Nursing care
Pneumothorax nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Pneumothorax nursing care depends entirely on which type you are facing. A tracheal shift away from the affected side, along with severe respiratory distress and absent breath sounds, is tension pneumothorax, and it needs immediate needle decompression, not a chest X-ray to confirm it first. Delaying for imaging in that scenario can be fatal.
The clinical picture
A simple or spontaneous pneumothorax presents with sudden, sharp pleuritic chest pain and shortness of breath, often in a tall, thin young adult with no prior lung disease, or in a patient with underlying COPD or a history of chest trauma. Breath sounds are diminished or absent on the affected side, and the patient may be tachypnoeic and anxious but is often hemodynamically stable.
Tension pneumothorax is a different emergency entirely. Air enters the pleural space with each breath and cannot escape, building pressure that collapses the lung and pushes the mediastinum toward the opposite side. The patient deteriorates rapidly: severe respiratory distress, jugular venous distension, hypotension, and tachycardia progressing to shock. The trachea shifts away from the affected side, a finding that is late but unmistakable, and by the time it is visible or palpable, the patient is in a true emergency, not a diagnostic workup.
Assessment: what to look for and in what order
Assess airway and breathing first, always. Check respiratory rate, effort, and symmetry of chest wall movement, then auscultate both lung fields, comparing side to side rather than assessing one side in isolation. Absent or markedly diminished breath sounds on one side, especially paired with hyperresonance to percussion, points toward pneumothorax.
Then assess circulation: heart rate, blood pressure, and jugular venous distension. Palpate the trachea at the suprasternal notch; a midline trachea is reassuring, but a trachea that has shifted away from the affected side, combined with hypotension and severe distress, is tension pneumothorax until proven otherwise. This is the one assessment finding in respiratory nursing that should stop you from ordering a confirmatory test and start you decompressing the chest. Do not wait for a chest X-ray if the clinical picture already tells you what is happening; imaging is for the stable patient, not the one in front of you with a shifted trachea and a falling blood pressure.
Immediate interventions
For a stable simple pneumothorax, apply supplemental oxygen, position the patient upright to ease breathing, and prepare for chest tube insertion connected to a water-seal drainage system, or in a small, stable spontaneous pneumothorax, prepare for observation with serial X-rays per physician order.
For tension pneumothorax, the intervention is needle decompression, performed by inserting a large-bore needle into the second intercostal space at the midclavicular line on the affected side, releasing the trapped air and converting the tension pneumothorax into a simple one while the team prepares for chest tube placement. This is done at the bedside based on clinical findings; sending the patient to radiology first, or waiting for a physician who is several minutes away when a nurse is trained and authorised to assist or perform this under protocol, can be the difference between survival and cardiac arrest from obstructive shock.
Ongoing nursing management
Once a chest tube is in place, maintain the water-seal drainage system below the level of the chest, monitor for tidaling in the water-seal chamber with respiration, and watch for continuous bubbling in the water-seal chamber, which suggests an air leak rather than normal lung re-expansion. Never clamp a chest tube without a specific order, since clamping a tube that is still draining a pneumothorax can recreate a tension pneumothorax.
Reassess breath sounds, oxygen saturation, and respiratory effort regularly, and track chest tube drainage volume and character if a hemothorax is also present. Encourage deep breathing and use of an incentive spirometer to promote lung re-expansion, and keep the tubing free of kinks and dependent loops that could impede drainage. Monitor the insertion site for subcutaneous emphysema, a crackling sensation under the skin from air tracking into the tissue, and note its extent so any progression is caught early.
Patient and family education
Explain the purpose of the chest tube in plain terms: it is removing trapped air so the lung can re-expand, and the drainage system must stay upright and below chest level at all times, including during transport. Teach the patient to report any sudden increase in shortness of breath, chest pain, or a feeling that something has come loose from the dressing.
For patients with spontaneous pneumothorax, particularly young, otherwise healthy patients, discuss the real recurrence risk, which is meaningful enough that many are counselled to avoid air travel and scuba diving for a period after the event and to seek immediate care if symptoms recur. Smoking cessation counselling is relevant here too, since smoking increases recurrence risk in spontaneous pneumothorax.
How this appears on the NCLEX
This is a classic priority-action question stem: the exam gives you tracheal deviation, absent breath sounds on one side, hypotension, and distress, then asks what you do first. The correct answer is needle decompression or immediately notifying the provider for emergency decompression, not obtaining a chest X-ray, not repositioning the patient, and not simply increasing oxygen. Any answer that delays decompression in favour of a diagnostic step is the wrong one when the stem describes tension physiology.
You will also see chest tube management questions: what to do if the drainage system is knocked over, what continuous bubbling in the water-seal chamber means, and why a chest tube should never be clamped without an order. Expect distractor options that sound cautious, such as clamping the tube to assess for a leak, which is precisely the unsafe action the question is testing you to avoid.
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 is the first sign of tension pneumothorax a nurse should act on?
Severe respiratory distress with absent breath sounds on the affected side and tracheal deviation away from that side. If the trachea has shifted and the patient is hypotensive, this is an emergency requiring immediate needle decompression, not a chest X-ray to confirm the finding first.
Why shouldn't a nurse wait for a chest X-ray before treating tension pneumothorax?
Tension pneumothorax causes rapidly worsening pressure that collapses the lung, shifts the mediastinum, and impairs venous return to the heart, leading to obstructive shock. Waiting for imaging delays a lifesaving intervention the patient may not survive; the clinical findings alone are enough to act.
What does continuous bubbling in the chest tube water-seal chamber mean?
Continuous bubbling suggests an air leak somewhere in the system, either from the pleural space, a loose connection, or the insertion site, rather than the intermittent bubbling expected during normal lung re-expansion. It should be reported and the system checked for loose connections before assuming the leak is from the patient.
Can a chest tube be clamped if the drainage system tips over?
No, a chest tube should not be routinely clamped, since doing so can trap air or fluid in the pleural space and cause a tension pneumothorax. If the drainage system is compromised, place the tube end in sterile water to maintain the water seal and notify the provider immediately rather than clamping it.