— 生理適應 · EASY · SATA —
護理師照護胸管引流病人時，應採取哪些措施？（選所有適合的）
Which actions should the nurse perform when caring for a client with a chest tube? (Select all that apply.)
- AKeep the drainage system below the level of the chest✓ 正解將引流系統保持在胸部水平以下
- BStrip or milk the tubing frequently to clear clots經常擠壓或剝離管路以清除血塊
- CEnsure the connections are taped securely✓ 正解確保連接處已牢固纏繞膠帶
- DReport continuous bubbling in the water seal chamber✓ 正解報告水封腔內持續冒泡的情況
- ECheck for fluctuations in the water seal chamber with respiration✓ 正解檢查水封腔內液面是否隨呼吸波動
— Explanation · 中文詳解 —
胸管護理重點在於維持引流效能與封閉性。引流瓶須低於胸腔以防逆流；接頭應膠帶封死防止氣胸；水封瓶持續冒泡代表系統漏氣需立即回報；呼吸時液面隨呼吸波動（Tidaling）是正常的，若消失可能代表管路阻塞或肺部已擴張。
The priorities of chest tube care are maintaining drainage effectiveness and a closed system. The drainage system must be kept below the chest to prevent backflow; all connections should be securely taped to prevent pneumothorax; continuous bubbling in the water seal chamber indicates an air leak and must be reported immediately; and tidaling of the fluid level in the water seal with respiration is normal, while its disappearance may indicate tubing obstruction or full lung re-expansion.
✦ 台美臨床差異
美國醫院多使用一次性乾式吸力控制裝置，台灣部分醫院仍使用濕式水封引流瓶。