— 降低風險 · HARD · SATA —
護理師照護一位使用胸腔引流管接水封瓶系統的病人，下列哪些發現需立即通知醫師？（選所有適合的）
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which findings warrant immediate notification of the provider? (Select all that apply.)
- AContinuous bubbling in the water-seal chamber✓ 正解水封瓶內持續冒泡
- BThe drainage volume is 50 mL over the last 8 hours過去8小時內的引流量為50毫升
- CThe client reports sudden shortness of breath and chest pain✓ 正解病人報告突然呼吸困難和胸痛
- DA sudden stop in fluctuation of the water seal✓ 正解水封瓶波動突然停止
- EThe tubing is dependent with a loop hanging below the drainage unit管路下垂並形成低於引流單位的懸垂環
— Explanation · 中文詳解 —
胸腔引流管照護需監測系統完整性。水封瓶持續氣泡通常代表胸膜腔有氣漏；呼吸困難與胸痛提示張力性氣胸或復張不全；水封波動突然停止若非因管路彎折，可能代表肺部已完全復張或管路阻塞。E選項需調整管路，雖不一定需立即通知醫師，但屬於護理處置範疇。
Continuous bubbling in the water-seal chamber indicates a persistent air leak, while sudden shortness of breath and chest pain suggest life-threatening complications like tension pneumothorax. A sudden stop in fluctuation may indicate lung re-expansion or tube obstruction, all of which require immediate provider notification.
✦ 台美臨床差異
美國護理師常依 protocol 進行胸管夾閉試驗評估，台灣護理師通常需醫師評估後才進行拔管前評估。