— 生理適應 · HARD · MCQ —
一位肺葉切除術後放置胸管的病人，水封瓶持續出現氣泡。護理師應如何判讀？
A client with a chest tube following a lobectomy has continuous bubbling in the water-seal chamber. What is the nurse's primary interpretation?
- AThere is a significant air leak in the system✓ 正解將管端置入無菌水中
- BThe lung has fully re-expanded貼上三邊密封之無菌封閉敷料
- CThe chest tube is occluded立即重新插入胸管
- DThe system is functioning correctly立即通知醫師
— Explanation · 中文詳解 —
水封瓶應只有在病人深呼吸或咳嗽時出現間歇性氣泡，若呈現「持續」冒泡，代表胸管系統或病人胸腔內有氣體滲漏（Air Leak）。護理師應檢查連接處是否鬆脫或是否有漏氣。肺部完全擴張應呈現無氣泡狀態。若管路阻塞，通常會看到水面波動（tidaling）停止，而非持續冒泡。
Continuous bubbling in the water-seal chamber indicates a significant air leak in the chest tube system or the pleural space, which is not a normal finding. Normal function typically presents with intermittent bubbling only during coughing or deep breathing, whereas a re-expanded lung would show no bubbling. Occlusion would result in the cessation of fluid level fluctuations rather than continuous bubbling.
✦ 台美臨床差異
台美胸管照護原則一致，皆需強調判讀氣泡意義，護理師需熟悉水封瓶結構與排除漏氣步驟。