一位裝有胸管的病人，過去一小時引流量為 150 mL。護理師首要行動是什麼？
A client with a chest tube has 150 mL of drainage in the last hour. What is the nurse's priority action?
- ADocument the finding記錄此發現
- BNotify the physician✓ 正解通知醫師
- CClamp the chest tube夾閉胸管
- DMilk the tubing to clear clots擠壓引流管以清除血塊
胸管引流是處理氣胸或血胸的重要醫療手段，目的在於引流胸腔內的空氣或液體，幫助肺部重新擴張。引流液的量是評估病人胸腔出血情況的關鍵指標。雖然術後或創傷後初期可能會有較多引流，但過多的引流量可能表示有活動性出血，這是一種危險的狀況，需要立即醫療介入。本題考驗護理師對胸管引流異常情況的判斷能力及處理優先級。護理師必須了解何時的引流量屬於正常範圍，何時需要立即通報醫師，以確保病人安全。
Chest tube drainage is an important intervention for managing pneumothorax or hemothorax; its purpose is to drain air or fluid from the pleural space and help the lung re-expand. The volume of drainage is a key indicator for assessing intrathoracic bleeding. Although drainage may be relatively heavy early after surgery or trauma, excessive output can signal active bleeding, a dangerous condition that requires immediate medical intervention. This question tests the nurse's ability to judge abnormalities in chest tube drainage and to set priorities for action. The nurse must know what volume of drainage is within normal range and when to notify the provider immediately to ensure client safety.
胸管引流的護理原則，包括引流量的監測與異常情況的處理，在美國和台灣的臨床實踐中是高度一致的。兩地都將每小時引流量超過 100 mL 視為應立即通報醫師的警示。在美國，護理師的臨床判斷和獨立處置權限較大，在通報醫師前，可能被要求快速評估病人的生命徵象和呼吸狀況。在台灣，護理師也會立即通報，同時持續密切監測病人。關於「擠奶式引流管」的操作，美國和台灣的指引都趨向於不建議常規執行，除非有特定醫囑或在特殊情況下，且需非常謹慎操作。