Pneumothorax and Hemothorax in Patient-Centered Care

Interprofessional Care for Pneumothorax and Hemothorax

• Respiratory services are consulted for ABGs, breathing treatments, and suctioning (airway management)
• Pulmonary services are consulted for chest tube management and pulmonary care
• Pain management services are consulted if pain persists or is uncontrolled
• Rehabilitation care is consulted if the client has prolonged weakness and needs assistance with increasing their level of activity

Therapeutic Procedures for Pneumothorax and Hemothorax

• Chest tube insertion is used to drain fluid, blood, or air, reestablishing negative pressure, facilitating lung expansion, and restoring normal intrapleural pressure
• Nursing actions for chest tube insertion include:
  • Obtaining informed consent, gathering supplies, and monitoring vital signs and chest tube drainage
  • Reporting abnormalities to the provider and administering pain medications as prescribed
  • Continuously monitoring vital signs and the client's response to the procedure
  • Monitoring chest tube placement, function of the chest drainage system, and dressing

Client Education for Pneumothorax and Hemothorax

• Participate in coughing, deep breathing, and use of incentive spirometry
• Take rest periods as needed
• Use proper hand hygiene to prevent infection
• Obtain immunizations for influenza and pneumonia
• Recovery from a pneumothorax/hemothorax can be lengthy
• Emotional support should be provided to the client and family
• Consider smoking cessation if applicable
• Follow up with the provider as instructed and report:
  • Upper respiratory infection
  • Fever
  • Sucking chest wounds, prolonged clamping of the tubing, kinks or obstruction in the tubing, or mechanical ventilation with high levels of positive end-expiratory pressure (PEEP)

Tension Pneumothorax

• Assessment findings include:
  • Tracheal deviation (toward the unaffected side)
  • Absent breath sounds on the affected side
  • Distended neck veins
  • Respiratory distress
  • Asymmetry of the chest
  • Cyanosis
• Notify the provider and rapid response team immediately
• Immediate treatment with needle decompression is necessary

Chest Tube Removal

• Provide pain medication 30 minutes before removing the chest tube
• Assist the provider with suture and chest tube removal
• Instruct the client to take a deep breath, exhale, and "bear down" (Valsalva maneuver) or to take a deep breath and hold it during chest tube removal
• Apply an airtight sterile petroleum jelly gauze dressing, secured with a heavyweight stretch tape
• Obtain chest x-rays as prescribed to verify the continued resolution of pneumothorax, hemothorax, and/or pleural effusion

Complications of Chest Tubes

• Air leaks can result if a connection is not taped securely
  • Monitor the water seal chamber for continuous bubbling (air leak finding)
  • Locate the source of the air leak and intervene accordingly
  • Check all connections
  • Notify the provider if an air leak is noted
• Accidental disconnection, system breakage, or removal can occur at any time and require immediate provider or rapid response team notification
  • If the tubing separates from the drainage system, instruct the client to exhale as much as possible and to cough to remove as much air as possible from the pleural space
  • If the chest drainage system is compromised, immerse the end of the chest tube in sterile water to provide a temporary water seal
  • If a chest tube is accidentally removed, dress the area with dry, sterile gauze (occlusive dressing taped on three sides, providing a one-way valve for air to escape)