— 降低風險 · HARD · SATA —
護理師評估一位胸管引流病人的系統，哪些發現需要立即介入？（選所有適合的）
A nurse is assessing a client with a chest tube 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
- CSubcutaneous emphysema palpated around the insertion site✓ 正解插入部位周圍觸及皮下氣腫
- DDrainage output of 250 mL in the last hour✓ 正解最後一小時的引流輸出量為250毫升
- EThe chest tube is disconnected from the drainage device✓ 正解胸管與引流裝置斷開連接
— Explanation · 中文詳解 —
胸管系統的異常需即刻處理以避免張力性氣胸。A（水封瓶持續冒泡）提示氣體持續外洩；C（皮下氣腫）表示氣體逸散至皮下；D（大量引流）提示活動性出血；E（管路脫落）會造成氣胸。B 是呼吸時的正常水封波動，代表管路通暢，無需干預。
Continuous bubbling in the water seal chamber indicates an air leak that requires investigation. Subcutaneous emphysema suggests air leakage into tissues, excessive drainage may indicate hemorrhage, and a disconnected tube can cause a pneumothorax. Tidaling is a normal finding indicating system patency.
✦ 台美臨床差異
美國醫院多使用乾式或濕式系統並有嚴格 SOP；台灣臨床偶見使用水封瓶過舊或管路固定強度不足。