— 生理適應 · MEDIUM · MCQ —
護理師照護一位胸管引流的病人，發現水封瓶持續冒泡。最可能的解釋為何？
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water-seal chamber. What is the most likely cause?
- AThe chest tube is obstructed胸腔引流管阻塞
- BThere is an air leak in the system✓ 正解系統中有空氣洩漏
- CThe client has a pneumothorax病人患有氣胸
- DThe lung has fully expanded肺部已完全擴張
— Explanation · 中文詳解 —
水封瓶內的「間歇性」冒泡通常與呼吸或咳嗽相關（氣胸），但「持續性」冒泡通常代表系統密閉性受損，即漏氣（Air leak）。若管路連結處鬆脫或破裂，空氣會直接被抽入水中。閉鎖不全需立即檢查連接點與敷料，確保系統密閉以維持胸腔負壓。
Continuous bubbling in the water-seal chamber indicates an air leak within the chest tube system, often due to loose connections or tubing damage. Unlike intermittent bubbling associated with a pneumothorax, constant bubbling suggests the system is not sealed, compromising the negative pressure needed for lung re-expansion.
✦ 台美臨床差異
台灣與美國對於胸管護理標準一致，皆著重於維持密閉系統與觀察波動變化。