— 降低風險 · EASY · MCQ —
護理師照護一位使用水封式胸管引流的病人，下列何者顯示系統功能正常？
A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. Which finding indicates the system is functioning correctly?
- AAbsence of fluid fluctuation in the water-seal chamber水封腔內無液體波動
- BNo drainage in the collection chamber收集腔內無引流液
- CContinuous bubbling in the water-seal chamber水封腔內持續冒泡
- DFluctuation of the fluid level in the water-seal chamber with respirations✓ 正解水封腔內液面隨呼吸波動
— Explanation · 中文詳解 —
胸管水封瓶內的液面會隨病人的呼吸運動出現漲落（tidaling），這是正常生理現象，代表胸腔壓力與大氣壓力的動態平衡。若無漲落，可能代表胸管阻塞或肺部已完全擴張。連續性氣泡（C）通常暗示漏氣（air leak），應進一步評估管路完整性。
Fluctuation of the fluid level in the water-seal chamber, known as tidaling, indicates that the chest tube system is functioning correctly and responding to respiratory changes in intrathoracic pressure. Continuous bubbling suggests an air leak, while absence of fluctuation may indicate a blockage or complete lung re-expansion, both of which require further assessment.
✦ 台美臨床差異
美國護理師常需自行判讀引流瓶並決定何時通知醫師；台灣胸管護理多依賴醫師指示，護理師監測功能較為固定。