病人的胸管連接水封式引流系統。哪項發現需要立即介入？
A client has a chest tube connected to a water-seal drainage system. Which finding requires immediate intervention?
- ASerosanguinous drainage in the collection chamber集氣瓶內有漿液血性引流液
- BOccasional bubbling in the suction control chamber抽吸控制瓶內偶爾冒泡
- CFluctuation of water level with respiration水位隨呼吸波動
- DConstant bubbling in the water-seal chamber✓ 正解水封瓶內持續冒泡
胸管水封式引流系統 (water-seal drainage system) 的主要目的是排出胸腔內的空氣或液體，同時防止外界空氣進入胸腔。護理師需定期評估引流系統的功能狀態，以確保其正常運作並及早發現潛在問題。其中，水封瓶 (water-seal chamber) 的觀察是關鍵，它能反映胸腔內壓力的變化以及是否存在空氣外洩。了解各個腔室的正常與異常表現，對於維持病人呼吸道的安全及胸腔引流的有效性至關重要。
A water-seal chest drainage system is designed to evacuate air or fluid from the pleural space while preventing outside air from entering. The nurse must regularly assess the system to ensure proper function and detect potential problems early. Observation of the water-seal chamber is key, as it reflects intrathoracic pressure changes and any air leaks. Recognizing normal versus abnormal findings in each chamber is essential to maintain airway safety and effective drainage.
胸管照護的原則在台灣與美國大致相同，都強調嚴密監測、維持系統密閉性。然而，美國護理師在某些情況下，可能會在醫師醫囑下自行調整胸管抽吸壓力或在評估後移除胸管。在台灣，胸管移除通常由醫師執行，護理師則負責移除後的傷口照護與觀察。此外，對於胸管系統的故障排除，美國護理師的決策權限可能更廣。