護理師照護疑似氣胸的病人,應預期觀察到哪些臨床表現?(選所有適合的)
A nurse is caring for a client with a suspected pneumothorax. Which clinical manifestations should the nurse expect to assess? (Select all that apply.)
- AAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- BTracheal deviation toward the affected side氣管向患側偏移
- CHyper-resonance on percussion of the affected side✓ 正解患側叩診呈過度回響音
- DTachypnea✓ 正解呼吸過速
- EPleuritic chest pain✓ 正解胸膜炎性胸痛
氣胸(pneumothorax)是指胸膜腔內積氣,導致肺部塌陷。臨床表現包括患側呼吸音消失(因肺部無法擴張)、叩診呈過度回響音(hyper-resonance,因充滿氣體)、呼吸急促(代償性反應)及肋膜性胸痛。氣管偏移則通常見於嚴重的張力性氣胸(tension pneumothorax),且應向「健側」偏移,而非患側。護理師應熟悉這些症狀,以利及早發現並啟動緊急處理措施。
Pneumothorax refers to accumulation of air in the pleural space, resulting in lung collapse. Clinical manifestations include absent breath sounds on the affected side (because the lung cannot expand), hyper-resonance on percussion (because of the trapped air), tachypnea (a compensatory response), and pleuritic chest pain. Tracheal deviation is typically seen in severe tension pneumothorax and should be toward the unaffected side rather than the affected side. The nurse should be familiar with these symptoms to facilitate early detection and initiation of emergency management.