— 生理適應 · HARD · MCQ —
護理師照護一位接有胸腔引流瓶的病患，若發現水封瓶持續冒泡，應採取什麼行動？
A nurse is caring for a client with a chest tube connected to a closed-chest drainage system. What should the nurse do upon observing continuous bubbling in the water seal chamber?
- ANotify the physician to remove the tube通知醫師拔除導管
- BAssess the chest tube system for air leaks✓ 正解評估胸腔引流系統是否有漏氣
- CIncrease the suction pressure增加抽吸壓力
- DClamp the chest tube immediately立即夾住胸腔引流管
— Explanation · 中文詳解 —
水封瓶持續冒泡（continuous bubbling）通常代表系統中存在氣體洩漏（air leak），這會破壞胸腔負壓環境。護理師應順著管路進行由上而下的連接點檢查，評估是否鬆脫或有裂縫。未經確診前禁止夾管，以免造成張力性氣胸。
Continuous bubbling in the water-seal chamber generally indicates an air leak in the system, which disrupts negative pressure within the pleural cavity. The nurse should systematically inspect the tubing from top to bottom to identify any loose connections or cracks. Clamping the tube before the cause is identified is prohibited, as it may cause tension pneumothorax.
✦ 台美臨床差異
台美針對胸管照護的 protocol 極為相似，皆嚴禁隨意夾管並強調水封瓶冒泡的鑑別。