護理師照顧一位使用水封瓶胸腔引流系統的病人,下列何種跡象顯示系統運作正常?
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which finding indicates the system is functioning correctly?
- ABubbling in the suction control chamber when suction is turned off關閉吸引時吸引控制室出現氣泡
- BAbsence of drainage in the collection chamber收集室無引流液
- CFluctuation of the fluid level in the water-seal chamber with inspiration✓ 正解水封室液面隨吸氣波動
- DContinuous bubbling in the water-seal chamber水封室持續性氣泡
胸腔引流系統的水封室(Water-seal chamber)若隨病人呼吸有液面波動(Tidaling),表示胸腔內壓力與系統相通且通暢。若波動停止,可能表示管路阻塞或肺部已完全擴張。連續性氣泡(Continuous bubbling)通常代表系統有漏氣;無引流液不代表運作正常,需視病人情況而定。
In a chest tube drainage system, fluctuation (tidaling) of the fluid level in the water seal chamber with the client's respirations indicates that the chest pressure is communicating with the system and the tube is patent. If fluctuation stops, this may indicate tube obstruction or full lung re-expansion. Continuous bubbling typically indicates an air leak in the system; the absence of drainage does not necessarily mean the system is functioning normally and must be interpreted according to the client's condition.
台美對於胸腔引流照護準則一致,皆強調每日檢查是否有漏氣(氣泡)及觀察液面波動。