— 生理適應 · MEDIUM · MCQ —
一位因氣胸置入胸管的個案，下列哪項發現顯示引流系統運作正常？
A nurse is caring for a client with a chest tube that was recently inserted for a pneumothorax. Which finding indicates the system is functioning correctly?
- AFluctuation of the fluid level in the water-seal chamber with respirations✓ 正解水封瓶內液面隨呼吸波動
- BContinuous bubbling in the water-seal chamber水封瓶內持續冒泡
- CDark red blood drainage of 500 mL in one hour一小時內引流出 500 mL 暗紅色血液
- DAbsence of fluid drainage in the collection chamber收集瓶內無液體引流
— Explanation · 中文詳解 —
胸管引流時，水封瓶內的液面會隨著病人的呼吸運動而上下波動（Tidaling），這是胸內壓正常的動力學表現。持續性氣泡代表有漏氣現象；無引流物在氣胸不一定異常，但大量出血則屬病理狀況。波動代表通路通暢，無阻塞。
Fluctuation of the fluid level in the water-seal chamber with respiration, known as tidaling, indicates that the chest tube system is patent and functioning correctly. Continuous bubbling suggests an air leak, while excessive drainage would require immediate provider notification.
✦ 台美臨床差異
台美臨床對於胸管護理標準一致，均需嚴格遵守無菌技術與引流瓶高度限制。