護理師照護一位放置胸管的病人,觀察到水封瓶出現持續性氣泡。護理師優先採取的行動為何?
A nurse is caring for a client with a chest tube. The nurse observes continuous bubbling in the water seal chamber. What is the priority nursing action?
- ADocument the findings as normal將發現記錄為正常
- BIncrease the suction pressure增加抽吸壓力
- CAssess for an air leak in the system✓ 正解評估系統是否有漏氣
- DClamp the chest tube immediately立即夾住胸管
胸管(Chest tube)引流系統用於移除胸腔內的氣體或液體,以幫助肺部重新擴張。水封瓶(Water seal chamber)是胸管系統的重要組成部分,用於監測胸腔內是否有漏氣。正常情況下,水封瓶會隨著病人的呼吸而出現水柱波動(tidaling),若有胸腔內漏氣,則會觀察到氣泡,但在氣體移除後應會停止。持續性氣泡(Continuous bubbling)的出現,則是一個異常的警訊。 持續性氣泡表示胸管系統中存在持續的空氣洩漏。護理師必須優先判斷這個洩漏是來自病人胸腔(如肺部撕裂傷尚未癒合)還是來自胸管引流系統本身的連接處鬆脫或破損。因為系統漏氣可能導致引流效率下降,甚至影響肺部復張,因此,優先評估和找出漏氣來源是確保治療效果和病人安全的重要步驟。
Continuous bubbling in the water seal chamber indicates an air leak within the drainage system or from the patient's lung, which is abnormal and requires immediate assessment. The nurse must locate the source of the leak to ensure effective drainage and prevent complications such as tension pneumothorax.
美國護理師常自行執行系統漏氣檢查;台灣通常需會同呼吸治療師或醫師評估。