— 生理適應 · HARD · MCQ —
護理師照護一位胸管引流病人，若胸管不慎脫落，應採取何種緊急行動？
A nurse is caring for a client with a chest drain. What should be done if the drain is accidentally disconnected?
- ACover the wound with a dry gauze以乾紗布覆蓋傷口
- BApply a sterile occlusive dressing taped on three sides✓ 正解貼上三面封閉的無菌密閉敷料
- CLeave the wound open保持傷口開放
- DImmediately place the tube in sterile water立即將胸管置入無菌水中
— Explanation · 中文詳解 —
胸管脫落時，為防止張力性氣胸（Tension pneumothorax），應立即使用無菌閉合性敷料進行密封，並以三面封閉（Taped on three sides）的方式貼膠帶。這種貼法允許空氣在吐氣時排出，但在吸氣時形成瓣膜避免外部空氣進入胸腔。
If a chest drain becomes disconnected, the nurse must immediately apply a sterile occlusive dressing taped on three sides to prevent a tension pneumothorax. This three-sided technique acts as a flutter valve, allowing air to escape during exhalation while preventing external air from entering the pleural space during inhalation.
✦ 台美臨床差異
台美對於胸管脫落的緊急處理原則一致，皆強調防止張力性氣胸的發生。