護理師照顧一位使用胸管連接水封瓶系統的病人，哪些發現需要立即介入處理？（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 require immediate intervention? (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 with respiration水封瓶內液面隨呼吸波動
- CThe drainage system is knocked over and the seal is broken✓ 正解引流系統被撞倒且密封破損
- DSudden decrease in the amount of drainage引流液突然減少
- ESubcutaneous emphysema noted at the insertion site✓ 正解插管處出現皮下氣腫
胸管系統的完整性與功能性是維護病人呼吸生理適應的關鍵。水封瓶內持續起泡（A）通常代表系統漏氣，這會影響胸腔負壓的重建，需立即檢查接頭；系統翻倒或密封失效（C）則可能引發氣胸，需緊急處理；皮下氣腫（E）顯示空氣未順利排出而積聚在皮下組織，暗示胸管阻塞或位置不當，這都會影響肺部擴張。反觀波動（B）是呼吸正常的生理反應，Drainage 減少（D）則需視臨床情況判斷，若是因為肺部已完全復張，則屬於正常進展。護理策略必須建立在『系統密閉性』與『氣體排出順暢性』兩大原則上，一旦發現系統功能異常，即刻處置以防發生張力性氣胸。
Continuous bubbling in the water-seal chamber indicates an air leak that compromises the negative pressure needed for lung re-expansion, while a broken seal from an overturned system poses an immediate risk of pneumothorax. Subcutaneous emphysema suggests air is trapped in the tissue rather than draining, indicating potential obstruction or malfunction. These findings require immediate intervention to restore system integrity and ensure adequate gas exchange.
美國護理訓練強調發生水封瓶破損時的緊急處置（如立即放入無菌水中以維持水封），台灣護理教育亦同，但在臨床現場，美國護理師常有更明確的醫院 Protocol 授權處理突發之胸管滑脫與空氣洩漏，台灣護理師則較傾向在發現異常時立即召喚醫師處理。