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.

Ineffective Breathing Pattern

Nursing Diagnosis

 Ineffective Breathing Pattern

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
Determine etiology and precipitating
factors (spontaneous collapse,
trauma, malignancy, infection, a
complication of mechanical
ventilation).
Check out respiratory function, noting
rapid or shallow respirations, dyspnea,
reports of “air hunger,” development
of cyanosis, changes in vital signs.
Observe for synchronous respiratory
pattern when using a mechanical
ventilator. Note changes in airway
pressures.
Auscultate breath sounds.
Rationale
Understanding the cause of lung collapse
is necessary for proper chest tube
placement and choice of other therapeutic
measures.
Respiratory distress and changes in vital
signs may occur as a result of
physiological stress and pain or may
indicate the development of shock due to
hypoxia or hemorrhage.
Difficulty breathing “with” ventilator and
increasing airway pressures suggests
worsening of condition or development of
complications (spontaneous rupture of a
bleb creating a new pneumothorax).
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 decreased sounds.
Regularly scheduled evaluation also helps
determine areas of good air exchange and
provides a baseline to evaluate the
resolution of pneumothorax.
 Nursing Interventions
Note chest excursion and position of
the trachea.
Assess for fremitus.
Assist patient with splinting painful
area when coughing, deep breathing.
Maintain a position of comfort,
usually with the head of bed elevated.
Turn to the affected side. Encourage
patient to sit up as much as possible.
Maintain a calm attitude, assisting the
patient to “take control” by using
slower and deeper respirations.
Once the chest tube is inserted:
Rationale
Chest excursion is unequal until lung re-
expands. Trachea deviates away from the
affected side with tension pneumothorax.
Voice and tactile fremitus (vibration) are
reduced in fluid-filled or consolidated
tissue.
Supporting chest and abdominal muscles
make coughing more effective and less
traumatic.
Promotes maximal inspiration; enhances
lung expansion and ventilation in
unaffected side.
Assists patient to deal with the
physiological effects of hypoxia, which
may be manifested as anxiety or fear.
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.
 Nursing Interventions
Check suction control chamber for a
correct amount of suction
(determined by water level, wall or
table regulator at correct setting;
Monitor fluid level in the water-seal chamber; maintain at prescribed level:
 Observe water-seal chamber
bubbling
 Know the location of air leak
(patient- or system-centered)
by clamping thoracic catheter
just distal to exit from the chest.

Rationale
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 leaves
it exposed to air, putting the 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.
Bubbling during expiration reflects venting
of pneumothorax (desired action).
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.
If bubbling stops when the catheter is
clamped at the insertion site, leak is
patient-centered (at insertion site or within
the patient).
 Nursing Interventions
 Place petrolatum
gauze and other appropriate
material around the insertion as
indicated.

 Clamp tubing in stepwise
fashion downward toward the
drainage unit if air leak
continues

 Seal drainage tubing
connection sites securely with
lengthwise tape or bands
according to established policy
 Position drainage system
tubing for an optimal function
like shorten tubing or coil extra
tubing on the bed, making sure
tubing is not kinked or hanging
below the entrance to drainage
container. Drain accumulated
fluid as necessary

 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
 device, which allows for salvage of shed
Rationale
Usually corrects insertion site air leak.
Isolates 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.
Prevents and corrects air leaks at
connector sites.
Improper position, kinking, or
accumulation of clots or fluid in the tubing
changes the desired negative pressure and
impedes air or fluid evacuation. Note: If a
dependent loop in the drainage tube
cannot be avoided, lifting and draining it
every 15 min will maintain adequate
drainage in the presence of a hemothorax.
Useful in evaluating resolution of
pneumothorax and development of
hemorrhage requiring prompt
intervention. Note: Some drainage systems
are equipped with an autotransfusion
 Nursing Interventions Rationale

blood.

Although routine stripping is not

recommended, it may be necessary
 Evaluate the need for tube
occasionally to maintain drainage in the
stripping (“milking”)
presence of fresh bleeding, large blood

clots or purulent exudate (empyema).

Stripping is usually uncomfortable for the

patient because of the change in
intrathoracic pressure, which may induce
 Strip tubes carefully per coughing or chest discomfort. Vigorous
protocol, in a manner that stripping can create very high intrathoracic
minimizes excess negative suction pressure, which can be injurious
pressure (invagination of tissue into catheter
 eyelets, collapse of tissues around the
catheter, and bleeding from rupture of
small blood vessels).

If the thoracic catheter is disconnected or dislodged: 

 Observe for signs of respiratory Pneumothorax may recur, requiring

distress. If possible, reconnect prompt intervention to prevent fatal
thoracic catheter to tubing or pulmonary and circulatory impairment.
suction, using clean technique.
If the catheter is dislodged
from the chest, cover insertion
site immediately with
petrolatum dressing and apply
firm pressure. Notify physician
 Nursing Interventions Rationale

at once.


 After the thoracic catheter is

removed:

 Cover insertion site with a

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

Monitors progress of resolving

hemothorax or pneumothorax and re-
 Review serial chest x-rays. expansion of the lung. Can identify
 malposition of the endotracheal tube (ET)
affecting lung re-expansion.

 Monitor and graph serial ABGs

Assesses status of gas exchange and
and pulse oximetry. Review vital
ventilation, need for continuation or
capacity and tidal volume
alterations in therapy.
measurements.


 Administer supplemental
Aids in reducing work of breathing;
oxygen via cannula, mask, or
promotes relief of respiratory distress and
mechanical ventilation as
cyanosis associated with hypoxemia.
indicated.


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