— 降低風險 · MEDIUM · SATA —
護理師照護一位放置胸管的病人，應執行哪些護理介入？（選所有適合的）
A nurse is caring for a client with a chest tube. Which interventions are appropriate for the nurse to perform? (Select all that apply.)
- AKeep the drainage system below the level of the client's chest✓ 正解將引流系統置於低於病人胸部的位置
- BMilk the chest tube every 2 hours to prevent clots每2小時擠壓胸管以防止血塊形成
- CEnsure all connections are secured with adhesive tape✓ 正解確保所有連接處已用膠帶固定
- DAssess the water seal chamber for tidal fluctuations✓ 正解評估水封腔是否有潮汐式波動
- EClamp the chest tube continuously持續夾住胸管
— Explanation · 中文詳解 —
胸管護理重點為維持引流系統的低位（重力引流）、確保管路密封（防止氣胸復發）、觀察水封瓶波动以確認肺部擴張情況。擠壓（Milk/Strip）管路極易造成胸腔內壓力驟變，除非醫師特別指示，否則不應常規執行。夾管（Clamp）會導致壓力堆積引發張力性氣胸，除非更換設備或尋找漏氣點，否則嚴禁連續夾管。
Proper chest tube management includes keeping the drainage system below chest level to prevent backflow, securing all connections to maintain a closed system, and monitoring the water seal chamber for tidal fluctuations to ensure patency.
✦ 台美臨床差異
台美皆嚴禁常規擠壓胸管，但在拔管後的評估重點上，台灣更傾向由專科護理師協助醫師執行。