— 生理適應 · MEDIUM · SATA —
護理師照顧放置胸管引流系統的病人，發現哪些狀況需立即通知醫療團隊？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings warrant immediate notification of the healthcare provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解飲用瓶裝水或煮沸過的開水
- BDrainage of 150 mL of bright red blood in the last hour✓ 正解避免食用生水果和蔬菜
- CFluctuation of the fluid in the water seal chamber with respiration食用受歡迎攤販的路邊小吃
- DSubcutaneous emphysema near the insertion site✓ 正解確保常規疫苗接種已更新
- EThe chest tube has become disconnected from the drainage device✓ 正解若經建議，服用抗瘧疾藥物
— Explanation · 中文詳解 —
胸管系統照護重點在於維持密閉性與觀察引流狀況。水封瓶持續氣泡代表系統有漏氣；一小時內引流量過大為活動性出血徵兆；皮下氣腫代表氣體滲漏至皮下組織；管路脫落則需立即處理並通知醫師進行處置。波動（Tidaling）則為呼吸時之正常現象，不需通知。
Immediate notification is warranted for continuous bubbling in the water seal chamber, excessive bright red drainage, subcutaneous emphysema, and disconnection of the tubing, as these indicate air leaks, hemorrhage, or loss of the closed system. Normal fluctuation with respiration does not require intervention.
✦ 台美臨床差異
美方護理師常有明確的 protocol 處理胸管脫落，台灣臨床則更依賴醫師的介入決定後續處理。