— 降低風險 · MEDIUM · SATA —
護理師照護一位胸管引流的病人。下列哪些發現表示需立即介入？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings indicate the need for immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- BDependent loops in the drainage tubing✓ 正解引流管路有下垂彎曲
- CFluctuation of the fluid in the water seal chamber during inhalation水封腔內液體隨吸氣波動
- DBright red drainage of 200 mL in the last hour✓ 正解最後一小時有 200 mL 鮮紅色引流液
- ESubcutaneous emphysema noted around the insertion site✓ 正解插管周圍發現皮下氣腫
— Explanation · 中文詳解 —
胸管護理需確保系統密閉與引流順暢。連續性氣泡代表系統漏氣；引流管下垂會阻礙回流；急性期每小時引流量>100mL表示活動性出血；皮下氣腫代表氣體洩漏至皮下組織。水封瓶液面隨呼吸波動（Tidaling）則是正常現象，不需介入。
Chest tube care requires a closed, patent system. Continuous bubbling in the water seal indicates an air leak; dependent loops impede gravity drainage; bright red drainage of >100 mL/hr suggests active hemorrhage; subcutaneous emphysema indicates air leakage into tissues. Fluctuation (tidaling) in the water seal during respiration is a normal finding indicating system patency.
✦ 台美臨床差異
兩地臨床皆高度重視胸管安全性。台灣在ICU訓練中對於「Tidaling」的評估更為嚴格，常見於護理交班重點。