— 降低風險 · MEDIUM · MCQ —
一位病人裝有胸腔引流管且連接水封瓶系統，護理師觀察到水封室有連續性氣泡。護理師應優先採取什麼行動？
A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. The nurse notes continuous bubbling in the water-seal chamber. What is the priority action?
- ADocument the finding in the medical record在病歷中記錄此發現
- BClamp the chest tube immediately立即夾閉胸腔引流管
- CIncrease the suction pressure增加吸引壓力
- DCheck the tubing connections for an air leak✓ 正解檢查管路連接處是否有漏氣
— Explanation · 中文詳解 —
水封室出現連續性氣泡通常代表胸腔引流管系統某處發生漏氣，這會嚴重影響肺擴張。護理師首先應系統性檢查從病人端到引流盒的連接處是否鬆脫，若排除連接處漏氣，則需評估病人是否有氣胸惡化風險。夾住引流管有造成張力性氣胸風險，絕對禁止。
Continuous bubbling in the water-seal chamber indicates an air leak within the drainage system, which can compromise lung re-expansion. The nurse should first check all tubing connections for looseness or disconnection before considering other interventions.
✦ 台美臨床差異
美台臨床皆視系統漏氣為需即刻處理的警訊，但台灣護理師更傾向先向醫師確認是否移除引流瓶。