# 一位胸腔切開術後且帶有胸腔引流管的個案，術後第1天。應將哪些措施納入照護計畫？請選出所有適用的選項。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374973&lang=zh-tw  
> language: zh-TW  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## 題目

一位胸腔切開術後且帶有胸腔引流管的個案，術後第1天。應將哪些措施納入照護計畫？請選出所有適用的選項。

1

清醒時每小時使用激勵性肺量計

2

臥床時穿戴序列性壓迫裝置

3

將引流系統置於胸部以上以防回流

4

連續2小時每小時引流超過100 mL須通報外科醫師

5

可耐受時協助早期走動,保持系統直立

## 解析

胸腔手術後照護組合可預防靜脈血栓栓塞(VTE)及肺擴張不全，包括：床上使用循序減壓裝置、每小時使用誘發性肺量計、早期下床活動。引流瓶必須保持在胸部水平以下，以避免重力使引流液回流至肋膜腔。若鮮紅色引流液每小時超過100毫升持續2小時，或第一小時內超過200毫升，應立即通知外科醫師，因可能發生出血。

## 深入解析

記憶:胸管系統低於胸部、搬運中嚴禁夾管(僅換瓶時短暫夾)、直立保持。Tidaling表示通暢,消失表示阻塞或完全再擴張。

## 臨床情境

過去8小時胸膜引流80 mL血清血性。PCA hydromorphone疼痛5/10。有tidaling。SCD備於床邊。

## 重要概念

- **Tidaling** — 水封腔液面隨呼吸波動 — 系統通暢。
- **序列性壓迫裝置(SCD)** — 防止不動病人VTE之氣壓腿套。
- **激勵性肺量計** — 促進深呼吸之裝置 — 預防術後肺塌陷。

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