— 降低風險 · HARD · SATA —
護理師評估一位裝有胸管引流系統的病人，哪些發現需立即回報醫療團隊？（選所有適合的）
A nurse is assessing a client with a chest tube drainage system. Which findings should the nurse report to the healthcare provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of fluid in the water seal tube during respiration呼吸時水封管內液面波動
- CDrainage of 150 mL of bright red blood in one hour✓ 正解一小時內引流150 mL鮮紅色血液
- DThe chest tube has become disconnected from the drainage system✓ 正解胸管從引流系統脫離
- EThe client reports mild discomfort at the insertion site病人報告插入部位有輕微不適
— Explanation · 中文詳解 —
胸管系統的異常包含：水封瓶連續氣泡（顯示系統漏氣）、引流量過大（>100mL/hr 為出血指標）、以及管路脫落（造成氣胸）。波動（Tidaling）為正常反應，顯示胸內壓隨呼吸改變；輕微不適感則是術後常見情形，非緊急狀況。
Continuous bubbling in the water seal chamber suggests an air leak in the system, while drainage exceeding 100 mL of bright red blood per hour indicates potential active hemorrhage. Additionally, a disconnected chest tube poses an immediate risk for tension pneumothorax and requires urgent attention. Normal findings include fluctuation (tidaling) during respiration and mild discomfort at the insertion site.
✦ 台美臨床差異
美國醫護對於胸管脫落的緊急處理（如封閉管口）有明確的 ACLS 指引；台灣則視醫師臨床經驗而定。