— 生理適應 · MEDIUM · MCQ —
病人胸管的水封瓶波動消失。護理師應先檢查什麼？
A client with a chest tube has decreased fluctuations in the water seal chamber. What should the nurse assess first?
- AThe water level in the seal chamber密封腔室中的水位
- BThe tubing for kinks or obstruction✓ 正解檢查管路是否有扭曲或阻塞
- CThe chest drain device position胸管裝置的位置
- DThe client's respiratory rate病人的呼吸頻率
— Explanation · 中文詳解 —
胸管水封瓶（Water seal chamber）的波動代表胸腔內壓隨呼吸的正常傳導。當波動消失時，首要考慮的是機械性阻塞，例如管路扭曲（Kinking）、受壓或血塊阻塞。護理師應先由病人端向引流瓶端檢查管路是否通暢。若排除機械因素後波動仍未恢復，則可能代表肺部已完全復張（Re-expanded），此時才考慮評估病人呼吸狀態。
Decreased or absent fluctuations in the water seal chamber often indicate a mechanical obstruction, such as tubing kinks or clots, which is the most common cause of cessation of tidal fluctuation. The nurse should first assess the tubing for patency from the client toward the drainage device before considering other causes like lung re-expansion.