— 生理適應 · HARD · SATA —
一位肺葉切除術後置放胸管的病人，下列哪些發現需立即回報醫師？（選所有適合的）
A nurse is caring for a client with a chest tube following a lobectomy. Which findings should the nurse report to the surgeon immediately? (Select all that apply.)
- A200 mL of bright red blood in the drainage chamber within the first hour✓ 正解第一小時內引流室出現 200 mL 鮮紅色血液
- BConstant bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- COscillation of the water level in the water seal chamber during inhalation吸氣時水封瓶內水位波動
- DSubcutaneous emphysema spreading around the chest tube insertion site✓ 正解胸管插入部位周圍出現皮下氣腫擴散
- EClient reports moderate pain at the incision site病人報告切口處中度疼痛
— Explanation · 中文詳解 —
胸管護理需嚴密監控異常引流。一小時內大出血（>100-150mL/hr）代表活動性出血；水封瓶持續氣泡代表系統漏氣或肺部瘻管；皮下氣腫擴散顯示氣體溢出組織間隙。波動是正常現象；傷口疼痛則屬預期內護理範疇，非立即危急。
Chest tube care focuses on monitoring abnormal drainage. Heavy bleeding (>100-150 mL/hr) within the first hour indicates active hemorrhage; continuous bubbling in the water seal chamber indicates a system air leak or pulmonary fistula; spreading subcutaneous emphysema indicates air leakage into the tissues. Oscillation is a normal finding, while incisional pain is an expected aspect of nursing care and is not immediately critical.
✦ 台美臨床差異
台美對胸管漏氣評估觀念一致，但美國護理師常需負責濕式/乾式引流系統的詳細維護與更換。