— 生理適應 · HARD · SATA —
護理師照顧一位放置胸管的病人。下列哪些評估結果代表可能出現併發症？（選所有適合的）
A nurse is caring for a client with a chest tube. Which assessment findings indicate a potential complication? (Select all that apply.)
- ASubcutaneous emphysema✓ 正解皮下氣腫
- BContinuous bubbling in the water seal chamber✓ 正解水封瓶持續冒泡
- CFluctuation in the water seal chamber with respiration水封瓶隨呼吸起伏
- DAbsent breath sounds on the affected side✓ 正解患側呼吸音消失
- ETracheal deviation✓ 正解氣管偏移
— Explanation · 中文詳解 —
胸管系統若發生空氣滲漏（水封瓶持續冒泡）或皮下氣腫，通常代表氣胸未完全緩解或系統氣漏。若出現患側呼吸音消失或氣管偏移，則暗示張力性氣胸的形成，屬於醫療急症。波動（Fluctuation/Tidaling）則是正常生理表現，隨呼吸起伏。
In a chest tube system, an air leak (continuous bubbling in the water seal chamber) or subcutaneous emphysema usually indicates that the pneumothorax has not fully resolved or that there is a leak in the system. Absent breath sounds on the affected side or tracheal deviation suggests development of a tension pneumothorax, which is a medical emergency. Fluctuation (tidaling) is a normal physiologic finding that varies with respiration.
✦ 台美臨床差異
美國護理師對胸管異常的評估與處置權限較高；台灣常需仰賴醫師親自評估後再決定是否重新放置或調整。