— 降低風險 · MEDIUM · SATA —
護理師照護一位放置胸管的病人。下列哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client who has a chest tube. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內有連續冒泡
- BDrainage of 150 mL bright red blood in 1 hour✓ 正解一小時內引流 150 mL 鮮紅色血液
- CFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- DThe chest tube has become disconnected from the drainage system✓ 正解胸管與引流系統脫離
- ESubcutaneous emphysema noted around the insertion site✓ 正解插入部位周圍出現皮下氣腫
— Explanation · 中文詳解 —
胸管照護中，水封瓶持續性氣泡表示氣胸漏氣或系統破損；短時間內大量出血（>100mL/hr）表活動性出血；管路脫落是生命威脅需緊急處理；皮下氣腫表管路功能異常或周邊縫合處漏氣。波動是正常生理反應，不需介入。
In chest tube care, continuous bubbling in the water seal chamber indicates an air leak from a pneumothorax or a break in the system; large amounts of bleeding within a short time (>100 mL/hr) indicate active hemorrhage; disconnection of the tubing is life-threatening and requires emergency action; and subcutaneous emphysema indicates abnormal tube function or air leakage at the suture site. Fluctuation is a normal physiologic finding and does not require intervention.
✦ 台美臨床差異
美國護理師對胸管護理的判讀教育較紮實；台灣部分地區交由外科醫師處理較多。