護理師照顧一位放置胸管引流系統的病人，哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water-seal chamber✓ 正解水封瓶內持續冒泡
- B200 mL of bright red blood drainage in 1 hour✓ 正解1 小時內引流 200 mL 鮮紅血液
- CFluctuation of the fluid level in the water-seal chamber with respiration水封瓶內液面隨呼吸波動
- DSubcutaneous emphysema around the insertion site✓ 正解插入部位周圍出現皮下氣腫
- EThe chest tube has become disconnected from the drainage unit✓ 正解胸管與引流裝置斷開
胸管系統的運作正常與否關係到肺部擴張及生命安全。連續性的水封瓶氣泡（Continuous bubbling）暗示系統有漏氣；每小時超過 100-200 mL 的鮮紅色引流通常代表活動性出血，需緊急處置。皮下氣腫代表氣體進入皮下組織，可能源於連接處鬆脫或管路阻塞；管路脫落會導致氣胸，需立即封閉連接處或浸入水中。波動（Tidaling）是正常的呼吸運動表現，表示胸腔內壓力隨呼吸變化，故 C 為正常現象。護理師必須保持警覺，識別系統異常與病人臨床狀態之間的關聯，以避免氣胸或張力性氣胸的發生。
Whether a chest drainage system is functioning properly is directly tied to lung expansion and patient safety. Continuous bubbling in the water-seal chamber suggests an air leak in the system; bright red drainage exceeding 100-200 mL per hour usually indicates active bleeding and requires emergency management. Subcutaneous emphysema represents air entering the subcutaneous tissue, which may originate from a loose connection or tubing obstruction; tubing dislodgement leads to pneumothorax, requiring immediate sealing of the connection site or submersion in water. Tidaling is a normal manifestation of respiratory movement, reflecting changes in intrathoracic pressure with breathing, so C is a normal finding. The nurse must remain vigilant in recognizing the relationship between system abnormalities and the patient's clinical status to prevent pneumothorax or tension pneumothorax.
美國護理教育強調『管路脫落立即浸入無菌水』的緊急措施，並常規執行胸管系統的『水封瓶氣泡監測』培訓；台灣臨床對『持續性氣泡』的處置常依賴胸腔外科醫師指導，護理師較傾向於先評估後通知。