— 降低風險 · MEDIUM · MCQ —
護理師照護一位使用胸腔引流管的病人，發現水封瓶持續冒泡。護理師應採取之優先措施為何？
A nurse is caring for a client who has a chest tube connected to a closed-chest drainage system. The nurse observes continuous bubbling in the water seal chamber. What is the priority nursing action?
- ACheck the entire system for air leaks✓ 正解檢查整個系統是否有漏氣
- BDocument the finding in the chart在病歷中記錄此發現
- CClamp the chest tube close to the insertion site在插入口附近夾住胸腔引流管
- DIncrease the suction pressure增加抽吸壓力
— Explanation · 中文詳解 —
水封瓶持續冒泡通常意味著系統出現漏氣，應沿管路檢查連接處是否鬆脫或破裂。若非系統漏氣，則需評估病人是否有氣胸惡化。不宜直接夾管，以免壓力過高導致張力性氣胸。此處置優先順序為排除設備故障，確保引流功能正常。
Continuous bubbling in the water-seal chamber typically indicates an air leak within the chest tube system, requiring immediate inspection of all connections and tubing for dislodgement or breaks. The nurse should check the entire system first to identify and correct the leak, as clamping the tube could lead to tension pneumothorax and documentation alone does not address the safety hazard.
✦ 台美臨床差異
台美對胸腔管照護準則一致，均強調嚴禁未經醫囑夾管，並需每日檢視水封瓶狀況。