7 Hemothorax and Pneumothorax Nursing Care Plans and Management

Both conditions put air or blood where it does not belong and shrink the lung's ability to breathe. Most of your work centers on the chest drainage system, the airway, and catching a tension pneumothorax before it kills the patient.

What is Hemothorax and Pneumothorax?

Hemothorax is blood in the pleural space. The source may be the chest wall, lung parenchyma, heart, or great vessels, and it is usually the result of blunt or penetrating trauma. Less often it follows disease, a procedure, or develops spontaneously.

Pneumothorax happens when the parietal or visceral pleura is breached and the pleural space is exposed to atmospheric pressure. Normally that space holds negative pressure, which is what keeps the lung inflated. Once a pleura is breached, air rushes in and the lung, or part of it, collapses.

Types of pneumothorax include simple, traumatic, and tension:

• Simple (spontaneous) pneumothorax. Air enters the pleural space through a breach of the parietal or visceral pleura, most often from a ruptured bleb or a bronchopleural fistula.
• Traumatic pneumothorax. Air escapes from a laceration in the lung or a chest wall wound. It follows blunt trauma, penetrating chest or abdominal trauma, or diaphragmatic tears.
• Tension pneumothorax. Air is drawn into the pleural space and trapped. Each inspiration adds more air that cannot escape, pressure builds, and the lung and mediastinum are pushed toward the other side. This is the emergency.

Nursing Care Plans and Management

For hemothorax, focus on respiratory function and bleeding: monitor vital signs, oxygen saturation, and breath sounds, give oxygen, assist with chest tube insertion and drainage, manage pain, and watch for shock.

For pneumothorax, relieve the collapse and re-expand the lung: assist with chest tube insertion, monitor drainage, assess respiratory status, give oxygen and pain medication, encourage mobility and deep breathing, and teach the patient the signs of recurrence.

Nursing Problem Priorities

• Maintaining airway patency and adequate ventilation
• Assessing and managing pain
• Providing wound care and watching for infection
• Preventing and monitoring for complications
• Teaching the disease process, prognosis, and treatment

Nursing Assessment

Signs depend on the size and cause. With a small simple pneumothorax, the patient may have only slight chest discomfort and tachypnea. If the lung collapses fully, acute respiratory distress sets in. In hemothorax, expect tachypnea and shallow breaths, diminished breath sounds on the affected side, and a dull percussion note. With significant blood loss, hypotension and tachycardia appear as hemorrhagic shock develops.

Assess for the following subjective and objective data:

• Hemothorax
  • Shortness of breath, difficulty breathing
  • Sharp or stabbing chest pain, or chest heaviness
  • Decreased breath sounds on the affected side
  • Dullness to percussion (fluid)
  • Decreased oxygen saturation
  • Signs of shock: hypotension, tachycardia, rapid weak pulse, pale clammy skin
• Pneumothorax
  • Sudden, sharp chest pain
  • Shortness of breath
  • Decreased or absent breath sounds
  • Hyperresonance on percussion (air)
  • Asymmetrical chest movement
  • Cyanosis, abnormal ABGs
  • Jugular vein distention (tension pneumothorax)

Assess for factors related to the cause:

• Decreased lung expansion (air or fluid accumulation)
• Musculoskeletal impairment
• Inflammatory process
• Malfunction of the chest drainage system
• Concurrent disease or injury
• Dependence on an external device (chest drainage system)
• Lack of safety education
• Ventilation-perfusion mismatch
• Alveolar-capillary membrane changes
• Impaired pleural integrity
• Presence of a chest tube
• Surgical intervention (thoracotomy)

Nursing Diagnosis

After assessment, form a nursing diagnosis that fits this patient's respiratory status and clinical picture. The label matters less than your judgment at the bedside.

Nursing Goals

Goals and expected outcomes may include:

• The patient establishes an effective respiratory pattern with ABGs in their normal range.
• The patient is free of cyanosis and other signs of hypoxia.
• Lung re-expansion is confirmed on chest x-ray.
• The patient shows adequate gas exchange: normal respiratory rate, no significant mental status changes, oriented to person, place, and time.

Nursing Interventions and Actions

1. Improving the Breathing Pattern

The pleural space normally holds negative pressure that keeps the lung expanded. Once air or blood invades that space, the lung collapses toward equilibrium, vital capacity drops, and the partial pressure of oxygen falls.

Determine the cause (spontaneous collapse, trauma, malignancy, infection, mechanical ventilation complication). The cause drives chest tube placement and the rest of the treatment plan, including the risk of recurrence.

Assess respiratory function: rapid or shallow respirations, dyspnea, "air hunger," cyanosis, and vital sign changes. These reflect physiologic stress and pain, or warn of shock from hypoxia or hemorrhage. Dyspnea is sudden in primary spontaneous pneumothorax and more severe in secondary cases because of lower lung reserve.

On a ventilator, watch for a patient who fights the vent and for rising airway pressures. Both suggest worsening or a new pneumothorax. High pressures and air trapping raise the risk of tension pneumothorax if the chest tube is not working.

Auscultate breath sounds. They may be diminished or absent over a collapsed lobe, segment, or whole lung. Regular checks give you a baseline to track resolution.

Note chest excursion and tracheal position. Excursion is unequal until the lung re-expands. The trachea deviates away from the affected side with tension pneumothorax. Get down to the patient's level when inspecting a supine patient; the difference can be subtle.

Assess for fremitus. Voice and tactile fremitus drop over fluid-filled or consolidated tissue, because air or fluid blocks the transmission of low-frequency vibrations.

Check mental and cardiac status frequently. Tachycardia, restlessness, anxiety, and mental status changes signal respiratory distress, which can mean the drainage system is failing.

Help the patient splint painful areas when coughing and deep breathing. A towel or pad against the chest makes coughing more effective and less painful.

Position for comfort, usually with the head of the bed up; turn to the affected side and encourage sitting up. A semi-Fowler or sitting position decreases the work of breathing and improves expansion on the unaffected side.

Stay calm and coach slower, deeper breaths. Hypoxia shows up as anxiety and fear. Your composure steadies the patient.

2. Managing Care for Patients with a Chest Tube

A chest tube evacuates air or blood from the pleural space and re-expands the lung. In an emergency, needle decompression comes first. Prolonged air leaks may need surgery.

Once the chest tube is inserted:

Identify whether it is a dry seal or water seal system. Both maintain the intrapleural negativity that promotes lung expansion and drainage. The water seal chamber acts as a one-way valve, letting air escape but not re-enter the chest.

Check the suction control chamber for the correct amount of suction. The water in a sealed chamber blocks atmospheric air from entering the pleural space if suction is lost. Underfilling exposes the patient to pneumothorax; overfilling, the more common error, keeps air from escaping and stalls resolution.

Monitor the fluid level in the water-seal chamber and maintain it at the prescribed level:

Maintain fluid in the water-seal and suction chambers at the correct levels. Many closed systems come pre-filled. The water level in the suction control chamber, not the suction source, sets the amount of suction applied.

Dial dry suction to the provider's order. This maintains air and fluid removal. Briefly removing suction for transport will not harm a closed system.

Watch the water-seal chamber for bubbling. Bubbling on expiration vents the pneumothorax, which is what you want. It decreases as the lung expands. Absent bubbling means full re-expansion or an obstruction in the tube.

Watch for continuous, abnormal bubbling. With suction on, this signals a persistent air leak from the insertion site or the drainage unit. Most intrathoracic leaks seal on their own over days. Large leaks, like those from a bronchopleural fistula, may need surgery.

Locate the air leak by briefly clamping the catheter just distal to the chest. If bubbling stops, the leak is at the insertion site or within the patient. If it continues, work down the circuit in a stepwise fashion to find it.

Apply petrolatum gauze around the insertion site as indicated. This corrects insertion-site leaks and provides an airtight seal if the tube becomes dislodged.

Clamp the tubing in a stepwise fashion toward the drainage unit if the leak continues. This isolates a system-centered leak. A suspected leak is one of the few times a chest tube should be clamped, and only very briefly.

Tape or band all drainage connection sites lengthwise per policy. This prevents and corrects leaks at the connectors and keeps the system closed.

Monitor "tidaling" in the water-seal chamber and note whether changes are transient or permanent. The chamber acts as an intrapleural manometer, so the fluid swings with the pressure difference between inspiration and expiration. Tidaling of 2 to 6 centimeters on inspiration is normal and may rise briefly with coughing. Excessive tidaling can mean airway obstruction or a large pneumothorax.

Position the tubing for optimal flow: shorten it or coil extra tubing on the bed, avoid kinks, and keep it from hanging below the drainage container. Poor positioning, kinks, or pooled clots change the negative pressure and block evacuation. If a dependent loop cannot be avoided, lift and drain it every 15 minutes to keep a hemothorax draining.

Assess the amount of chest tube drainage; note if the tube is warm and full of blood and the fluid level is rising. This tracks resolution and flags hemorrhage. Some systems include an autotransfusion device that salvages shed blood for re-infusion.

Evaluate the need for tube stripping ("milking"). Routine stripping is not recommended but may be needed for fresh bleeding, large clots, or purulent exudate (empyema). Secure the tube at the incision first to prevent dislodgement, then pinch and milk away from the patient.

Strip tubes carefully per protocol, minimizing excess negative pressure. Vigorous stripping creates dangerously high intrathoracic suction that can pull tissue into the catheter, collapse tissue around it, and rupture small vessels. Avoid it unless the provider orders it.

If the catheter is disconnected or dislodged:

Watch for respiratory distress. Reconnect to tubing or suction with clean technique if possible. If the catheter pulls out of the chest, cover the site immediately with petrolatum dressing, apply firm pressure, and notify the provider at once. Pneumothorax can recur fast. Submerging a disconnected tube in sterile water gives a temporary closed drainage system.

After the catheter is removed:

Cover the site with a sterile occlusive dressing and watch for recurrence (shortness of breath, pain). Inspect the site and note the character of any drainage. Early detection of recurrence or infection is essential. Petroleum-impregnated gauze makes a good occlusive cover.

Review serial chest x-rays. These track resolution and re-expansion and can catch a malpositioned endotracheal tube affecting the lung.

Monitor and graph serial ABGs and pulse oximetry; review vital capacity and tidal volume. These show gas exchange and ventilation and whether therapy needs to change. ABGs measure the degree of acidemia, hypercarbia, and hypoxemia, which depend on the extent of cardiopulmonary compromise.

Give supplemental oxygen via cannula, mask, or ventilation as indicated. Oxygen reduces the work of breathing and relieves cyanosis. Oxygen at 3 L/minute by nasal cannula or higher treats hypoxemia and produces a fourfold increase in pleural air absorption compared with room air alone.

Assist with reinflation procedures: simple aspiration, Heimlich valve, or chest tube placement. Simple aspiration succeeded in up to 87% of 131 cases of small spontaneous pneumothorax and is as safe and effective as a chest tube for primary spontaneous pneumothorax, with shorter stays and fewer admissions. A Heimlich valve is a one-way flutter valve that evacuates air not under tension.

3. Promoting Effective Gas Exchange

In tension pneumothorax, injured tissue forms a one-way valve: air enters on inhalation and cannot leave. Pressure climbs with each breath, the lung on the affected side collapses, and the lung on the other side is compressed. Both compromise gas exchange and drive hypoxia.

Assess for signs of hypoxia. Rising restlessness, anxiety, tachycardia, and mental status changes are early warnings of respiratory compromise.

Monitor ABGs and oxygen saturation. Falling PaO2 or O2 saturation and rising PaCO2 signal impending respiratory failure and respiratory acidosis.

Assess vital signs and breath sounds every 2 hours or as indicated. Tachycardia, tachypnea, and unilateral decreased breath sounds mean the condition is worsening. Tachycardia and hypotension point to shock.

Auscultate breath sounds. Unilaterally decreased or absent sounds are common, though decreased air entry may be absent even in advanced disease.

Assess for a declining level of consciousness. Decreased alertness can signal a severe acidotic state that needs immediate attention.

After chest tube insertion, assess the patient every 15 minutes until stable. Watch for tachypnea, diminished or paradoxical chest wall movement, increased work of breathing, accessory muscle use, increasing dyspnea, unilateral diminished breath sounds, and cyanosis.

Position the patient in semi-Fowler. This enables full expansion of the unaffected lung and descent of the diaphragm. Semi-Fowler helps evacuate air in pneumothorax; high-Fowler helps drain fluid in hemothorax.

Help the patient change positions every 2 hours. This promotes drainage, lung re-expansion, and alveolar perfusion. Keep the collection chamber below the chest at all times so fluid cannot siphon back into the pleural space.

Encourage deep breathing and splinting the thoracotomy site with arms, a pillow, or a folded blanket. Deep breathing expands the lung and decreases atelectasis. Splinting and analgesia ease the discomfort.

Provide a low-carbohydrate, high-fat diet as appropriate. This reduces CO2 production and supports respiratory muscle function. High sodium and animal protein worsen acidosis; vegetables and fruit help.

Give humidified supplemental oxygen as indicated. This corrects the hypoxemia likely present with a large pneumothorax or hemothorax. Humidity limits moisture loss.

Refer for pulmonary rehabilitation as indicated. Bronchial hygiene, breathing retraining, and exercise conditioning help reverse respiratory acidosis.

4. Managing Pain and Discomfort

Chest tubes hurt. The pleura is richly innervated, so significant analgesia is usually required, and pain control directly affects how well the patient breathes and recovers.

Assess pain frequently with a self-report scale. This tracks the trend and shows whether interventions are working.

Observe verbal and nonverbal cues. A mismatch between the two hints at the real degree of pain. Pleuritic chest pain is often severe or stabbing, radiates to the same-side shoulder, and worsens with inspiration.

Assess physiologic and psychological causes of pain. Fear and anxiety impair coping, and the chest tube itself adds discomfort. Patients already on opioids will not get the same relief from them postoperatively.

Evaluate the effectiveness of pain control. Pain is subjective, so let the patient guide it. If they cannot respond, watch physiologic and nonverbal signs and medicate on a schedule.

Encourage the patient to verbalize feelings about pain. Fear raises muscle tension and lowers the pain threshold. Some patients hide pain for fear of becoming dependent on the medication.

Encourage the patient to ask for analgesics before pain becomes severe. Prolonged pain stimulation raises sensitivity and the dose needed for relief.

Teach splinting of the affected side when coughing, moving, or repositioning. Splinting supports the incision and surrounding tissue and reduces pain.

Premedicate 30 minutes before initial coughing, exercising, repositioning, or pleurodesis. Chemical pleurodesis is extremely painful and demands diligent pain management. It also lowers the chance of recurrence.

Schedule rest, sleep, and activity. Rest decreases oxygen demand and pain. A quiet environment conserves energy and improves coping.

Stabilize the chest tube to the thorax with tape or a securement device and avoid dependent loops. This reduces drag on the connector, prevents discomfort, and keeps drainage flowing. Cross-taping gives a strong connection and a window to inspect it.

Assist with self-care, arm exercises, and ambulation. This prevents fatigue and incisional strain. The patient may need support before they can do these confidently because of pain or fear of pain.

Administer pain medications as prescribed. See Pharmacologic Management.

5. Preventing Respiratory Trauma and Infection

A chest tube is simple compared with major surgery, but it carries real complications: misplacement, damage to nearby organs, subcutaneous emphysema, infection, and bleeding. Nurses spend the most time with the patient and carry most of the responsibility for catching these early.

Identify changes to report: a change in bubbling, sudden "air hunger," chest pain, or disconnected equipment. Timely intervention prevents serious complications. After an accidental tube removal, use a pulse oximeter to check for respiratory compromise.

Inspect the insertion site, noting skin condition and the presence and character of drainage. Change the sterile occlusive dressing as needed. This catches skin erosion or infection early. Small amounts of ooze can be normal after surgery, but fever or tenderness warrants a swab and a clinical photo.

Watch for respiratory distress if the catheter is disconnected or dislodged. Pneumothorax can recur or worsen. A worsening pneumothorax lets air build in the intrapleural space, causing mediastinal shift, pulmonary shunting, and circulatory collapse.

Assess for pain, and document it every 4 hours unless more often is needed. Give regular pain relief, and arrange it before mobilization, physiotherapy, and any movement.

Assess the color and consistency of the drainage, documenting it hourly with the volume. Notify the provider for hemoserous, bright red serous, or creamy drainage.

Check the suction pressure against the order. Suction is not always needed and can cause tissue trauma or prolong an air leak. Make sure suction is on when it should be and that the indicator bellows is fully extended.

Label the drainage bottles clearly and regularly. A clear, durable label lets the nurse remove the correct drain and should note the position and side of placement without covering the measurement marks.

Explain the purpose and function of the drainage unit, including its safety features. Understanding the system reassures the patient and lowers anxiety. Tailor the teaching, since chest tube management is not one-size-fits-all.

Tell the patient not to lie on or pull the tubing. This avoids obstructing drainage or disconnecting the tube. Keep the tubing free of kinks and check that it is not pinned under the patient or a bed rail.

Anchor the catheter to the chest wall and leave extra tubing before turning or moving the patient. Secure it per institutional preference. This prevents dislodgement, disconnection, and the pain of pulling on the tubing.

Secure the tubing connection sites. Examine the wound for loose connections or dislodgement. Cross-taping is the most secure method and leaves a window to inspect the connection.

Pad banding sites with gauze or tape. This protects skin from irritation and pressure. A latex-free, hypoallergenic paper tape works on damp or fragile skin and tolerates repeated taping.

Secure the drainage unit to the bed, a stand, or a cart in a low-traffic area. Keep it upright to avoid tipping. The underwater seal bottle should sit erect and at least 100 cm below the patient's chest. Never lift the system above the chest, or fluid can siphon back in.

Transport safely. Before moving the patient, check the water-seal chamber for the correct fluid level, bubbling, and tidaling. This maintains evacuation during transport. If the patient is draining large amounts of fluid or air, do not clamp the tube or interrupt suction, since trapped fluid or air can compromise respiratory status.

Change the tubes and drainage system as indicated, replacing with sterile equivalents. Wash and disinfect equipment to remove residue before sterilization.

Apply the correct amount of suction as indicated. Connecting to suction for the first 1 to 2 days is common. When needed, use constant low-pressure suction to clear the pleural contents without causing discomfort. The recommended range is -5 to -20 cm H2O. Greater negative pressure speeds removal but can damage lung tissue.

Administer antibiotics and prophylactic vaccination as prescribed. See Pharmacologic Management.

6. Administering Medications and Pharmacological Support

Pharmacologic treatment centers on pain control, infection prevention, and supportive care:

Ibuprofen or acetaminophen. Ibuprofen (an NSAID) and acetaminophen control mild to moderate pain.

Morphine. A potent opioid for moderate to severe pain, given IV or by patient-controlled analgesia (PCA). Watch for respiratory depression and sedation.

Pneumococcal and influenza vaccinations. These lower the risk of respiratory infection. Pneumococcal vaccines cover Streptococcus pneumoniae; influenza vaccines cover seasonal flu.

7. Providing Patient Education and Health Teachings

Teach the patient the condition, its causes, symptoms, and complications, and stress getting medical attention immediately if concerning symptoms return.

Explain the pathology of the individual problem. Understanding the condition reduces fear of the unknown and clarifies why each treatment matters.

Address the likelihood of recurrence and long-term complications. Severe COPD and malignancy raise recurrence risk. In otherwise healthy patients, recurrence after a spontaneous pneumothorax runs 10% to 50%, and after a second episode the risk of a third climbs to 60%. Prompt treatment of bronchopulmonary infections lowers the risk.

Review the symptoms that require immediate evaluation: sudden chest pain, dyspnea, air hunger, and progressive respiratory distress. Recurrence needs medical intervention. Simple aspiration or chest tube drainage does not prevent it.

Review good health practices: adequate nutrition, rest, and exercise. Daily walking and avoiding alcohol and smoking aid recovery. Expect about 3 to 4 weeks to recover from having a chest tube.

Advise against air travel or remote travel until imaging shows full resolution. Cabin pressurization causes only minimal change in gas volume, but spontaneous pneumothorax has occurred during commercial flights.

Promote smoking cessation. Smoking raises the chance of bleb rupture and recurrence in a dose-related way. Assess readiness to quit and offer pharmacotherapy.

Teach about surgical pleurodesis. It carries a recurrence-prevention rate above 90%. Approaches range from VATS to surgical thoracotomy and pleurectomy.

Promote incentive spirometry and deep breathing. Incentive spirometry uses visual feedback to encourage maximal inspiration with a breath hold, re-expanding collapsed lung and mobilizing secretions.

Explain intrapleural fibrinolysis. Some centers use fibrinolytic agents to clear a residual hemothorax when tube drainage is inadequate. Daily instillations over 2 to 15 days have produced an overall success rate of 92%.