— 生理適應 · MEDIUM · SATA —
護理師照顧一位置放胸管的病患。哪些發現顯示需要立即處理？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings indicate a need for immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶持續冒泡
- BSubcutaneous emphysema around the insertion site插管周圍皮下氣腫
- CDrainage output of 200 mL in one hour✓ 正解一小時引流液量達 200 mL
- DTidaling in the water seal chamber水封瓶出現潮汐現象
- EAbsence of breath sounds on the affected side✓ 正解患側呼吸音消失
— Explanation · 中文詳解 —
胸管護理的緊急紅旗包括：水封瓶持續氣泡（表示空氣洩漏）、短時間內大量出血（>100-200ml/h 需考慮活動性出血）、患側呼吸音消失（提示管路阻塞或氣胸復發）。皮下氣腫需監測但非立即致死；Tidaling 是正常呼吸隨動現象。
Continuous bubbling in the water seal chamber indicates a persistent air leak requiring immediate attention. Drainage exceeding 200 mL in one hour suggests active hemorrhage, and absent breath sounds on the affected side may indicate lung re-collapse or tube obstruction. These findings necessitate prompt intervention to prevent respiratory compromise.
✦ 台美臨床差異
台美胸管護理標準一致，但美國常使用自動感應水封系統，而台灣部分機構仍多依賴傳統玻璃水封瓶。