— 生理適應 · HARD · SATA —
護理師照護一位胸管置入的病人，下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client with a chest tube. Which nursing interventions are appropriate? (Select all that apply.)
- ATape all connections between the chest tube and drainage system✓ 正解用膠帶固定胸管與引流系統之間的所有連接處
- BKeep the drainage system below the level of the client's chest✓ 正解保持引流系統低於病人胸部水平
- CStrip or milk the chest tube every 2 hours to maintain patency每兩小時擠壓或捋胸管以維持通暢
- DMonitor for constant bubbling in the water seal chamber監測水封腔內的持續冒泡現象
- EClamp the chest tube if the system needs to be changed若需更換系統則夾閉胸管
— Explanation · 中文詳解 —
胸管照護重點：管路連接處應確實貼紮以維持密封。引流瓶需低於胸腔平面利用重力引流。不可用力擠壓（strip）或推擠（milk）管路，以免造成極大負壓損害胸膜。水封瓶若持續冒泡（constant bubbling）代表有氣體外漏，非正常現象。變更系統時 clamp 不可超過數秒且需醫師醫囑。
Securing all connections with tape prevents air leaks into the pleural space, while keeping the drainage system below the chest level ensures gravity-assisted drainage and prevents backflow. These measures are essential for maintaining system integrity and effective lung re-expansion.
✦ 台美臨床差異
美台臨床對胸管擠壓的觀念皆已趨保守，但在設備更換時的 clamp 操作 protocol 略有不同。