— 生理適應 · EASY · MCQ —
一名使用胸管的病患，下列哪項發現需優先告知醫師？
A nurse is caring for a client with a chest tube. Which finding should the nurse prioritize reporting to the provider?
- ASmall subcutaneous emphysema around the site穿刺點周圍少量皮下氣腫
- BContinuous bubbling in the water seal chamber水封瓶內持續冒泡
- COscillation of fluid in the water seal tube水封管內液體波動
- D200 mL of bright red blood in the drainage chamber over 1 hour✓ 正解引流瓶內一小時內出現 200 mL 鮮紅色血液
— Explanation · 中文詳解 —
胸管引流量若在 1 小時內超過 100-200 mL，通常被視為活動性出血。這在術後早期尤其危險，可能導致低血容量性休克或心包填塞。其他選項中，潮動（Oscillation）是正常的，少許皮下氣腫需監測但非立即致命，持續氣泡則代表有漏氣。
Chest tube drainage exceeding 100-200 mL in one hour is generally considered active bleeding. This is particularly dangerous in the early postoperative period and can lead to hypovolemic shock or cardiac tamponade. Of the other options, oscillation (tidaling) is normal, small amounts of subcutaneous emphysema require monitoring but are not immediately life-threatening, and continuous bubbling indicates an air leak.
✦ 台美臨床差異
美國護理師常依護理執業範圍調整 suction 設定；台灣則多需嚴格遵循醫師設定之壓力數值。