— 降低風險 · MEDIUM · SATA —
護理師照護一位放置胸管的病人。下列哪些行動能確保安全性？（選所有適合的）
A nurse is caring for a client with a new chest tube. Which actions are appropriate to ensure safety? (Select all that apply.)
- AKeep the drainage system below the client's chest level✓ 正解保持引流系統低於病人胸部水平
- BClamp the chest tube when the client is ambulatory當病人下床活動時夾住胸管
- CCheck for tidaling in the water seal chamber✓ 正解檢查水封腔內的潮汐現象
- DEnsure the tubing is free of kinks✓ 正解確保管路無扭曲
- EStrip the chest tube to ensure patency擠壓胸管以確保通暢
— Explanation · 中文詳解 —
胸管照護首重防止逆流（瓶身需低於胸腔）與維持引流管通暢（不可有打結）。水封瓶內的潮汐現象（tidaling）反映呼吸時胸膜腔壓力變化，表示系統運作正常。夾管與用力擠壓管路（stripping）均會造成負壓改變，增加氣胸或胸膜受損風險。
To ensure safety, the chest drainage system must remain below the client’s chest level to prevent backflow into the pleural space via gravity. The nurse should check for tidaling in the water seal chamber, which indicates the system is patent and functioning correctly, and ensure tubing is free of kinks to maintain drainage. Clamping the tube or stripping it can create dangerous negative pressures or cause tension pneumothorax.
✦ 台美臨床差異
美國教學傾向嚴格禁止 Stripping；台灣部分老一代臨床習慣仍偶見擠壓管路動作，目前護理教育亦趨向同步國際標準。