— 降低風險 · MEDIUM · SATA —
護理師照護一位放置胸管的病人。下列哪些發現應回報給醫師？（選所有適合的）
A nurse is providing care to a client who has a chest tube. Which findings should the nurse report to the healthcare provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- BTracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
- C200 mL of bright red blood drainage in one hour✓ 正解一小時內有 200 mL 鮮紅色引流液
- DAbsence of tidaling in the water seal chamber✓ 正解水封腔內無潮動現象
- EFluctuation of fluid levels with respiration液面隨呼吸波動
— Explanation · 中文詳解 —
胸管監測重點：水封瓶（water seal）持續氣泡暗示空氣洩漏；氣管偏移表示張力性氣胸風險；大量鮮紅血塊（>100mL/hr）提示活動性出血；若潮動（tidaling）消失代表肺已擴張或管路阻塞，需評估。選項 E 為正常現象，不需回報。
Key chest tube monitoring: continuous bubbling in the water seal chamber suggests an air leak; tracheal deviation indicates the risk of tension pneumothorax; large amounts of bright red blood (>100 mL/hr) suggest active bleeding; absence of tidaling indicates either lung re-expansion or tubing obstruction and requires assessment. Option E is a normal finding and does not require reporting.
✦ 台美臨床差異
台灣胸管照顧常由護理師進行管路抽吸衛教與監測，美國則對管路引流後的肺部聽診有更嚴格的呼吸治療師協作機制。