— 生理適應 · MEDIUM · SATA —
護理師照顧放置胸管的病人。下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client with a chest tube. Which nursing interventions are appropriate for managing the system? (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
- BStrip or milk the tubing every hour to prevent clots每小時擠壓或捋壓管路以防止血栓形成
- CAssess the water seal chamber for tidaling with respiration✓ 正解評估水封瓶隨呼吸出現的波動現象
- DClamp the chest tube if the client is being transferred to radiology若客戶轉往放射科檢查，夾住胸管
- EMonitor the insertion site for subcutaneous emphysema✓ 正解監測插入部位是否有皮下氣腫
— Explanation · 中文詳解 —
胸管護理重點為維持密閉系統與引流重力效應。A 正確，重力引流；C 正確，潮氣現象代表管路通暢；E 正確，皮下氣腫代表氣體滲漏至皮下。B 嚴禁擠壓管路（可能產生負壓導致肺部損傷）；D 禁隨意夾管，除非更換系統或判斷脫落。
Appropriate chest tube management includes keeping the drainage system below the chest level to facilitate gravity drainage and assessing the water seal chamber for tidaling, which confirms patency. The nurse should also monitor the insertion site for subcutaneous emphysema, indicating a potential air leak. Stripping tubing is contraindicated due to the risk of creating dangerous negative pressure, and clamping the tube can lead to tension pneumothorax.
✦ 台美臨床差異
台美臨床對於胸管擠壓（stripping）的認知已趨一致，皆不建議執行。