— 生理適應 · MEDIUM · SATA —
護理師照護胸管病人，下列哪些介入是必要的？（選所有適合的）
Which of the following interventions is essential when caring for a client with a chest tube? (Select all that apply.)
- AKeep the drainage system below chest level✓ 正解保持引流系統低於胸部水平
- BClamp the chest tube if the patient leaves the room若病人離開房間則夾住胸管
- CMonitor for tidaling in the water-seal chamber✓ 正解監測水封腔內的波動現象
- DCheck the insertion site for subcutaneous emphysema✓ 正解檢查插入部位是否有皮下氣腫
- EEnsure the drainage system is kept upright✓ 正解確保引流系統保持直立
— Explanation · 中文詳解 —
胸管照護重點：利用重力引流（低於胸部），確認水封管有波動（tidaling）代表肺部膨脹良好。若觸診有皮下氣腫（握雪感）需回報。絕對不可擅自夾管，除非更換設備或由醫師指示，否則易造成張力性氣胸。系統必須維持直立以免封水倒流。
Key points of chest tube care: use gravity drainage (keep below chest level); confirm tidaling in the water-seal chamber, which indicates good lung expansion. Subcutaneous emphysema (crepitus on palpation) must be reported. Never clamp the tube without an order, except for equipment change or under physician direction; otherwise, tension pneumothorax may result. The drainage system must be kept upright to prevent the water seal from being lost.
✦ 台美臨床差異
台美皆嚴禁隨意夾管，但在美國胸管拔除訓練中護理師角色較吃重，台灣則多由醫師執行拔除。