— 降低風險 · MEDIUM · MCQ —
護理師照護一位使用密閉式胸腔引流系統的病人，下列何種評估發現需要立即護理介入？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. Which assessment finding requires immediate nursing intervention?
- AThe chest tube is secured to the client's gown胸管已固定於病人衣服上
- BPresence of sanguineous drainage in the collection chamber收集腔內有血性引流液
- CContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- DFluctuation of the fluid level in the water seal chamber水封腔內液面隨呼吸波動
— Explanation · 中文詳解 —
水封瓶持續冒泡（continuous bubbling）通常代表系統某處有氣體滲漏（air leak），因為正常情況下僅在呼氣或咳嗽時出現間歇性冒泡。此情況會影響氣胸的癒合與肺部擴張，需檢查接頭處或導管位置。B 是正常現象，D 是正常的液面波動，A 是正確的管路保護措施。
Continuous bubbling in the water seal chamber indicates a significant air leak within the chest tube system, which requires immediate investigation to ensure proper lung re-expansion. Intermittent tidaling is normal, while sanguineous drainage is expected post-operatively, and securing the tube prevents accidental dislodgement.
✦ 台美臨床差異
美台臨床對於胸腔引流系統的照護原則一致，皆重視水封瓶冒泡的鑑別診斷與防止管路滑脫。