— 生理適應 · HARD · SATA —
一位肺葉切除術後置放胸管的病人，護理師應向外科醫師回報哪些情形？（選所有適合的）
A nurse is caring for a client with a chest tube following a lobectomy. Which findings should the nurse report to the surgeon? (Select all that apply.)
- A250 mL of bloody drainage in the first hour✓ 正解第一小時內有 250 mL 的血性引流液
- BConstant bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- COscillation of fluid in the water seal tube with inspiration水封管內液面隨吸氣波動
- DSubcutaneous emphysema noted around the insertion site✓ 正解插入處周圍出現皮下氣腫
- ESpO2 drop from 94% to 88% with respiratory distress✓ 正解伴隨呼吸窘迫，血氧飽和度從 94% 降至 88%
— Explanation · 中文詳解 —
胸管護理重點在於監測異常引流。A（量多且快）、B（持續漏氣代表系統或肺部損傷）、D（皮下氣腫代表氣體外洩至組織）、E（生命徵象惡化）皆為危險警訊。C 選項（波動）是胸管維持通暢的正常生理表現，不需回報。
The focus of chest tube care is monitoring for abnormal drainage. A (large and rapid output), B (continuous air leak indicating system or lung injury), D (subcutaneous emphysema indicating air leakage into tissues), and E (deteriorating vital signs) are all warning signs. Option C (tidaling/fluctuation) is the normal physiologic finding that indicates patency of the chest tube and does not require reporting.
✦ 台美臨床差異
台美對胸管漏氣的定義一致，但在美國，護理師對胸管異常處置的授權程度較高。