— 生理適應 · MEDIUM · MCQ —
一位安置胸管的病人在水封瓶發現持續性氣泡。護理師應優先採取的行動為何？
A client with a chest tube has continuous bubbling in the water seal chamber. What is the priority action?
- AClamp the chest tube immediately立即夾閉胸管
- BPosition the client on the unaffected side將病人置於未患側臥位
- CCheck the connection sites for air leaks✓ 正解檢查連接處是否有漏氣
- DIncrease the suction pressure增加抽吸壓力
— Explanation · 中文詳解 —
水封瓶出現持續性氣泡代表系統有漏氣。首要步驟應檢查胸管系統從插入處到引流瓶的連接處是否有鬆脫，而非直接夾管，因為夾管可能導致緊張性氣胸。確認氣體來源後，若連接處緊密，則應通知醫師處理，因為可能是胸腔內持續漏氣。
Continuous bubbling in the water seal chamber indicates an air leak in the system. The first step is to check the chest tube system from the insertion site to the drainage unit for loose connections, rather than clamping the tube directly, since clamping can cause a tension pneumothorax. Once the source of air is identified, if all connections are secure, the physician should be notified because the leak may be ongoing within the pleural space.
✦ 台美臨床差異
美台臨床對於胸管護理標準一致，皆強調嚴禁任意夾閉胸管，除非為了尋找漏氣位置或更換瓶身，且操作時間需極短。