fine skeletal muscle tremor especially hands, tachycardia, palpitations, muscle cramps, headache, paradoxical bronchospasm, angioedema, urticaria, hypotension and collapse. Potentially Fatal: Potentially serious hypokalaemia after large doses. Headache, peripheral oedema, fatigue, somnolence, nausea, abdominal pain, flushing, dyspepsia,

voltage-sensitive channels of the vascular smooth muscle and myocardium during depolarisation. It also increases myocardial O2 delivery in patients with vasospastic angina.

CARVEDILOL

Hypertension and Chest Pain

Carvedilol causes vasodilation by blocking the activity of blockers, mainly at alpha-1 receptors. It exerts antihypertensive effect partly by reducing total peripheral resistance and vasodilation. It is used in patients with renal impairment, NIDDM or IDDM

Telmisartan (Pritor)

Hypertension

Telmisartan is a nonpeptide AT1 angiotensin II receptor antagonist. Exerts

palpitations, dizziness. Rarely pruritus, rash, dyspnoea, asthenia, muscle cramps. Potentially Fatal: Hypotension, bradycardia, conductive system delay and CCF. Monitor BP 15 minutes before administration and 15 minutes after administration. Watch out for Bradycardia, AV block, angina pectoris, hypervolaemia, leucopenia, hypotension, peripheral oedema, allergy, malaise, fluid overload, melena, periodontitis, hyperuricaemia, hyponatraemia, increased alkaline phosphatase, glycosuria, prothrombin time, SGPT and SGOT levels, purpura, somnolence, impotence, albuminuria, hypokinesia, nervousness, sleep disorder, skin reaction, tinnitus, dry mouth, anaemia, sweating, fatigue, arthralgia, aggravation, dizziness. Diarrhoea, nausea, vomiting, insomnia, hypercholesterolaemia, weight gain, abnormal vision, rhinitis, pharyngitis and hypertriglyceridaemia. Watch out for URTI, dizziness, back pain, sinusitis, pharyngitis

antihypertensive activity by preventing angiotensin II from binding to AT1receptors thus inhibiting the vasoconstriction and aldosterone-secreting effects of angiotensin II. Zykast (Levocetirizine Bronchospasm + Montelukast) Levocetirizine: Levocetirizine, an active isomer of cetirizine, selectively inhibits histamine H1-receptors. Montelukast: Montelukast is a selective leukotriene receptor antagonist that blocks the effects of cysteinyl leukotrienes in the airways. Celecoxib has COX-2 specific inhibitory activity. It inhibits the conversion of arachidonic acid to prostaglandins while having no effect on the formation of prostaglandins that mediate the normal homeostasis in the GI tract, kidneys and platelets catalysed by COX-1.

CELECOXIB

For pain management post op

HYDROCORTISONE Prevention of bronchial inflammation after surgery.

Hydrocortisone is a corticosteroid used for its antiinflammatory and immunosuppressive effects. Its anti-inflammatory action is due to the suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability. It may also be used as replacement therapy in adrenocortical insufficiency. Methylprednisolone is a

and diarrhoea. Slight elevations in liver enzymes. Potentially Fatal: Rarely angioedema, rash, pruritus and urticari Monitor BP frequently Watch out for Asthenia, fatigue, fever, abdominal pain, trauma, dyspepsia, infectious gastroenteritis, dental pain, dizziness, headache, nasal congestion, cough & influenza. Watch out for Abdominal pain, diarrhea, nausea, oedema, dizziness, headache, insomnia, upper respiratory tract infections; rash. Potentially Fatal: Serious skin reactions such as exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Give after meals or with a full glass of water or milk. Do not give for a long period of time. Watch out for signs of infection. Watch out for signs and symptoms of Cushings syndrome. Avoid crowded places when in steroid therapy.

MEDROL

Prevention of

Watch out for

(methylprednisolone)

bronchial inflammation

synthetic corticosteroid with mainly glucocorticoid activity and minimal mineralocorticoid properties. It decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability.

Loricid (Allopurinol)

Hyperuricemia (Resolved)

Allopurinol is an inhibitor of the enzyme xanthine oxidase which converts hypoxanthine to xanthine then uric acid. The reduced production of uric acid relieves all symptoms associated with hyperuricaemia and gout. Inhibition of xanthine oxidase leads to accumulation of its substrates hypoxanthine and xanthine but since their renal clearance is more than 10 times that of uric acid, there is no risk of nephrolithiasis.

Elartan (Isosorbide Mononitrate)

Chest pain

Isosorbide mononitrate relaxes vascular smooth muscles by stimulating cyclic-GMP. It decreases left ventricular pressure (preload) and arterial resistance (afterload).

Oedema, hypertension, arrhythmia; CNS, endocrine, metabolic and GI effects; hirsutism, acne, skin atrophy, bruising, hyperpigmentation; transient leukocytosis; arthralgia, muscle weakness, osteoporosis, fractures, cataracts, glaucoma; infections, hypersensitivity reactions, avascular necrosis, secondary malignancy, intractable hiccups. Avoid crowded places Watch out for Rash; alopoecia; GI disorders, taste disturbances, nausea, vomiting, abdominal pain, diarrhoea; paraesthesia, peripheral neuropathy, vertigo, headache, hepatic necrosis, drowsiness, neuritis, arthralgia; hypertension. Potentially Fatal: StevensJonhson and/or Lyell's Syndrome (urticaria, fever, lymphadenopathy, arthralgia). Occasionally, thrombocytopaenia, agranulocytosis and aplastic anaemia. Watch out for Hypotension, tachycardia, flushing, headache, dizziness, palpitation, syncope, confusion. Nausea, vomiting, abdominal pain. Restlessness, weakness and vertigo.

SPIRIVA (ipratropium bromide)

For Ipratropium bromide blocks bronchoconstriction the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation.

Ipratropium, Salbutamol (Duaven)

For Salbutamol is a direct-acting bronchoconstriction sympathomimetic with adrenergic activity and selective action on 2 receptors, producing bronchodilating effects. It also decreases uterine contractility. Ipratropium bromide blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation. Zykast (theophylline)

Dry mouth, chest pain, back pain, oedema, fatigue, abdominal pain, constipation, diarrhoea, dyspepsia and flatulence. Potentially Fatal: Severe hypotension and cardiac failure. Watch out for Dry mouth, urinary retention, buccal ulceration, paralytic ileus, headache, nausea, constipation, paradoxical bronchospasm, immediate hypersensitivity reactions (urticaria, angioedema), acute angle-closure glaucoma, nasal dryness and epistaxis (nasal spray). Potentially Fatal: Anaphylactic reactions, atrial fibrillation, supraventricular tachycardia. Watch out for Headache, pain, influenza, chest pain, nausea. Bronchitis, dyspnea, coughing, pneumonia, bronchospasm, pharyngitis, sinusitis, rhinitis. Edema, fatigue, Hypertension, dizziness, nervousness, paresthesia, tremor, dysphonia, insomnia, diarrhea, dry mouth, dyspepsia, vomiting, arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, taste

Zykast (theophylline)

For bronchospasm

Theophylline competitively blocks phosphodiesterase which increases cAMP tissue concentrations causing bronchodilatation, diuresis, CNS and cardiac stimulation, and gastric acid secretion.

perversion and UTI/dysuria. Allergictype reactions Watch out for Nausea, vomiting, abdominal pain, diarrhoea, headache, insomnia, dizziness, anxiety, restlessness, tremor, palpitations. Potentially Fatal: Convulsions, cardiac arrhythmias, hypotension and sudden death after too rapid IV inj.

Diagnostic Examinations and Laboratory Results

Diagnostic/Lab Exam XRAY

Result/Interpretation Both lung fields are hyperinflated with lightly flattened diaphragmatic leaflets. An area of 810 lucency devoid of vascular markings seen at the right lower peripheral hemithorax. Cardiac shadow is unenlarged with AAR right sided CTT There is near complete resolution of subcutaneous emphysema in the right lateral chest wall Mid to lwer reticular and hazy densities probably pneumonic, minimal pleural effusion with probably lamellar and interlobar component Right apical pleural reaction PNEUMOTHORAX RIGHT Hemoglobin: 103g/L (decreased) Erythrocyte: 0.31 (decreased) Leukocytes: 16700 mm/L (increased)

Indication/Significance Indicated for the patient as an initial investigation of the pneumothorax to assess the location, the amount and the gravidity of the insult. Also, this is to serve as baseline for the assessment and evaluation of the effectivity of the surgical, medical and nursing procedures. This is also to determine if the CTT is inserted at the correct area.

CBC

This is important as baseline before surgery to determine the amount of hematocrit, RBC, Hemoglobin and WBC which are all integral in the recovery of the patient. Also, this is significant in order to assess the amount of oxygen being delivered to the body as per hemoglobin count to reveal the degree of perfusion problems. Also, the increase in leukocytes may also indicate an ongoing bacterial invasion from the surgical interventions.