Nursing care
Hemothorax nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated September 2026
Short answer
Hemothorax is blood accumulating in the pleural space, most often after chest trauma, rib fracture, or a penetrating injury to a lung or intercostal vessel. Chest tube drainage over 200 mL per hour, or 1,000 to 1,500 mL immediately, signals ongoing haemorrhage severe enough to require surgical exploration rather than continued observation.
What it is and why it happens
Hemothorax is blood collecting in the pleural space, most commonly from blunt or penetrating chest trauma that lacerates an intercostal artery, the internal mammary artery, or lung parenchyma itself. Rib fractures are a frequent cause, since a fractured rib end can tear the pleura and underlying vessels.
It can also occur after central line placement, thoracic surgery, or anticoagulant therapy in a patient with an existing lung or pleural injury. The blood in the pleural space compresses the lung on the affected side, reducing its ability to expand and impairing gas exchange, while ongoing bleeding can also cause haemorrhagic shock if the volume is large.
How it presents — what you will actually see
Expect decreased or absent breath sounds on the affected side, dullness to percussion, and asymmetric chest expansion. The patient is often tachypnoeic and reports pleuritic chest pain, and in significant bleeds you will see the signs of hypovolaemia — tachycardia, hypotension, cool clammy skin, and a falling haemoglobin on serial labs.
Tracheal deviation away from the affected side can occur with a large hemothorax, though it is less common than with tension pneumothorax. A chest X-ray typically shows blunting of the costophrenic angle or a diffuse opacity on the affected side, and a CT scan gives a more precise estimate of blood volume when time allows.
Nursing assessment priorities
Airway, breathing and circulation come first, as with any trauma patient. Assess respiratory rate, oxygen saturation, and work of breathing, and auscultate both lung fields to confirm the side and extent of the finding.
Monitor vital signs frequently for evolving shock, and track haemoglobin and haematocrit trends, since a falling value alongside ongoing chest tube output confirms active bleeding rather than a stable, resolving collection. Assess pain, since inadequate analgesia limits deep breathing and coughing, which increases the risk of atelectasis and pneumonia on the affected side.
Interventions and what to do first
Chest tube insertion connected to a closed drainage system is the primary intervention, allowing blood to drain and the lung to re-expand while you monitor output. Record hourly drainage, and treat output over 200 mL per hour, or an initial drain of 1,000 to 1,500 mL, as an indication for surgical exploration, since this volume signals a bleeding source that will not stop on its own.
Establish large-bore IV access and prepare for fluid resuscitation or blood product administration if signs of shock are present. Position the patient to optimise breathing, typically semi-Fowler's, and administer supplemental oxygen as needed. Keep the drainage system below chest level at all times and never clamp a draining chest tube without a specific order, since clamping can convert a hemothorax into a tension physiology.
Complications to watch for
Retained hemothorax occurs when clotted blood is not fully drained by the chest tube, which can organise into fibrous tissue and trap the lung — this is a known reason for persistent hypoxia or reduced lung expansion on follow-up imaging despite a tube in place.
Empyema is a later complication, where retained blood becomes infected, presenting with fever and purulent drainage days after the initial injury. Ongoing haemorrhagic shock, tension physiology from a rapidly filling pleural space, and pneumonia from splinting and reduced deep breathing are the other complications nurses monitor for throughout the admission.
Patient teaching before discharge
Teach the patient to report worsening shortness of breath, fever, or chest pain after discharge, since these can indicate a retained hemothorax or developing empyema that was not apparent on the initial post-removal chest X-ray. Reinforce the importance of the follow-up imaging appointment for this reason.
Encourage incentive spirometry and deep breathing exercises to promote full lung re-expansion and reduce the risk of atelectasis and pneumonia, particularly if rib fractures limit the depth of breathing. Advise against strenuous activity or heavy lifting for the period the provider specifies, since chest wall healing and pleural resolution both take time.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our respiratory practice questions are the closest set to what this page covers.
Common questions
What chest tube output means the patient needs surgery for hemothorax?
Drainage exceeding 200 mL per hour, or an initial output of 1,000 to 1,500 mL at the time of tube placement, is generally the threshold that prompts surgical exploration. This volume indicates active bleeding from a vessel that is unlikely to stop with drainage alone.
How is hemothorax different from pneumothorax?
Hemothorax is blood in the pleural space, while pneumothorax is air. Both can cause decreased breath sounds and respiratory distress, but hemothorax carries the added risk of haemorrhagic shock and is monitored with serial haemoglobin as well as respiratory assessment.
Can a chest tube be clamped if drainage is heavy?
No, not without a specific order from the provider. Clamping a chest tube that is actively draining a hemothorax can cause blood and air to accumulate rapidly and produce tension physiology, which is dangerous.
What are the first signs that a hemothorax is developing after a rib fracture?
Watch for decreased breath sounds on the affected side, dullness to percussion, worsening shortness of breath, and pleuritic chest pain. Falling blood pressure with rising heart rate suggests the bleed is significant and needs urgent evaluation.
Why might a patient develop a fever days after a hemothorax has been drained?
Blood left in the pleural space after drainage can become infected, leading to an empyema, which typically presents with fever and sometimes purulent drainage days to weeks after the initial injury. This is why follow-up imaging is part of standard care after tube removal.