— 生理適應 · MEDIUM · SATA —
護理師照護一位放置胸管的病患，下列哪些觀察結果屬於預期範圍？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings are expected? (Select all that apply.)
- AFluctuation of fluid in the water-seal chamber with inspiration✓ 正解水封瓶內液面隨吸氣波動
- BContinuous bubbling in the suction control chamber✓ 正解抽吸控制瓶內持續冒泡
- CSmall amount of subcutaneous emphysema near the insertion site插管處附近有少量皮下氣腫
- DBright red drainage of 300 mL in the first hour第一小時內有 300 mL 鮮紅色引流液
- EAbsence of bubbling in the water-seal chamber水封瓶內無冒泡現象
— Explanation · 中文詳解 —
胸管水封瓶在吸氣時液面會隨呼吸波動（Tidaling），若消失可能代表阻塞或肺部擴張完全；抽吸室持續氣泡代表抽吸機功能正常。選項 C 皮下氣腫需報告，D 超過 100mL/hr 出血量為異常，E 若水封室無氣泡是正常的，但本題選擇題結構要求選出「預期功能表現」。
Expected findings in a functioning chest tube system include tidaling, which is the fluctuation of fluid in the water-seal chamber with respiration, indicating patency. Additionally, continuous bubbling in the suction control chamber confirms that the suction device is operating correctly. Subcutaneous emphysema or excessive bright red drainage would indicate complications such as leaks or hemorrhage.
✦ 台美臨床差異
美台臨床皆強調胸管護理的無菌原則，美國護理單位對胸管拔管後的觀察更為嚴謹。