— 降低風險 · EASY · MCQ —
護理師照護一位胸管引流病人。若胸管意外從引流系統脫落，應採取何種正確行動？
A nurse is providing care to a client with a chest tube. Which action is appropriate if the chest tube is disconnected from the drainage system?
- ANotify the surgeon immediately立即通知外科醫師
- BCover the site with an occlusive dressing以封閉性敷料覆蓋傷口
- CPlace the end of the tube in a container of sterile water✓ 正解將胸管末端置於無菌水中
- DClamp the chest tube immediately立即夾閉胸管
— Explanation · 中文詳解 —
胸管脫落屬於緊急狀況，護理目標是防止空氣進入胸膜腔引發氣胸。正確做法是將管子末端置入無菌水中，建立「水封（Water Seal）」，既能防止空氣進入（因水中壓力大於胸膜腔），又能讓多餘氣體排出。絕對不可夾住胸管，否則會導致胸內氣體無法排出，進而引發張力性氣胸（Tension Pneumothorax）。
Placing the end of the disconnected chest tube in a container of sterile water establishes a temporary water seal, preventing air from entering the pleural space while allowing trapped air to escape. Clamping the tube is contraindicated as it can lead to a tension pneumothorax, and notifying the surgeon occurs after securing the airway.