— 生理適應 · MEDIUM · SATA —
護理師在照護一位裝有胸管的病患時，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take when caring for a client with a chest tube? (Select all that apply.)
- AKeep the drainage system below the level of the client's chest✓ 正解保持引流系統低於病人胸部水平
- BStrip or milk the chest tube every 2 hours to maintain patency每2小時擠壓或擠捏胸管以維持通暢
- CEnsure the chest tube dressing is occlusive and sterile✓ 正解確保胸管敷料具有密封性和無菌
- DClamp the chest tube if the client needs to be transported若病人需要轉運，夾住胸管
- EMonitor for continuous bubbling in the water seal chamber監測水封腔內是否有連續冒泡現象
— Explanation · 中文詳解 —
胸管照護重點在於維持引流系統的重力虹吸效應（低於胸腔）並保持密封。選項 B 嚴禁實行，因會產生極高負壓損傷肺組織；選項 D 除非經醫師指示或更換系統，否則嚴禁夾閉胸管以免引發張力性氣胸；選項 E 持續氣泡通常代表系統漏氣，而非正確的照護行為。
The drainage system must remain below the level of the client's chest to utilize gravity and prevent fluid backflow into the pleural space. Additionally, the dressing over the insertion site should be sterile and occlusive to prevent air from entering the pleural cavity. Interventions such as stripping the tube, clamping without specific orders, or expecting continuous bubbling are inappropriate or indicate complications.
✦ 台美臨床差異
台灣醫院對「擠壓胸管」的規範日益嚴格，美國臨床亦全面禁止除非有醫師特殊醫囑，兩地規範趨於一致。