— 生理適應 · MEDIUM · SATA —
護理師照護一位放置胸管的病人，應採取哪些措施以維護系統完整性？（選所有適合的）
A nurse is caring for a client with a chest tube. Which actions should the nurse take to maintain system integrity? (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
- BMilk or strip the chest tube every 2 hours每 2 小時擠壓或剝離胸管
- CEnsure all connections are taped and secure✓ 正解確保所有連接處都已用膠帶固定妥當
- DKeep a bottle of sterile water at the bedside✓ 正解在床邊準備一瓶無菌水
- EClamp the chest tube when the client ambulates當病人下床活動時夾住胸管
— Explanation · 中文詳解 —
維護胸管系統應採取重力引流原則（低於胸部），確保連接處密閉以防漏氣，並備妥無菌生理食鹽水以便管路脫落時進行水封急救。擠壓管路（Milk/Strip）會增加胸內負壓，可能造成肺組織損傷。嚴禁在病人移動時夾住管路，以免引發張力性氣胸。
To maintain chest tube system integrity, the drainage unit must be kept below the level of the chest to facilitate gravity drainage and prevent fluid reflux. All connections should be securely taped to prevent air leaks, and sterile water should be kept at the bedside to create an emergency water seal if the tube becomes disconnected.
✦ 台美臨床差異
台灣臨床偶見傳統玻璃瓶引流，美國多使用一次性負壓引流盒，但在無菌水處理上觀念一致。