— 降低風險 · EASY · MCQ —
護理師照護一位使用密閉式胸腔引流系統的病人。下列何種觀察顯示系統功能正常？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. Which observation indicates the system is functioning correctly?
- AAbsence of fluid movement in the tubing管路中無液體流動
- BFluctuation of the fluid level in the water-seal chamber✓ 正解水封室中液面隨呼吸波動
- CExcessive drainage in the collection chamber收集室中有過多引流液
- DContinuous bubbling in the water-seal chamber水封室中有持續冒泡現象
— Explanation · 中文詳解 —
胸腔引流系統正常運作時，水封瓶液面應隨病人的呼吸運動而上下波動（潮氣現象）。若連續冒泡（D）通常代表系統有漏氣；若完全不動（A）可能代表管路阻塞或肺部已完全擴張；過量引流（C）則需根據臨床狀況判斷，非功能正常的必要條件。
When a chest drainage system is functioning normally, the fluid level in the water-seal chamber should rise and fall with the patient's respirations (tidaling). Continuous bubbling (D) usually indicates an air leak in the system; absence of any movement (A) may indicate a blocked tube or full lung re-expansion; excessive drainage (C) must be interpreted clinically and is not a necessary feature of normal function.
✦ 台美臨床差異
美台皆強調 tidaling，但台灣臨床常需醫師確認是否夾管，美國則依循單位 protocol 處理。