一位病人昨天因肋膜積液置入胸管引流，胸管接上濕式抽吸胸腔引流系統，抽吸壓力設定為 -20 cm H2O。護理師應判斷哪些發現屬於預期表現？（選所有適合的）
A client had a chest tube inserted yesterday to drain a pleural effusion. The chest tube is connected to a wet-suction chest drainage system with the suction set at -20 cm H2O. Which findings should the nurse identify as expected? (Select all that apply.)
- AFluid in the water-seal chamber that rises and falls with the client's respirations水封瓶內的液面隨病人呼吸上下波動正確答案
- BGentle, continuous bubbling in the suction control chamber of the drainage system引流系統的抽吸控制瓶出現輕柔的持續冒泡正確答案
- CCrepitus over the neck and upper chest wall that is spreading beyond the marked border頸部與上胸壁的捻髮音範圍持續向標記線外擴大
- DBright red drainage of 300 mL in the collection chamber over the past hour過去 1 小時內收集瓶出現 300 mL 鮮紅色引流液
- EAbsence of bubbling in the water-seal chamber of the drainage system引流系統的水封瓶沒有出現冒泡正確答案
- A水封瓶內的液面隨病人呼吸上下波動
- B引流系統的抽吸控制瓶出現輕柔的持續冒泡
- E引流系統的水封瓶沒有出現冒泡
正確答案是 A、B、E。A：水封瓶液面隨呼吸上下波動（tidaling），代表胸管通暢且肋膜腔壓力隨呼吸變化；自主呼吸時吸氣上升、呼氣下降，使用正壓呼吸器時方向相反。抽吸開啟時波動幅度會被抑制而較不明顯，可短暫將管路與抽吸源分離後再觀察；波動完全消失可能代表管路阻塞、扭折或肺已完全擴張。B：濕式抽吸系統以抽吸控制瓶的水柱高度決定抽吸壓力，輕柔的持續冒泡代表設定的抽吸正在作用；冒泡過於劇烈只是加速水分蒸發並製造噪音，應調低抽吸源。E：肋膜積液的病人肋膜腔內是液體而非空氣，沒有氣漏，水封瓶不冒泡屬預期表現；若出現冒泡代表有氣漏或系統接頭鬆脫。C：捻髮音代表空氣跑進皮下組織，範圍持續向標記線外擴大屬於惡化的皮下氣腫，必須通報並找出氣漏來源。D：鮮紅色引流每小時超過 100 mL 即屬出血，1 小時 300 mL 必須立即通報醫療提供者。來源：Lewis, Medical-Surgical Nursing（Chest drainage systems）；Potter & Perry, Fundamentals of Nursing。
- A · 正確答案水封瓶內的液面隨病人呼吸上下波動
正確。水封瓶液面隨呼吸波動代表胸管通暢；抽吸開啟時波動會較不明顯，可短暫與抽吸源分離後確認。
- B · 正確答案引流系統的抽吸控制瓶出現輕柔的持續冒泡
正確。濕式抽吸系統的抽吸控制瓶出現輕柔持續冒泡，代表設定的抽吸壓力正在作用；冒泡過於劇烈時應調低抽吸源。
- C頸部與上胸壁的捻髮音範圍持續向標記線外擴大
錯誤。捻髮音代表空氣進入皮下組織，範圍持續向標記線外擴大屬於惡化的皮下氣腫，必須通報並找出氣漏來源。
- D過去 1 小時內收集瓶出現 300 mL 鮮紅色引流液
錯誤。鮮紅色引流每小時超過 100 mL 即屬出血，1 小時 300 mL 必須立即通報醫療提供者。
- E · 正確答案引流系統的水封瓶沒有出現冒泡
正確。肋膜積液的病人肋膜腔內沒有空氣，水封瓶不冒泡是預期表現；若出現冒泡則代表氣漏或接頭鬆脫。
美國病房普遍使用一體式三腔胸腔引流系統，護理師依院內流程逐班記錄氣漏與波動；台灣多數醫院同樣使用一體式系統，但部分單位仍可見傳統水封瓶組，護理師需熟悉兩種系統在冒泡判讀上的差異。
English explanation
Options A, B, and E are correct. Fluid that rises and falls in the water-seal chamber, called tidaling, shows that the chest tube is patent and that intrapleural pressure still changes with respiration; in a spontaneously breathing client the level rises on inspiration and falls on expiration, and the pattern is reversed during positive-pressure ventilation. Tidaling is dampened while suction is running, so the nurse can briefly disconnect the tubing from the suction source to confirm it, and a complete loss of tidaling may mean obstruction, kinking, or full lung re-expansion. Gentle, continuous bubbling in the suction control chamber of a wet-suction system indicates that the ordered suction level is being delivered; vigorous bubbling only evaporates water and creates noise and should be turned down. Because a pleural effusion contains fluid rather than air, no air leak is expected, so absence of bubbling in the water-seal chamber is a normal finding. Option C is incorrect because crepitus spreading beyond the marked border represents worsening subcutaneous emphysema and must be reported so the source of the leak can be found. Option D is incorrect because bright red drainage exceeding 100 mL per hour signals bleeding, and 300 mL in one hour requires immediate provider notification. Source: Lewis, Medical-Surgical Nursing (chest drainage systems); Potter & Perry, Fundamentals of Nursing.
最近修訂：2026-10-10