— 降低風險 · HARD · SATA —
護理師照護一位使用水封瓶胸管引流的病人。下列哪些發現需要立即告知醫師？（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 should the nurse report to the provider? (Select all that apply.)
- AContinuous bubbling in the water-seal chamber✓ 正解水封室持續冒泡
- BFluctuation of the fluid level in the water-seal chamber水封室內液面波動
- CExcessive drainage of 200 mL of bright red blood in one hour✓ 正解一小時內大量引流 200 mL 鮮紅色血液
- DSubcutaneous emphysema noted around the insertion site✓ 正解插入部位周圍發現皮下氣腫
- EThe chest tube becomes disconnected from the drainage system✓ 正解胸管從引流系統脫離
— Explanation · 中文詳解 —
水封瓶持續冒泡（A）暗示系統漏氣；每小時出血量超過 100-200 mL（C）屬異常出血；皮下氣腫（D）代表空氣漏入皮下組織；胸管脫落（E）會造成張力性氣胸風險。選項 B 的波動是正常現象，顯示胸腔壓力與呼吸運動同步。
Continuous bubbling in the water-seal chamber indicates an air leak in the system, while excessive bright red drainage suggests hemorrhage. Subcutaneous emphysema signals air leakage into tissues, and disconnection compromises the negative pressure needed for lung re-expansion.
✦ 台美臨床差異
美國護理師對胸管脫落有明確的標準操作程序（放入無菌水中），台灣則強調必須立即尋求外科醫師處理。