— 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。下列何種發現代表系統運作正常？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. Which finding indicates the system is working correctly?
- AExcessive drainage of bright red blood into the collection chamber收集瓶中有過量的鮮紅色引流液
- BFluctuation of the fluid level in the water seal chamber with respiration✓ 正解水封瓶內的液面隨呼吸波動
- CContinuous bubbling in the water seal chamber水封瓶內有持續冒泡現象
- DAbsence of fluid in the drainage tubing引流管內無液體
— Explanation · 中文詳解 —
胸腔引流系統的水封瓶（water seal）液面隨呼吸波動（tidaling）是正常的生理現象，代表胸腔內壓力與系統相通。若停止波動，可能意味著肺部重新擴張或管路阻塞；若持續性氣泡（continuous bubbling）則暗示系統有氣漏（air leak）。
In a chest drainage system, fluctuation (tidaling) of the fluid level in the water seal chamber with respiration is a normal physiological finding, indicating that the pressure in the pleural space communicates properly with the system. If tidaling ceases, it may indicate lung re-expansion or tubing obstruction; continuous bubbling suggests an air leak in the system.
✦ 台美臨床差異
台美在胸腔引流護理上皆重視監測漏氣與波動，美國護理師常依 protocol 自行檢查氣漏。