— 生理適應 · EASY · MCQ —
護理師照護一位接有封閉式胸腔引流系統的病人。下列何種發現顯示系統運作正常？
A nurse is caring for a client with a chest tube that is connected to a closed-chest drainage system. Which finding indicates the system is working properly?
- AContinuous bubbling in the water-seal chamber水封瓶內持續冒泡
- BDark red drainage of 500 mL in the first hour第一小時內有 500 mL 暗紅色引流液
- CFluctuation of the fluid level in the water-seal chamber with respiration✓ 正解水封瓶內液面隨呼吸波動
- DAbsence of bubbling in the suction control chamber吸引控制瓶內無冒泡現象
— Explanation · 中文詳解 —
水封瓶內的液面隨呼吸波動（Tidaling）是胸腔引流系統功能正常的指標，代表系統與胸腔壓力相通。若無波動，可能代表管路阻塞或肺部已完全擴張。持續氣泡則代表有空氣洩漏，大量引流（500 mL/hr）則需警惕血胸，吸入室無氣泡則代表負壓未啟動。
Fluctuation of the fluid level in the water-seal chamber with respiration, known as tidaling, indicates that the drainage system is patent and functioning correctly. Continuous bubbling suggests an air leak, while the absence of fluctuation may indicate tubing obstruction or complete lung expansion.
✦ 台美臨床差異
在美國，這類胸管護理多由 RN 獨立判斷並執行；台灣部分醫療院所由胸腔外科醫師或專科護理師密切追蹤引流數據。