護理師評估一位放置胸管的病人。下列哪些發現應立即回報醫師？（選所有適合的）
A nurse is assessing a client with a chest tube. Which findings should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內有連續氣泡
- BTracheal deviation toward the unaffected side✓ 正解氣管向未患側偏移
- C200 mL of bright red blood drainage in the last hour✓ 正解過去一小時內有 200 mL 鮮紅色引流液
- DFluctuation of the fluid level in the water seal chamber during breathing水封瓶內液面隨呼吸波動
- ESubcutaneous emphysema around the insertion site✓ 正解插口周圍有皮下氣腫
胸管照護的紅旗徵兆：A（水封瓶持續氣泡代表系統漏氣或肺部瘻管）；B（氣管偏移為張力性氣胸症狀，屬急症）；C（短時間內大量出血）；E（皮下氣腫惡化代表氣體溢出組織間隙）。D 選項則為呼吸時水封瓶液面隨呼吸波動，這是胸管功能正常之表現。
Red flags in chest tube care: A (continuous bubbling in the water seal chamber indicates a system leak or bronchopleural fistula); B (tracheal deviation is a sign of tension pneumothorax, a medical emergency); C (a large volume of bleeding within a short period); E (worsening subcutaneous emphysema reflects air leaking into the soft tissues). Option D, fluctuation of the fluid level in the water seal chamber with breathing (tidaling), represents normal chest tube function.
美國護理師常依據 Protocol 處理 chest tube 問題，台灣對於 chest tube 異常狀況多會同步通知住院醫師進行檢查。