— 降低風險 · MEDIUM · MCQ —
一位放置胸管的病人出現下列哪項徵象時，護理師應立即通知醫師？
Which of the following findings in a client with a chest tube should the nurse report to the healthcare provider immediately?
- AFluctuation of the fluid in the water seal tube水封瓶內液體波動
- BContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- CPresence of a small amount of subcutaneous emphysema存在少量皮下氣腫
- DSerosanguineous drainage of 50 mL in 4 hours4 小時內有 50 mL 漿液血性引流
— Explanation · 中文詳解 —
胸管水封瓶（Water seal chamber）中的持續性冒泡通常意味著胸膜腔內出現「空氣洩漏」（Air leak）。在正常狀況下，水封瓶僅應在病人咳嗽或深呼吸時出現間歇性冒泡或波動。若出現持續性冒泡，代表空氣持續進入胸膜腔或系統氣密性失效，必須立即檢查管路連接處並通知醫師，以防張力性氣胸的發生。
Continuous bubbling in the water seal chamber of a chest tube usually indicates an air leak in the pleural space. Under normal conditions, bubbling or fluctuation in the water seal chamber should occur intermittently only with coughing or deep breathing. Continuous bubbling indicates ongoing air entry into the pleural space or loss of system air-tightness; the tubing connections must be inspected immediately and the provider notified to prevent tension pneumothorax.