5 Hemothorax and Pneumothorax Nursing Care Plans

Ineffective Breathing Pattern

In normal respiration, the pleural space has a negative pressure. As the chest wall expands outward, the surface tension between the parietal and visceral pleura expands the lung outward. The lung tissue intrinsically has an elastic recoil, tending to collapse inwards. If the pleural space is invaded by gas from a ruptured bleb, the lung collapses until equilibrium is achieved or the rupture is sealed. As the pneumothorax enlarges, the lung becomes smaller. The main physiologic consequence of this process is a decrease in vital capacity and partial pressure of oxygen (Daley & Mancini, 2022).

Nursing Diagnosis

• Ineffective Breathing Pattern

May be related to

• Decreased lung expansion (air/fluid accumulation)
• Musculoskeletal impairment
• Pain/anxiety
• Inflammatory process
• Malfunction of the chest drainage system

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

• The client will establish a normal/effective respiratory pattern with ABGs within the client’s normal range.
• The client will be free of cyanosis and other signs/symptoms of hypoxia.
• The client’s lung expansion will be noted on the chest x-ray.

Nursing Assessment and Rationales

1. Determine etiology and precipitating factors (spontaneous collapse, trauma, malignancy, infection, complication of mechanical ventilation).
Understanding the cause of lung collapse is necessary for proper chest tube placement and the choice of other therapeutic measures. Selection among the various management options requires an understanding of the natural history of the pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of each treatment option and a discussion with the client (Daley & Mancini, 2022).

2. Assess respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
Respiratory distress and changes in vital signs may occur due to physiological stress and pain or may indicate the development of shock due to hypoxia or hemorrhage. Shortness of breath or dyspnea in primary spontaneous pneumothorax is generally sudden in onset and tends to be more severe with secondary spontaneous pneumothorax because of decreased lung reserve (Daley & Mancini, 2022).

3. Observe a synchronous respiratory pattern when using a mechanical ventilator. Note changes in airway pressures.
Difficulty breathing “with” the ventilator and increasing airway pressures suggests worsening of the condition or development of complications (spontaneous rupture of a bleb creating a new pneumothorax). High pressures and air trapping place the client at risk for tension pneumothorax if the thoracostomy is not functioning (Daley & Mancini, 2022).

4. Auscultate breath sounds.
Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). The atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. The regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate the resolution of pneumothorax.

5. Note chest excursion and position of the trachea.
Chest excursion is unequal until the lung re-expands. The trachea deviates away from the affected side with tension pneumothorax. When examining a client for suspected tension pneumothorax, any clue may be helpful, as subtle thoracic size and thoracic mobility differences may be elicited by performing careful visual inspection along the line of the thorax. In a supine client, the nurse should lower themselves to be on a level with the client (Daley & Mancini, 2022).

6. Assess for fremitus.
Voice and tactile fremitus (vibration) are reduced in fluid-filled or consolidated tissue. Air or fluid accumulates in the potential space between the chest wall and lung parenchyma, decreasing the transmission of lower-frequency sound vibrations (Modi, 2022).

7. Assess the client’s mental and cardiac status at frequent intervals.
This assessment monitors the client’s status while the chest drainage system is in place. The purpose of a chest drainage system is to drain air or fluid and re-expand the lung. Tachycardia, restlessness, anxiety, and changes in mental status are signs of respiratory distress that may occur due to chest drainage system malfunction.

Nursing Interventions and Rationale

1. Assist the client with splinting painful areas when coughing and deep breathing.
Supporting chest and abdominal muscles make coughing more effective and less traumatic. The client may be instructed to use a towel pad to support the chest while coughing, sneezing, laughing, etc (Bhagwani et al., 2022).

2. Maintain a position of comfort, usually with the head of the bed elevated. Turn to the affected side. Encourage the client to sit up as much as possible.
This promotes maximal inspiration; enhances lung expansion and ventilation on the unaffected side. The client may be positioned in a semi-Fowler or sitting position to decrease the work of breathing.

3. Maintain a calm attitude, assisting the client to “take control” by using slower and deeper respirations.
This assists the client in dealing with the physiological effects of hypoxia, which may be manifested as anxiety or fear. The pain and fear associated with a pneumothorax contribute to the overall stress level of the client, and the nurse’s calm demeanor can influence the client’s state of mind.

4. Once the chest tube is inserted:

• 4.1. Determine if a dry seal chest drain or water seal system is used.
  This maintains prescribed intrapleural negativity, which promotes optimum lung expansion and fluid drainage. Note: Dry-seal setups are also used with an automatic control valve (AVC), which provides a one-way valve seal similar to that achieved with the water-seal system. The water seal chamber acts as a one-way valve allowing air to escape from gravity, but not to re-enter the thoracic cavity (Ravi & McKnight, 2022).
• 4.2. Check the suction control chamber for the correct amount of suction (determined by water level, wall, or table regulator at the correct setting;
  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 appropriately. Note: Underfilling the water-seal chamber exposes it to air, putting the client at risk for pneumothorax or tension pneumothorax. Overfilling (a more common mistake) prevents air from easily exiting the pleural space, thus preventing the resolution of pneumothorax or tension pneumothorax.

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

• 5.1. Maintain fluid in the water-seal chamber and suction chamber at appropriate levels.
  Many closed systems come pre-filled with water. Otherwise, the suction apparatus does not regulate the amount of suction applied to the closest chest drainage system. The amount of suction is determined by the water level in the suction control chamber.
• 5.2. Dial the level of dry suction per the healthcare provider’s recommendation.
  This action maintains air and fluid removal from the pleural space. Suction aids in lung re-expansion, but removing suction for short periods, such as transporting, will not be detrimental or disrupt the closed chest drainage system.
• 5.3. Observe the water-seal chamber bubbling
  Bubbling during expiration reflects the venting of pneumothorax (the desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. The absence of bubbling may indicate complete lung re-expansion (normal) or represent complications such as obstruction in the tube.
• 5.4. Observe for abnormal and continuous water-seal chamber bubbling
  With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (client-centered) or chest drainage unit (system-centered). Most intrathoracic air leaks will usually seal spontaneously, and resolution can be tracked by witnessing decreased bubbling in the device over days. Larger air leaks, such as those caused by bronchopleural fistulas, may require surgical intervention (Merkle & Cindass, 2022).
• 5.5. Know the location of the air leak (client- or system-centered) by clamping of the thoracic catheter just distal to exit from the chest.
  If bubbling stops when the catheter is clamped at the insertion site, the leak is client-centered (at the insertion site or within the client). Should the presence of an air leak continue after the client has been isolated from the circuit, it is incumbent on the provider to work in a stepwise fashion to determine which section of the circuit has the air leak (Merkle & Cindass, 2022).
• 5.6. Place petrolatum gauze and other appropriate material around the insertion as indicated.
  This usually corrects insertion site air leaks. A petrolatum gauze pad is applied over the insertion site if the chest tube becomes dislodged. The use of this dressing provides an airtight seal to prevent recurrent pneumothorax.
• 5.7. Clamp tubing in a stepwise fashion downward toward the drainage unit if the air leak continues
  Clamping downward isolates the location of a system-centered air leak. Note: Information indicates that clamping for a suspected leak may be the only time that the chest tube should be clamped. Often the evaluation will begin at the chest tube insertion site to assess if there is atmospheric air tracking into the thoracic space via the chest tube insertion site. Clamping of the tube should occur very briefly or the tube can be mechanically occluded to determine if an ongoing air leak is downstream from the client (Merkle & Cindass, 2022).
• 5.8. Seal drainage tubing connection sites securely with lengthwise tape or bands according to established policy
  This prevents and corrects air leaks at connector sites. Tape all connections and secure the chest tube to the thorax with tape or other securement devices. These actions help maintain a closed chest drainage system and facilitate drainage.
• 5.9. Monitor water-seal chamber “tidaling.” Note whether the change is transient or permanent
  The water-seal chamber serves as an intrapleural manometer (gauges intrapleural pressure); therefore, fluctuation (tidaling) reflects pressure differences between inspiration and expiration. Tidaling of the chest tube, when the fluid in the chamber or along a dependent portion of the tubing is seen to move back and forth with respiration, is a sign that a patent chest tube is affected by the negative pressure created by the diaphragm (Merkle & Cindass, 2022). Tidaling of two to six centimeters during inspiration is normal and may increase briefly during coughing episodes. The continuation of excessive tidal fluctuations may indicate the existence of airway obstruction or the presence of a large pneumothorax.
• 5.10. Position drainage system tubing for an optimal function like shortening the tubing or coiling the extra tubing on the bed, ensuring the tubing is not kinked or hanging below the entrance to the drainage container. Drain accumulated fluid as necessary.
  Improper position, kinking, or accumulation of clots or fluid in the tubing changes the desired negative pressure and impedes air or fluid evacuation. Ensure that the bed and equipment are not compressing any system component. These actions help maintain the chest drainage system and facilitate drainage. Note: If a dependent loop in the drainage tube cannot be avoided, lifting and draining it every 15 minutes will maintain adequate drainage in the presence of a hemothorax.
• 5.11. Assess the amount of chest tube drainage, noting whether the tube is warm and full of blood and bloody fluid level in the water-seal bottle is rising.
  This is useful in evaluating the resolution of pneumothorax and the development of hemorrhage requiring prompt intervention. Note: Some drainage systems are equipped with an autotransfusion device, which allows for the salvage of shed blood. One low-cost option is to utilize simple underwater drainage bottles connected to a chest tube to collect blood from an acute hemothorax and then salvage the blood for re-infusion via an empty saline bag (Hardcastle, 2021).
• 5.12. Evaluate the need for tube stripping (“milking”).
  Although routine stripping is not recommended, it may be necessary occasionally to maintain drainage in the presence of fresh bleeding, large blood clots, or purulent exudate (empyema). Should the healthcare provider request line stripping, the procedure is accomplished by first securing the tube at the incision site with a hand to prevent accidental dislodgement during the procedure. The tube is then pinched and “milked” away from the client. Using an alcohol wipe will provide helpful lubrication while sliding fingers along the tube. An alternative is to use two pens that are held together in one hand to provide occlusion of the line (Merkle & Cindass, 2022).
• 5.13. Strip tubes carefully per protocol, in a manner that minimizes excess negative pressure.
  Stripping is usually uncomfortable for the client because of the change in intrathoracic pressure, which may induce coughing or chest discomfort. Vigorous stripping can create very high intrathoracic suction pressure, which can be injurious (invagination of tissue into catheter eyelets, the collapse of tissues around the catheter, and bleeding from the rupture of small blood vessels). Creating high negative pressures in the pleural space may also damage fragile lung tissue. Stripping must be avoided as much as possible and should not be performed without orders from the healthcare provider.

6. If the thoracic catheter is disconnected or dislodged: 

• 6.1. Observe for signs of respiratory distress. If possible, reconnect the thoracic catheter to tubing or suction, using a clean technique. If the catheter is dislodged from the chest, cover it at the insertion site immediately with petrolatum dressing and apply firm pressure. Notify the healthcare provider at once.
  Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment. Submerging the chest tube in a bottle of sterile water if it becomes disconnected from the water-seal system provides for a temporary closed-chest drainage system.

7. After the thoracic catheter is removed:

• 7.1. Cover the insertion site with a sterile occlusive dressing. Observe for signs and symptoms that may indicate recurrence of pneumothorax (shortness of breath, reports of pain. Inspect the insertion site, note the character of drainage).
  Early detection of a developing complication is essential (recurrence of pneumothorax, presence of infection). One method is to cover the tube site with an occlusive dressing such as petroleum-impregnated gauze. Another method is to tie the suture, which was securing the tube close to the wound (Merkle & Cindass, 2022).
• 7.2. Review serial chest x-rays.
  Chest x-rays monitor the progress of resolving hemothorax or pneumothorax and re-expansion of the lung. It can also identify malposition of the endotracheal tube (ET), affecting lung re-expansion. If conservative management of retained collections is chosen, serial chest x-rays should be obtained to ensure that resolution is occurring (Mancini & Milliken, 2022).
• 7.3. Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
  This assesses the status of gas exchange and ventilation and the need for continuation or alterations in therapy. ABG studies measure the degrees of acidemia, hypercarbia, and hypoxemia, the occurrence of which depends on the extent of cardiopulmonary compromise at the time of collection (Daley & Mancini, 2022).
• 7.4. Administer supplemental oxygen via cannula, mask, or mechanical ventilation as indicated.
  Oxygen aids in reducing the work of breathing; promotes relief of respiratory distress and cyanosis associated with hypoxemia. However, oxygen administration at 3L/minute nasal cannula or higher flow treats possible hypoxemia and is associated with a fourfold increase in the rate of pleural air absorption compared with room air alone (Daley & Mancini, 2022).
• 7.5. Assist with and prepare for reinflation procedures, such as simple aspiration, Heimlich valve, and chest tube placement with chest tube drainage.
  Simple aspiration in 131 cases of small spontaneous pneumothorax yielded successful results up to 87%. A subsequent ED study found needle aspiration to be as safe and effective as chest tube placement for PSP, conferring the additional benefits of shorter lengths of stay and fewer hospital admissions.  A Heimlich valve is a one-way rubber flutter valve that allows complete evacuation of air that is not under tension. Chest tube placement occurs when a tube inserted into the pleural space is connected to a device with a one-way flow for air removal (Daley & Mancini, 2022).