— 降低風險 · MEDIUM · MCQ —
護理師評估一位胸管置入兩小時後的病人，下列哪項發現需要立即通知醫師？
A nurse is assessing a client with a chest tube that was inserted 2 hours ago. Which finding requires immediate notification of the provider?
- A200 mL of bright red blood in the drainage collection chamber✓ 正解引流收集室中有 200 mL 鮮紅色血液
- BContinuous bubbling in the water seal chamber水封室持續冒泡
- CFluctuation of the fluid in the water seal tube with respiration水封管內液體隨呼吸波動
- DSubcutaneous emphysema near the insertion site置管處附近有皮下氣腫
— Explanation · 中文詳解 —
胸管術後引流量過多是活動性出血的警訊。通常術後早期引流量若在短時間內迅速增加（如 2 小時內超過 100-200 mL），且顏色鮮紅，暗示血管損傷或結紮處脫落，需緊急介入。其餘選項雖需觀察，但不如活動性大量出血緊急。
Excessive chest tube drainage in the postoperative period is a warning sign of active bleeding. Generally, a rapid rise in early postoperative drainage (such as >100-200 mL within 2 hours) of bright red color suggests vascular injury or dislodgement of a ligature and requires emergency intervention. Other options also warrant monitoring but are not as urgent as active large-volume bleeding.
✦ 台美臨床差異
美國護理師對胸管引流量監測標準化程度極高，台灣常見由醫師評估後判斷是否為異常。