護理師照護一位裝有連續胸管引流系統的病患。下列哪項觀察結果需要立即處置？
A nurse is caring for a client with a continuous chest tube drainage system. Which observation requires immediate intervention?
- AContinuous bubbling in the water-seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of the water level (tidaling) with respiration隨呼吸出現的水位波動（潮汐現象）
- CDark red drainage of 50 mL in the first hour post-operatively術後第一小時內有 50 mL 的暗紅色引流液
- DIntermittent bubbling in the water-seal chamber during coughing咳嗽時水封瓶內出現間歇性冒泡
胸管系統的判讀是呼吸護理的關鍵。核心概念：水封瓶（Water-seal chamber）的作用是防止空氣回流進胸腔。在水封瓶中，隨著呼吸產生的波動（Tidaling，選項 B）是正常的，代表管路通暢。當病患咳嗽或深呼吸時出現間歇性氣泡（選項 D）也是正常的，代表正在排出胸腔內的空氣。然而，如果出現「持續性氣泡」（Continuous bubbling），則意味著系統內有漏氣（Air leak），可能是管路連接處鬆脫或是病患胸部傷口漏氣。這會導致肺部無法重新擴張，甚至引發氣胸。選項 C 的出血量在術後初期屬於可接受範圍（通常 >100 mL/hr 才需警覺）。因此，護理師必須立即檢查所有接頭並通知醫師。
Interpretation of chest tube systems is critical respiratory care. The water-seal chamber prevents air from re-entering the pleural space. Tidaling with respiration (B) is normal and indicates a patent system. Intermittent bubbling during cough or deep breath (D) is also normal and indicates air being evacuated from the pleural space. Continuous bubbling, however, signals an air leak—either at a tubing connection or from the patient's chest wound—which prevents lung re-expansion and can cause pneumothorax. Option C drainage is within an acceptable post-op range (concern arises at >100 mL/hr). The nurse must immediately inspect all connections and notify the provider.
在美國，胸管漏氣的初步檢查（檢查接頭、暫時夾管判斷漏氣點）是護理師的標準評估動作；台灣臨床護理師同樣會進行檢查，但對於「夾管（Clamping）」的時機規範較嚴，多數醫院要求除非更換系統或有醫囑，否則嚴禁擅自夾管。