— 生理適應 · MEDIUM · SATA —
護理師照護胸管引流系統。哪些介入措施是正確的？（選所有適合的）
A nurse is managing a client with a chest tube drainage system. Which interventions are appropriate? (Select all that apply.)
- ATape all connections between chest tube and drainage system✓ 正解用膠帶固定胸管與引流系統間的所有連接處
- BKeep the drainage system below the level of the chest✓ 正解保持引流系統低於胸腔水平
- CClamp the chest tube if the patient needs to be transported若病人需要轉運則夾住胸管
- DEncourage deep breathing and coughing✓ 正解鼓勵深呼吸與咳嗽
- EObserve for tidaling in the water seal chamber✓ 正解觀察水封瓶內的液面波動
— Explanation · 中文詳解 —
胸管照護：連結處應加固以免氣體進入；引流瓶須低於胸腔以利重力引流；禁止隨意夾管（除非醫師指示，否則會導致壓力堆積引發張力性氣胸）；深呼吸咳嗽促進肺擴張；觀察水封瓶震盪（tidaling）代表系統通暢。
Appropriate chest tube management includes taping all connections to prevent air leaks, keeping the drainage system below the chest level to utilize gravity, and encouraging deep breathing to promote lung expansion. Nurses should also observe for tidaling in the water seal chamber to ensure the system is patent and avoid clamping the tube unless specifically instructed.
✦ 台美臨床差異
美國護理師常執行胸管拆除後的傷口敷料更換，台灣常見由醫師執行或在護理師輔助下完成。