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Pneumothorax, haemothorax and rib fractures on the ward: what to watch and when to call

  • Assessment

The nurse checks breathing, pain and cough often in patients with chest injury and calls at once for signs of a collapsed lung or bleeding into the chest.

Updated

What it is

Patients with rib fractures, a pneumothorax or a haemothorax can look stable and then worsen. Pain makes them breathe shallowly and avoid coughing, which leads to pneumonia; older adults and those with several fractures do worst. Air or blood in the pleural space can grow, and a tension pneumothorax is an emergency. On the ward the nurse measures, repeatedly, the breathing rate, SpO2, pulse, blood pressure, breath sounds on both sides, chest movement, the trachea, the skin around the chest and neck, pain and the ability to breathe deeply and cough. The first response and the call for help are this page's focus; the ICU phase belongs to the critical-care pages.

Reference values

  • Expected: respiratory rate, SpO2, pulse and blood pressure within the patient's usual range and stable over time.
  • Expected: equal breath sounds and chest movement on both sides; trachea in the midline.
  • Expected: pain controlled enough for the patient to take deep breaths and cough.
  • Healing of rib fractures takes at least 6 weeks.
  • Flail chest is a severe injury that needs hospital care and carries higher mortality.

What you need

  • Pulse oximeter, blood pressure monitor and the early-warning chart.
  • Stethoscope for breath sounds on both sides.
  • A pain scale and, if the team uses it, a breathing device to record how deep the patient can breathe.
  • A skin marker to outline subcutaneous emphysema.
  • Chest drain equipment at the bedside if a drain is in place (see the chest tube page).

How to measure it (and why)

  1. Measure rate, SpO2, pulse and blood pressure at the frequency ordered and compare trends: worsening is often gradual.
  2. Listen to both sides of the chest and watch chest movement: a quiet side or uneven movement may mean air or blood.
  3. Look at the trachea: deviation in a breathless patient is an emergency.
  4. Feel the skin of the chest and neck for crackling and mark its edge: spreading air suggests a worsening leak.
  5. Assess pain at rest and on deep breathing and coughing, and give analgesia as prescribed: pain control prevents pneumonia.
  6. Coach deep breaths and gentle coughing every 2 hours with a pillow over the injury, and record how well the patient does it.
  7. Check sputum, temperature and mental state: fever, more sputum or new confusion suggest pneumonia or hypoxia.
  8. If a chest drain is in place, check the system, bubbling and drainage each round and report changes.

How to read it

  • Bundled rib-fracture protocols score pain, depth of breath and cough regularly and alert the team when they worsen, even if SpO2 is normal.
  • Asymmetric breath sounds plus low blood pressure and a fast pulse suggest a haemothorax or a tension pneumothorax.
  • Rib fractures often occur with injuries to other organs, so new abdominal pain or a falling blood pressure is not attributed to the ribs alone.
  • Patients with asthma or emphysema have a higher risk of breathing problems and infection after rib fracture.

Next step: when to call for help

  • Call for urgent help at once: sudden breathlessness, tracheal deviation, absent breath sounds on one side, low blood pressure or SpO2 falling rapidly.
  • Call at once: signs of shock (fast pulse, low blood pressure, cold, damp, pale skin) or heavy bright-red drainage from a chest drain.
  • If a chest drain comes out: cover the site with a sterile occlusive dressing taped on three sides and call for help.
  • Report the same shift: pain that prevents deep breathing or coughing despite analgesia, fever, more or bloody sputum, or new or spreading crepitus.

Test yourself

Think of the answer, then tap the question to see it.

Why are rib fractures dangerous even when the lung is not punctured?

Pain makes the patient breathe shallowly and avoid coughing, which leads to pneumonia; older adults and those with several fractures are at highest risk.

Which findings suggest a tension pneumothorax?

Reduced breath sounds and uneven chest movement on one side, low blood pressure, a fast or slow heart rate and tracheal deviation in a breathless patient.

Is a chest binder used for rib fractures?

No. A binder limits rib movement, which can impair breathing and lead to pneumonia; the patient holds a pillow against the injury when coughing instead.

What does the nurse do if a chest drain falls out?

Follows the emergency policy: covers the site with a sterile occlusive dressing taped on three sides, calls for help and monitors breathing closely.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol (Trauma Surgery & Acute Care Open (open access, PMC), 2017); Rib fracture - aftercare (MedlinePlus, U.S. National Library of Medicine, 2026); Collapsed lung (pneumothorax) (MedlinePlus, U.S. National Library of Medicine, 2026); Nursing Advanced Skills, 6.4: Troubleshooting problems and complications (chest tubes) (Open RN, Chippewa Valley Technical College (CC BY 4.0), LibreTexts, 2023).

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