# 右下葉切除術後12小時,護理師發現胸管插入部位至鎖骨出現新的捻髮音,胸腔引流系統氣漏腔持續冒泡。護理師首先應採取的行動?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374962&lang=zh-tw  
> language: zh-TW  
> subject: NCLEX-RN  
> category: PPT

## 題目

右下葉切除術後12小時,護理師發現胸管插入部位至鎖骨出現新的捻髮音,胸腔引流系統氣漏腔持續冒泡。護理師首先應採取的行動?

## 選項

1. 夾住胸管並立即通知外科醫師
2. 檢查所有胸管接頭與敷料密封狀況 **✔ 正確答案**
3. 將壁式抽吸增至-30 cmH2O以克服漏氣
4. 每15分鐘擠壓胸管管路

**正確答案: 2**

## 解析

新發皮下氣腫合併持續氣泡提示漏氣源(常為鬆脫接頭或管孔露出皮膚)。檢查接頭並加強密封敷料是首要措施,常可解決。漏氣時夾管可能引發張力性氣胸,屬禁忌。增加抽吸無法修復漏氣。擠壓管路產生危險負壓,亦屬禁忌。

## 深入解析

優先:檢查接頭(侵入性最低且具診斷性)。漏氣時絕不可夾管。捻髮音快速上行至頸部應在檢查後通報醫師。

## 臨床情境

術後第1天,右開胸28 Fr胸管-20 cmH2O抽吸。生命徵象:BP 118/72、HR 96、RR 22、SpO2 94%(鼻導管2 L)。

## 重要概念

- **皮下氣腫** — 空氣積於皮下組織,觸診時出現捻髮音。
- **氣漏腔** — 胸腔引流系統中間腔,持續冒泡表示持續漏氣。
- **肺葉切除術** — 以手術切除一個肺葉。

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