— 生理適應 · HARD · SATA —
護理師照顧一位氣胸病人，下列哪些護理措施正確？（選所有適合的）
A nurse is caring for a client with a pneumothorax. Which interventions are appropriate? (Select all that apply.)
- AMonitor chest tube drainage for color and amount✓ 正解監測胸腔引流管的顏色和量
- BKeep the drainage system below the level of the chest✓ 正解保持引流系統低於胸腔水平
- CClamp the chest tube if the client needs to ambulate若病人需要行走，夾住胸腔引流管
- DAssess the insertion site for subcutaneous emphysema✓ 正解評估插入部位是否有皮下氣腫
- EEnsure the water seal chamber shows bubbling during inspiration確保水封瓶在吸氣時顯示冒泡
— Explanation · 中文詳解 —
氣胸病人使用胸管引流時，必須維持系統低於胸部水平以利重力引流。監測引流量與性質可判斷氣胸改善情形。皮下氣腫是氣體滲漏的指標需評估。C 錯誤：絕對不可夾住管路，恐導致張力性氣胸。E 錯誤：水封瓶若持續冒氣泡代表有空氣滲漏（Air leak）。
Maintaining the drainage system below the level of the chest ensures effective gravity drainage. Monitoring the color and amount of drainage helps assess the resolution of the pneumothorax. Assessing the insertion site for subcutaneous emphysema is crucial as it indicates air leaking into the tissues.
✦ 台美臨床差異
台美臨床對於胸管護理的共識極高，皆極度強調防逆流與禁夾管原則。