Pneumothorax, Hemothorax

A collapsed lung happens when air (pneumothorax), blood (hemothorax), or other

fluids (pleural effusion) enters the pleural space, the area between the lung and the
chest wall. The intrathoracic pressure changes induced by increased pleural space
volumes reduce lung capacity, causing respiratory distress and gas exchange problems
and producing tension on mediastinal structures that can impede cardiac and systemic
circulation. Pneumothorax may be traumatic (open or closed) or spontaneous.

Nursing Care Plans

Nursing care planning and management for patients with hemothorax or

pneumothorax includes management of chest tube drainage, monitoring respiratory
status, and providing supportive care.

Below are three (3) nursing care plans for patients with pneumothorax and
hemothorax:

1. Ineffective Breathing Pattern

2. Risk for Trauma/Suffocation
3. Deficient Knowledge
4. Other Nursing Care Plans

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate
ventilation

May be related to

 Decreased lung expansion (air/fluid accumulation)

 Musculoskeletal impairment
 Pain/anxiety
 Inflammatory process

Possibly evidenced by
  Dyspnea, tachypnea
 Changes in depth/equality of respirations; altered chest excursion
 Use of accessory muscles, nasal flaring
 Cyanosis, abnormal ABGs

Desired Outcomes

 Establish a normal/effective respiratory pattern with ABGs within patient’s

normal range.
 Be free of cyanosis and other signs/symptoms of hypoxia.

Nursing Interventions Rationale

Determine etiology and precipitating factors

(spontaneous collapse,
malignancy, infection,
of mechanical ventilation).
Understanding the cause of lung collapse is
trauma,
necessary for proper chest tube placement and
complication
choice of other therapeutic measures.

Respiratory distress and changes in vital signs

Check out respiratory function, noting rapid or
may occur as a result of
shallow respirations, dyspnea, reports of “air
physiological stress and pain or may indicate
hunger,” development of cyanosis, changes in
development of shock due to hypoxia or
vital signs.
hemorrhage.

Difficulty breathing “with” ventilator and

Observe for synchronous respiratory pattern increasing airway pressures suggests worsening
when using mechanical ventilator. Note of condition or development of complications
changes in airway pressures. (spontaneous rupture of a bleb creating a new
pneumo -thorax).

Breath sounds may be diminished or absent in

a lobe, lung segment, or entire lung field
(unilateral). Atelectatic area will have no breath
sounds, and partially collapsed areas have
Auscultate breath sounds.
decreased sounds. Regularly scheduled
evaluation also helps determine areas of good
air exchange and provides a baseline to
evaluate resolution of pneumothorax.

Note chest excursion and position of trachea. Chest excursion is unequal until lung re-
expands. Trachea deviates away from affected
Nursing Interventions Rationale

side with tension pneumothorax.

Voice and tactile fremitus (vibration) is

Evaluate fremitus.
reduced in fluid-filled or consolidated tissue.

Supporting chest and abdominal muscles

Assist patient with splinting painful area when
makes coughing more effective and less
coughing, deep breathing.
traumatic.

Maintain position of comfort, usually with head

Promotes maximal inspiration; enhances lung
of bed elevated. Turn to affected side.
expansion and ventilation in unaffected side.
Encourage patient to sit up as much as possible.

Maintain a calm attitude, assisting patient to Assists patient to deal with the physiological
“take control” by using slower and deeper effects of hypoxia, which may be manifested as
respirations. anxiety or fear.

Maintains prescribed intrapleural negativity,

which promotes optimum lung expansion and
fluid drainage. Note: Dry- seal setups are also
Once chest tube is inserted:
used with an automatic control valve (AVC),
which provides a one-way valve seal similar to
that achieved with the water-seal system.

Water in a sealed chamber serves as a barrier

that prevents atmospheric air from entering the
pleural space should the suction source be
disconnected and aids in evaluating whether
the chest drainage system is functioning
Check suction control chamber for correct
appropriately. Note: Underfilling the water-seal
amount of suction (determined by water level,
chamber leaves it exposed to air, putting
wall or table regulator at correct setting;
patient at risk for pneumothorax or tension
pneumothorax. Overfilling (a more common
mistake) prevents air from easily exiting the
pleural space, thus preventing resolution of
pneumothorax or tension pneumothorax.

Monitor fluid level in water-seal chamber; maintain at prescribed level:

Bubbling during expiration reflects venting of

 Observe water-seal chamber pneumothorax (desired action). Bubbling
Nursing Interventions Rationale

bubbling usually decreases as the lung expands or may

occur only during expiration or coughing as the
pleural space diminishes. Absence of bubbling
may indicate complete lung re-expansion
(normal) or represent complications such as
obstruction in the tube.
With suction applied, this indicates a persistent
 Observe for abnormal and continuous
air leak that may be from a large pneumothorax
water-seal chamber bubbling at the chest insertion site (patient-centered) or
chest drainage unit (system-centered).
 Know the location of air leak
(patient- or by If bubbling stops when catheter is clamped at
system-centered)
clamping thoracic catheter just distal insertion site, leak is patient- centered (at
insertion site or within the patient).
to exit from chest;

 Place petrolatum gauze and other

appropriate material around the Usually corrects insertion site air leak.
insertion as indicated.

 Clamp tubing in Isolates location of a system-centered air

stepwise fashiondownward toward leak.Note: Information indicates that clamping
for a suspected leak may be the only time that
drainage unit if air leak continues chest tube should be clamped.

 Seal drainage tubing connection sites

securely with lengthwise tape or Prevents and corrects air leaks at connector
sites.
bands according to established policy

The water-seal chamber serves as an

intrapleural manometer (gauges intrapleural
pressure); therefore, fluctuation (tidaling)
 Monitor water-seal chamber reflects pressure differences between
“tidaling.” Note whether change is inspiration and expiration. Tidaling of 2–6 cm
during inspiration is normal and may increase
transient or permanent
briefly during coughing episodes. Continuation
of excessive tidal fluctuations may indicate
existence of airway obstruction or presence of a
large pneumothorax.
Nursing Interventions Rationale

 Position drainage system tubing for

Improper position, kinking, or accumulation of
optimal function like shorten tubing clots or fluid in the tubing changes the desired
or coil extra tubing on bed, making negative pressure and impedes air or fluid
sure tubing is not kinked or hanging evacuation. Note: If a dependent loop in the
drainage tube cannot be avoided, lifting and
below entrance to drainage container. draining it every 15 min will maintain adequate
Drain accumulated fluid as necessary drainage in the presence of a hemothorax.

 Assess amount of chest tube

Useful in evaluating resolution of
drainage, noting whether tube is pneumothorax and development of hemorrhage
warm and full of blood and bloody requiring prompt intervention. Note: Some
drainage systems are equipped with an
fluid level in water-seal bottle is
autotransfusion device, which allows for
rising salvage of shed blood.

Although routine stripping is not

 Evaluate need for tube stripping recommended, it may be necessary
(“milking”) occasionally to maintain drainage in the
presence of fresh bleeding, large blood clots or
purulent exudate (empyema).
Stripping is usually uncomfortable for patient
because of the change in intrathoracic pressure,
 Strip tubes carefully per protocol, in
which may induce coughing or chest
discomfort. Vigorous stripping can create very
a manner that minimizes excess high intrathoracic suction pressure, which can
negative pressure be injurious (invagination of tissue into
catheter eyelets, collapse of tissues around the
catheter, and bleeding from rupture of small
blood vessels).
If thoracic catheter is disconnected or dislodged:
 Observe for signs of respiratory
distress. If possible, reconnect
thoracic catheter to tubing or suction, Pneumothorax may recur, requiring prompt
using clean technique. If the catheter intervention to prevent fatal pulmonary and
circulatory impairment.
is dislodged from the chest, cover
insertion site immediately with
petrolatum dressing and apply firm
Nursing Interventions Rationale

pressure. Notify physician at once.

After thoracic catheter is removed:

 Cover insertion site with sterile
occlusive dressing. Observe for signs
and symptoms that may indicate
Early detection of a developing complication is
recurrence of pneumothorax essential (recurrence of pneumothorax,
(shortness of breath, reports of pain. presence of infection).
Inspect insertion site, note character
of drainage).

Monitors progress of resolving hemothorax or

pneumothorax and re-expansion of lung. Can
Review serial chest x-rays.
identify malposition of endotracheal tube (ET)
affecting lung re-expansion.
Monitor and graph serial ABGs and pulse Assesses status of gas exchange and
oximetry. Review vital capacity and tidal ventilation, need for continuation or alterations
volume measurements. in therapy.
Aids in reducing work of breathing; promotes
Administer supplemental oxygen via cannula,
relief of respiratory distress and cyanosis
mask, or mechanical ventilation as indicated.
associated with hypoxemia.
Risk for Trauma: The state in which an individual is at risk of accidental tissue injury (e.g.,
wound, burns, fracture).

Risk factors may include

 Concurrent disease/injury process

 Dependence on external device (chest drainage system)
 Lack of safety education/precautions

Desired Outcomes

 Recognize need for/seek assistance to prevent complications.

 Correct/avoid environmental and physical hazards.
Nursing Interventions Rationale

Explain with patient purpose and function of

Information on how system works provides
chest drainage unit, taking note of safety
reassurance, reducing patient anxiety.
features.

Advise patient to avoid lying and pulling on Reduces risk of obstructing drainage and
tubing. inadvertently disconnecting tubing.

Identify changes or situations that should be

reported to caregivers such as change in sound Timely intervention may prevent serious
of bubbling, sudden “air hunger” and chest complications.
pain, disconnection of equipment.

Prevents thoracic catheter dislodgment or

Anchor thoracic catheter to chest wall and
tubing disconnection and reduces pain and
provide extra length of tubing before turning or
discomfort associated with pulling or jarring of
moving patient;
tubing.

Secure tubing connection sites; Prevents tubing disconnection.

Pad banding sites with gauze or tape. Protects skin from irritation and pressure.

Secure drainage unit to patient’s bed, stand or Maintains upright position and reduces risk of
cart placed in low-traffic area. accidental tipping and breaking of unit.

Implement safe transportation if patient is sent

off unit for diagnostic purposes. Before
transporting: check water-seal chamber for
correct fluid level, presence or absence of
bubbling; presence, degree and timing of
tidaling. Ascertain whether or not chest tube
can be clamped or disconnected from suction
source.
Promotes continuation of optimal evacuation of
fluid or air during transport. If patient is
draining large amounts of chest fluid or air,
tube should not be clamped or suction
interrupted because of risk of reaccumulation
of fluid or air, compromising respiratory status.

Observe thoracic insertion site, noting

condition of skin, presence and characteristics Provides for early recognition and treatment of
of drainage from around the catheter. Change developing skin or tissue erosion or infection.
or reapply sterile occlusive dressing as needed.

Pneumothorax may recur or worsen,

Observe for signs of respiratory distress if
compromising respiratory function and
Nursing Interventions Rationale

thoracic catheter is disconnected or dislodged. requiring emergency intervention.

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

 Lack of exposure to information

Possibly evidenced by

 Expressions of concern, request for information

 Recurrence of problem

Desired Outcomes

 Verbalize understanding of cause of problem (when known).

 Identify signs/symptoms requiring medical follow-up.
 Follow therapeutic regimen and demonstrate lifestyle changes if necessary
to prevent recurrence.

Nursing Interventions Rationale

Information reduces fear of unknown. Provides

knowledge base for understanding underlying
Ascertain pathology of individual problem.
dynamics of condition and significance of
therapeutic interventions.

Certain underlying lung diseases such as

severe COPD and malignancies may increase
incidence of recurrence. In otherwise healthy
Determine likelihood for recurrence and long- patients who suffered a spontaneous
term complications. pneumothorax, incidence of recurrence is
10%–50%. Those who have a second
spontaneous episode are at high risk for a third
incident (60%).
Nursing Interventions Rationale

Reassess signs and symptoms requiring

Recurrence of pneumothorax or hemothorax
immediate medical evaluation such as sudden
requires medical intervention to prevent or
chest pain, dyspnea or air hunger, progressive
reduce potential complications.
respiratory distress.

Review significance of good health practices Maintenance of general well-being promotes

(adequate nutrition, rest, exercise). healing and may prevent or limit recurrences.