— 生理適應 · HARD · SATA —
護理師照護一位放置胸管引流系統的病人，下列哪些發現需通知醫師？（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 provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- B250 mL of bright red blood in the drainage chamber over one hour✓ 正解一小時內引流瓶中有 250 mL 鮮紅色血液
- CFluctuation of the fluid level in the water seal chamber during respiration水封瓶內液面隨呼吸波動
- DSubcutaneous emphysema noted around the insertion site✓ 正解插入部位周圍出現皮下氣腫
- EThe chest tube has become disconnected from the drainage system✓ 正解胸管從引流系統脫離
— Explanation · 中文詳解 —
水封瓶持續氣泡代表系統有漏氣；每小時引流量超過 100 mL 屬於出血過量；皮下氣腫代表氣體滲入組織，需確認管路位置；管路脫落是緊急狀況。波動（Fluctuation/Tidaling）則是正常呼吸運動的表現，表示胸管通暢。
Continuous bubbling in the water-seal chamber indicates an air leak in the system; drainage exceeding 100 mL per hour is excessive bleeding; subcutaneous emphysema indicates that air has leaked into the tissues and the catheter position must be confirmed; and a disconnected chest tube is an emergency. Fluctuation (tidaling) is a normal manifestation of respiration and indicates that the chest tube is patent.
✦ 台美臨床差異
美國護理師受過專業訓練可自行緊急處理管路脫落；台灣醫院通常嚴格要求管路脫落需醫師到場處理。