— 降低風險 · HARD · SATA —
護理師照護一位裝有胸管引流系統的病人。哪些發現需要立即回報醫療團隊？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- B200 mL of bright red blood drainage in one hour✓ 正解一小時內引出 200 mL 鮮紅色引流液
- CFluctuation of the fluid in the water seal chamber during inhalation吸氣時水封瓶內液體波動
- DSubcutaneous emphysema around the insertion site✓ 正解插管周圍出現皮下氣腫
- EThe drainage system is tipped over引流系統傾倒
— Explanation · 中文詳解 —
胸管系統的異常包含：水封瓶持續氣泡代表存在氣胸滲漏；一小時內超過 100-200 mL 的鮮紅血液表示出血過多；皮下氣腫代表氣體從胸腔溢散至皮下。波動（Tidaling）是正常現象，而傾倒系統應嘗試復原或更換。
Abnormal chest-tube findings include continuous bubbling in the water seal chamber (suggests an active air leak), more than 100-200 mL of bright red blood drainage per hour (active hemorrhage), and subcutaneous emphysema (air leakage into tissues). Tidaling with respiration is normal, and a tipped-over system can usually be restored or replaced without provider notification.
✦ 台美臨床差異
美國護理師對胸管異常的判讀與處置權限較高，台灣常傾向於先請值班醫師評估。