— 降低風險 · HARD · SATA —
護理師評估一位放置胸管的病人。哪些發現需要立即介入處理？（選所有適合的）
A nurse is assessing a client who has a chest tube. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內有持續性氣泡
- B100 mL of dark red drainage in the first hour第一小時內有 100 mL 的暗紅色引流液
- CSubcutaneous emphysema around the insertion site✓ 正解插管處周圍有皮下氣腫
- DFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- EThe chest tube has become disconnected from the drainage system✓ 正解胸管與引流系統脫離
— Explanation · 中文詳解 —
胸管系統中，水封瓶持續氣泡代表有空氣外漏，需查出漏氣點；皮下氣腫表示空氣逸散至軟組織，需報告；脫落則是急症，需立即處理。100 mL 紅色引流在術後第一小時屬正常；波動（Tidaling）則是胸管運作良好的指標。
In a chest tube system, continuous bubbling in the water seal chamber indicates an air leak, and the source must be identified. Subcutaneous emphysema indicates that air is escaping into the soft tissues and must be reported. Disconnection is an emergency and requires immediate intervention. 100 mL of red drainage in the first postoperative hour is within normal limits, and fluctuation (tidaling) is an indicator that the chest tube is functioning properly.
✦ 台美臨床差異
美國教學強調即刻將脫落管端放入無菌水中，台灣教學亦同，這已是國際護理標準流程。