— 降低風險 · MEDIUM · MCQ —
一位裝有胸管的病人，其水封瓶（water seal chamber）出現持續性氣泡。護理師應如何判讀此現象？
A client with a chest tube has continuous bubbling in the water seal chamber. What does the nurse interpret this as?
- AA leak in the chest tube system✓ 正解胸管系統有漏氣
- BExpected results of pleural drainage胸腔引流的預期結果
- CA malfunction of the suction device抽吸裝置故障
- DNormal lung re-expansion肺部正常復張
— Explanation · 中文詳解 —
胸管水封瓶（water seal chamber）設計是為了利用水封機制防止空氣逆流進入胸腔。正常情況下，水封瓶內的水位應隨呼吸呈現波動（tidaling），僅在病人咳嗽或深呼吸時可能出現短暫氣泡。當水封瓶出現持續性氣泡（continuous bubbling），代表有空氣持續不斷地進入系統，這暗示了系統密閉性被破壞（如連接處鬆脫、胸管裂開）或病人體內存在持續的漏氣（如肺部破裂）。護理師應採取「由上而下」的評估原則，優先檢查管路連接處是否緊密，若非管路問題，則需評估病人傷口及呼吸狀態，並立即通知醫師。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, suggesting a breach in the tubing connections or a persistent leak from the lung. This is not a normal finding, as expected bubbling should be intermittent and occur only during coughing or deep breathing.