— 生理適應 · MEDIUM · SATA —
護理師護理胸管置入的病人，下列哪些照護措施是正確的？（選所有適合的）
A nurse is caring for a client with a chest tube. Which interventions are appropriate for managing the system? (Select all that apply.)
- AKeep the drainage system below the level of the chest✓ 正解保持引流系統低於胸腔水平
- BStrip the chest tube daily to maintain patency每日擠壓胸管以維持通暢
- CClamp the chest tube whenever ambulating行走時隨時夾閉胸管
- DMonitor for continuous bubbling in the water seal chamber監測水封腔內是否有連續冒泡
- ECheck the insertion site dressing for crepitus✓ 正解檢查插入處敷料是否有捻創感
— Explanation · 中文詳解 —
胸管照護首重重力引流，胸管瓶需低於胸腔位置。皮下氣腫（crepitus）需評估，因為可能顯示空氣滲漏至皮下。B 選項「擠壓胸管」可能導致胸腔內高負壓而損傷肺組織；C 選項除醫師醫囑外嚴禁夾閉胸管以免導致氣胸；D 選項「連續冒泡」在水封瓶通常代表系統有漏氣，非正常現象。
The chest tube drainage system must be kept below the level of the client's chest to facilitate gravity drainage and prevent backflow into the pleural space. Nurses should also assess the insertion site dressing for crepitus, which may indicate subcutaneous emphysema from an air leak, while avoiding actions like stripping the tube or clamping it unnecessarily.
✦ 台美臨床差異
台美臨床對於胸管護理標準一致，但美國醫院常見使用拋棄式無菌引流系統，台灣則視醫院設備而定。