— 降低風險 · MEDIUM · MCQ —
護理師照護一位胸管引流的術後病人，發現水封瓶中有持續性的氣泡，護理師應優先採取什麼行動？
A nurse is caring for a postoperative client who has a chest tube. The nurse observes continuous bubbling in the water seal chamber. What should be the nurse's first action?
- ADocument the finding in the chart在病歷中記錄此發現
- BCheck the tubing connections for an air leak✓ 正解檢查管路連接處是否有漏氣
- CIncrease the suction pressure增加抽吸壓力
- DClamp the chest tube immediately立即夾住胸管
— Explanation · 中文詳解 —
水封瓶出現持續性氣泡通常代表系統有漏氣（air leak），需優先檢查管路連接處是否密合。間歇性氣泡在術後初期是正常的（代表肺部殘餘氣體排出），但持續性氣泡則代表異常漏氣。C 選項會加劇漏氣風險；A 選項忽視了潛在的問題；D 選項為錯誤操作，除非有醫師醫囑，否則夾閉管路極易導致張力性氣胸。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, which requires immediate assessment of tubing connections for tightness. Unlike intermittent bubbling, which may be normal postoperatively, persistent bubling suggests a breach that must be identified and corrected to ensure proper lung re-expansion.
✦ 台美臨床差異
美國護理師在胸管照護上權限較大，可逕行檢查系統與更換引流瓶；台灣臨床多半要求異常時立即通知專科醫師或胸腔外科醫師確認。