一位病人的胸管連接至水封瓶引流系統。護理師評估時發現水封瓶內有持續性氣泡。護理師應採取的優先措施為何？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Upon assessment, the nurse notes continuous bubbling in the water-seal chamber. What is the nurse's priority action?
- AClamp the chest tube near the insertion site在插入部位附近夾住胸管
- BCheck the entire system from the insertion site to the unit for air leaks✓ 正解從插入部位到引流裝置檢查整個系統是否有漏氣
- CIncrease the suction pressure增加吸引壓力
- DDocument the finding as a normal expected outcome將此發現記錄為正常的預期結果
胸管水封瓶內出現持續性氣泡（continuous bubbling）通常代表系統中某處存在漏氣。首先應檢查從病人插入部位到引流瓶之間的管路連接處是否鬆脫、膠帶是否密合，或者引流瓶本身是否有裂縫。正確的排除程序是沿著管路檢查，若檢查後仍有氣泡，則需通知醫師。C選項增加壓力無法解決空氣洩漏問題；A選項夾住胸管有造成張力性氣胸（tension pneumothorax）的極高風險，絕對禁止在未經指示下隨意執行；D選項錯誤，因為水封瓶應僅在深呼吸或咳嗽時出現間歇性氣泡，持續性氣泡是不正常的徵象。護理思路應遵循『先檢查、後評估、再回報』的邏輯，確保系統維持密閉狀態以促進肺部再擴張。
Continuous bubbling in the water-seal chamber of a chest drainage system typically indicates an air leak somewhere in the system. The nurse should first inspect for loose tubing connections, secure tape, or cracks in the drainage unit, working from the insertion site down to the collection chamber. The proper troubleshooting sequence is to inspect along the tubing, and if bubbling persists after inspection, notify the physician. Option C is incorrect because increasing suction pressure does not resolve an air leak; option A is incorrect because clamping the chest tube carries a very high risk of causing a tension pneumothorax and is absolutely prohibited without specific orders; option D is incorrect because the water-seal chamber should bubble only intermittently with deep inspiration or coughing, and continuous bubbling is an abnormal finding. The nurse's reasoning should follow 'inspect, assess, then report' to maintain a closed system that promotes lung re-expansion.
在美國臨床護理中，胸管照護極為強調密閉性與管路標記，護理師被嚴格訓練不能隨意夾管；台灣醫院實務上，部分病房對於胸管護理的教育訓練品質差異較大，需強化護理師對『持續性氣泡』代表『系統性漏氣』的警覺。