— 生理適應 · MEDIUM · MCQ —
護理師照護一位放置胸管的病人，發現水封瓶持續冒泡。此跡象代表什麼？
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water seal chamber. What does this finding indicate?
- AThe lung has fully re-expanded肺部已完全復張
- BThe suction pressure is too high吸力壓力過高
- CThe chest tube is kinked胸管扭結
- DThere is an air leak in the system✓ 正解系統中有空氣洩漏
— Explanation · 中文詳解 —
水封瓶（Water seal chamber）的功能是防止空氣回流至胸腔。正常情況下，隨呼吸會有波動（tidaling），但不可有持續冒泡（continuous bubbling），持續冒泡顯示系統密合度不良，有空氣漏入胸管路徑中。護理師應檢查連接處是否鬆脫或引流瓶是否有裂痕。
The function of the water seal chamber is to prevent air from flowing back into the pleural cavity. Normally, there is tidaling with respiration, but there should be no continuous bubbling; continuous bubbling indicates a leak in the system, with air entering somewhere along the chest tube pathway. The nurse should check for loose connections or cracks in the drainage unit.
✦ 台美臨床差異
台美皆採相同判斷標準，但美國偏向護理師自行排查，台灣若無法解決通常會直接通知醫師。