— 降低風險 · EASY · MCQ —
護理師照顧一位置放胸管並接上密閉引流系統的病人，下列哪項觀察顯示系統運作正常？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. Which observation indicates the system is functioning as expected?
- AAbsence of drainage in the collection chamber收集室無引流液
- BFluctuation of the fluid level in the water-seal chamber✓ 正解水封室液面波動
- CContinuous bubbling in the water-seal chamber水封室持續冒泡
- DThe chest tube is clamped to prevent air leakage胸管夾閉以防止漏氣
— Explanation · 中文詳解 —
胸管水封瓶（water-seal chamber）的水面隨呼吸上下波動（tidaling）是正常的，代表胸腔內壓力與大氣壓相互作用。若波動停止，可能表示管路阻塞、扭曲或肺部已完全復張。持續性氣泡通常意味著系統有漏氣，而平時不能隨意夾住管路，除非是為了更換瓶子或移除前測試。
When a chest tube becomes dislodged, the priority is to prevent air from entering the pleural space, which could cause a life-threatening tension pneumothorax. Applying a sterile occlusive dressing taped on three sides creates a one-way valve effect, allowing air to escape during exhalation while preventing entry during inhalation.
✦ 台美臨床差異
美國護理規範嚴禁未經醫師同意擅自夾住胸管；台灣醫院 protocol 亦同，但針對意外脫落的處理流程標準化程度在兩地均極高。