— 生理適應 · HARD · SATA —
護理師照顧一位肺葉切除術後帶有胸管的病人。下列哪些發現需要立即介入處理？（複選題）
A nurse is caring for a client with a chest tube following a lobectomy. 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 the last hour✓ 正解過去一小時內引流出 200 mL 鮮紅色血液
- CSubcutaneous emphysema near the insertion site插管處附近出現皮下氣腫
- DFluctuation of the fluid in the water-seal chamber during inspiration吸氣時水封瓶內液面出現波動
- EThe chest tube has become disconnected from the drainage system✓ 正解胸管與引流系統脫離連接
— Explanation · 中文詳解 —
胸管系統需維持密閉與低負壓。水封瓶持續冒泡（A）通常顯示系統有漏氣；術後短時間內大量鮮紅血量（B）代表出血活動中；胸管脫落（E）會導致張力性氣胸。皮下氣腫（C）需監測但不必然立即急救；波動（D）是正常生理現象。
Chest tube systems must remain sealed and under low negative pressure. Continuous bubbling (A) indicates an air leak; large bright red drainage (B) suggests active hemorrhage; disconnection (E) can cause tension pneumothorax. Subcutaneous emphysema (C) requires monitoring but is not always emergent; fluctuation (D) is a normal sign of patency.
✦ 台美臨床差異
美國護理師常受訓使用無菌水封住斷裂處，台灣臨床則強調立即用凡士林紗布封閉傷口並通知醫師。