— 降低風險 · HARD · SATA —
護理師照護一位放置胸管的病人。下列哪些發現應立即報告醫師？（選所有適合的）
A nurse is providing care to a client who has a chest tube. Which findings should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BDrainage of 150 mL of bright red blood in 1 hour✓ 正解一小時內引流出 150 mL 鮮紅色血液
- CFluctuation of the fluid in the water seal chamber with respiration水封瓶內液面隨呼吸波動
- DThe client reports sharp pain during deep inspiration病患報告深層吸氣時有尖銳疼痛
- ESubcutaneous emphysema noted around the insertion site✓ 正解插管周圍發現皮下氣腫
— Explanation · 中文詳解 —
胸管照護的緊急指標包括：水封瓶持續冒泡（代表系統漏氣）、短時間內引流量過大（代表活動性出血）以及皮下氣腫（代表管路移位或引流不全）。選項 C 為正常呼吸波動；選項 D 術後疼痛雖需處理，但不屬緊急管路問題。
Continuous bubbling in the water seal chamber indicates an air leak, excessive bright red drainage suggests active hemorrhage, and subcutaneous emphysema implies air escaping into tissues; all require immediate provider notification. Normal fluctuation with respiration and expected post-procedural pain do not constitute emergencies.
✦ 台美臨床差異
美台護理對胸管護理標準一致，重點均在於維持密閉系統完整性與觀察引流性質。