— 生理適應 · MEDIUM · MCQ —
護理師照護的一位病人的胸管脫出，最合適的立即處理措施為何？
A nurse is caring for a client with a chest tube that has become dislodged. What is the most appropriate immediate action?
- ACover the site with an occlusive dressing✓ 正解以密閉式敷料覆蓋傷口
- BCall the physician immediately立即通知醫師
- CCover the site with sterile gauze taped on three sides以無菌紗布覆蓋並黏貼三邊
- DAttempt to reinsert the chest tube嘗試重新插入胸管
— Explanation · 中文詳解 —
胸管滑脫時，必須使用封閉式敷料（occlusive dressing）蓋住傷口，防止空氣持續進入胸膜腔導致張力性氣胸。三邊封閉敷料常見於穿透性胸傷，但在胸管滑脫的情境下，為了防止空氣進入應完全密合覆蓋。
When a chest tube becomes dislodged, an occlusive dressing must be used to cover the wound to prevent air from continuously entering the pleural space and causing tension pneumothorax. A three-sided dressing is commonly used for penetrating chest wounds, but in the scenario of a dislodged chest tube, the site must be completely sealed to prevent air entry.
✦ 台美臨床差異
台美醫療常規皆要求先封閉傷口再通知醫師，重點在於維持胸腔負壓。