— 降低風險 · HARD · SATA —
胸管引流病人出現下列哪些情況時，護理師應立即向醫師報告？（選所有適合的）
Which of the following findings in a client with a chest tube should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- CSudden decrease in drainage output after repositioning改變姿勢後引流液突然減少
- DSubcutaneous emphysema near the insertion site✓ 正解插管處附近出現皮下氣腫
- EDrainage of 150 mL of bright red blood in one hour✓ 正解一小時內引出150 mL鮮紅色血液
— Explanation · 中文詳解 —
胸管引流的紅旗指標包括：水封瓶持續氣泡（表示氣胸未閉合或系統漏氣）、皮下氣腫（空氣滲入組織，代表胸管阻塞或位置偏移）、以及每小時引流超過 100 mL 的鮮紅色出血。波動屬於正常呼吸循環，減少則視為阻塞風險但需進一步評估。
The nurse must immediately report continuous bubbling in the water seal chamber, which suggests an air leak, subcutaneous emphysema indicating tissue leakage, and excessive bright red drainage (over 100 mL/hour) signaling active hemorrhage. Fluctuation of the fluid level is a normal finding indicating system patency, while decreased drainage requires assessment for obstruction but is not an immediate emergency like the other findings.
✦ 台美臨床差異
美國護理師對於胸管照護的專業自主權較高；台灣常需由醫師親自評估或調整胸管。