— 生理適應 · HARD · MCQ —
護理師照護一位帶有胸管的病人，下列哪項評估發現需要立即處理？
A nurse is caring for a client with a chest tube. Which nursing assessment requires immediate intervention?
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSubcutaneous emphysema near the insertion site插管處附近出現皮下氣腫
- CFluctuation of fluid in the water seal chamber水封瓶內液面隨呼吸波動
- DPresence of a small amount of serosanguineous drainage有少量漿液血性引流液
— Explanation · 中文詳解 —
胸管水封瓶（water seal）出現持續性氣泡（Continuous bubbling）代表胸膜腔有持續漏氣（Air leak），若已排除管路銜接處問題，則病人可能發生氣胸惡化或肺部破裂，需緊急通知醫師。波動（Fluctuation）是正常的呼吸同步現象；少量漿液血水是術後常見；皮下氣腫通常代表漏氣，需觀察但不一定比持續性大量氣泡更危險。
Continuous bubbling in the water seal chamber indicates an air leak, which may suggest worsening pneumothorax or lung rupture if not due to a loose connection. While fluctuation is normal, subcutaneous emphysema, and expected drainage, continuous bubbling requires immediate assessment and intervention to ensure system integrity and client safety.
✦ 台美臨床差異
台美皆強調胸管護理重點，但美國護理師對於胸管拔除的判斷依據（如無氣泡後 X 光結果）常需與專科醫師密切協調。