— 生理適應 · MEDIUM · MCQ —
一位 45 歲病人裝有胸管引流，水封瓶出現持續性冒泡，護理師應如何判讀此徵象？
A 45-year-old client with a chest tube drainage system has continuous bubbling in the water seal chamber. What does the nurse interpret this finding as?
- AA leak exists in the chest tube system✓ 正解胸管系統存在洩漏
- BThe suction pressure is too high抽吸壓力過高
- CThe lung has successfully re-expanded肺部已成功復張
- DNormal expected finding during inspiration吸氣期間的正常預期發現
— Explanation · 中文詳解 —
水封瓶持續冒泡代表系統密閉性遭到破壞，空氣直接進入水封瓶而非來自胸腔。正常情況應僅隨呼吸週期有間歇性波動或冒泡，若持續冒泡需檢查管路接口是否鬆脫、有無破裂。此為臨床常見的設備故障，必須立即排查以防氣胸惡化。
Continuous bubbling in the water seal chamber indicates a leak in the chest tube system, allowing air to enter rather than just exiting the pleural space. While intermittent bubbling may occur with expiration, persistent bubbling suggests a breach in system integrity, such as a loose connection or tube rupture, which requires immediate assessment.
✦ 台美臨床差異
美台臨床皆視持續冒泡為系統滲漏信號，需立即夾管評估位置，但美國護理師常有權限進行特定排查步驟，台灣通常需同時評估病人呼吸狀態並通知醫師。