一位肺葉切除術後的病人置有胸管。下列哪些發現護理師應立即回報醫師？（選所有適合的）
A nurse is assessing a client with a chest tube following a lobectomy. Which findings should the nurse report to the provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BDrainage of 150 mL of frank blood in 1 hour✓ 正解1小時內引流150 mL 鮮血
- CClient reports sharp chest pain during deep breathing病人在深呼吸時報告胸部劇痛
- DAbsence of fluctuation in the water seal chamber水封瓶內無波動
- ESubcutaneous emphysema around the insertion site✓ 正解插口周圍出現皮下氣腫
胸管護理重點在於監測氣漏與出血量。水封瓶持續氣泡代表存在氣漏，出血量若大於 100 mL/hr 可能暗示活動性出血，皮下氣腫則顯示空氣滲入皮下組織，皆需緊急處置。波動消失可能為管路阻塞或肺部膨脹完全；術後胸痛則屬於術後常見症狀。
Chest tube care focuses on monitoring for air leaks and bleeding volume. Continuous bubbling in the water seal chamber indicates an air leak; bleeding greater than 100 mL/hr suggests active hemorrhage; and subcutaneous emphysema indicates air leakage into subcutaneous tissue—all require urgent intervention. Absence of fluctuation may indicate tube obstruction or complete lung re-expansion; post-operative chest pain is a common, expected symptom after thoracotomy.
美國護理師對於胸管護理的判讀教育非常紮實，台灣護理師則常會與醫師共同評估引流量。