— 生理適應 · MEDIUM · SATA —
護理師照顧一位放置胸管的病人，下列哪些護理措施是正確的？（選所有適合的）
A nurse is caring for a client with a chest tube. Which interventions are indicated for proper management? (Select all that apply.)
- AKeep the drainage system below the level of the chest✓ 正解將引流系統保持在胸部水平以下
- BClamp the chest tube whenever the client moves病人移動時夾住胸管
- CCheck for fluctuation in the water seal chamber✓ 正解檢查水封瓶內的波動
- DCoil the drainage tubing on the bed將引流管盤繞在床上
- EMaintain a sterile, occlusive dressing at the insertion site✓ 正解在插入部位維持無菌、密閉的敷料
— Explanation · 中文詳解 —
胸管護理重點為維持密閉引流系統。保持低於胸廓位置可利用重力引流並防止逆流。水封瓶波動代表呼吸運動，顯示系統通暢。傷口處敷料需密閉防止氣胸發生。B 錯誤：禁止夾閉管道，除非需更換裝置或尋找氣漏。D 錯誤：管道應在床旁自然垂下，不可捲曲於床墊上以免阻礙引流。
Chest tube management requires maintaining a closed drainage system. Keeping the system below chest level uses gravity to promote drainage and prevent backflow. Fluctuation (tidaling) in the water-seal chamber confirms a patent system. A sterile occlusive dressing prevents air entry at the insertion site. Clamping is contraindicated as it can cause tension pneumothorax; tubing should hang straight, not be coiled.
✦ 台美臨床差異
美台對於胸管拔管後的觀察皆極為重視，台灣臨床護理師常需更頻繁協助醫師進行管路評估與胸部 X 光確認。