Guide — Respiratory
Pneumothorax & Chest Trauma Nursing Care
Air (or blood) in the pleural space collapses the lung. Most pneumothoraces are managed with a chest tube — but a tension pneumothorax is a true emergency that needs immediate needle decompression. Knowing which is which is the whole game.
9 min read · Respiratory
Educational use only. Tension pneumothorax is a life-threatening emergency. Procedures and treatment are provider-directed and individualized. This is educational background for nursing care. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Overview
Normally the pleural space holds a thin film of fluid at negative pressure that keeps the lung expanded. When air enters the pleural space (pneumothorax) or blood collects (hemothorax), that negative pressure is lost and the lung collapses. Causes range from spontaneous rupture of a bleb (tall, thin young men), to trauma, to procedures (central line, thoracentesis, barotrauma from positive-pressure ventilation).
Key Concepts
Simple / spontaneous pneumothorax
Air enters without ongoing buildup; the lung partially collapses. Findings: sudden pleuritic pain, dyspnea, decreased/absent breath sounds and hyperresonance on the affected side. Small ones may be observed; larger ones need a chest tube.
Tension pneumothorax — the emergency
A one-way valve lets air in but not out, so pressure builds and shifts the mediastinum, compressing the heart and great vessels. The classic signs: tracheal deviation AWAY from the affected side, absent breath sounds, distended neck veins, hypotension, and severe respiratory distress. Treatment is immediate needle decompression (large-bore needle, 2nd intercostal space, midclavicular line) followed by a chest tube — do not wait for imaging.
Open pneumothorax & hemothorax
Open (“sucking chest wound”): a chest-wall defect; cover with an occlusive dressing taped on three sides (flutter-valve effect to prevent creating a tension). Hemothorax: blood in the pleural space — watch for hypovolemia and significant chest-tube blood output.
Flail chest
Two or more adjacent ribs broken in two places create a free-floating segment with paradoxical movement (in on inspiration, out on expiration). Manage pain and oxygenation; severe cases need positive-pressure ventilation.
Assessment Findings
Hallmarks: decreased or absent breath sounds and decreased chest expansion on the affected side, pleuritic pain, dyspnea, tachypnea, tachycardia, and hypoxia. Percussion is hyperresonant over a pneumothorax and dull over a hemothorax. The red flags of a tension pneumothorax — tracheal deviation, JVD, hypotension, and rapidly worsening distress — demand immediate action. Confirm stable cases with a chest x-ray.
Nursing Priorities
Recognize tension and act
If you see tracheal deviation, absent breath sounds, JVD, and hypotension, call for emergency help and anticipate immediate needle decompression — this cannot wait for x-ray. Give high-flow oxygen and position upright if tolerated.
Manage the chest tube
Maintain the closed water-seal drainage system below chest level; keep connections taped and the system upright. Continuous bubbling in the water-seal chamber suggests an air leak; tidaling (fluid moving with respiration) is expected. If the tube is dislodged, cover the site with a dressing taped on three sides; if the system breaks, place the tube end in sterile water. Do not routinely clamp.
Support oxygenation and monitor output
Monitor respiratory status, SpO₂, and pain. For hemothorax, track chest-tube blood output and hemodynamics — large or rising output is reported promptly.
Therapeutic Communication Considerations
Air hunger and a chest tube are frightening. Explain what the tube does and why it must stay below the chest and connected, and coach slow breathing. Reassure trauma patients during a fast-moving resuscitation, and prepare them for the discomfort of the tube and the importance of deep breathing and incentive spirometry to re-expand the lung.
Patient & Family Education
Teach deep breathing and incentive spirometry to re-expand the lung, splinting for cough/pain, and not pulling on the chest-tube tubing. For spontaneous pneumothorax, review the recurrence risk, smoking cessation, and avoiding scuba diving and high-altitude flying until cleared. Teach the warning signs to report (worsening shortness of breath, chest pain, fever) after discharge.
NCLEX Pearls
- ✦Pneumothorax = decreased/absent breath sounds + hyperresonance on the affected side; hemothorax = dullness.
- ✦Tension pneumothorax: tracheal deviation AWAY, JVD, hypotension, absent breath sounds → immediate needle decompression (don't wait for x-ray).
- ✦Open ('sucking') chest wound: occlusive dressing taped on THREE sides (flutter valve).
- ✦Flail chest = paradoxical chest movement from ribs broken in two places.
- ✦Chest tube: continuous bubbling = air leak; tidaling is expected; keep the system upright and below chest level.
- ✦If the chest tube dislodges, cover with a dressing taped on three sides; if the system breaks, submerge the end in sterile water.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Association for Respiratory Care (AARC) · GOLD (COPD) / ATS / CHEST. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →