— 降低風險 · MEDIUM · SATA —
護理師觀察一位放置胸管的病人，哪些發現需要立即介入？（選所有適合的）
A nurse is monitoring a client who has a chest tube. Which findings indicate the need for immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封腔內持續冒泡
- BFluctuation of the fluid in the water seal chamber with respiration水封腔內液體隨呼吸波動
- CSubcutaneous emphysema noted around the insertion site✓ 正解插管周圍出現皮下氣腫
- DAn output of 200 mL of bright red blood in one hour✓ 正解一小時內排出200 mL鮮紅色血液
- EThe chest tube is disconnected from the drainage system✓ 正解胸管與引流系統脫離
— Explanation · 中文詳解 —
胸管系統中，水封瓶持續冒泡（A）代表系統有空氣洩漏；皮下氣腫（C）代表空氣滲漏至皮下組織；短時間內引流量過大（D）提示術後出血；引流管斷開（E）會造成氣胸危險。呼吸時的水封瓶液面波動（B）是正常的臨床表現，無需過度擔憂。
Immediate intervention is required for continuous bubbling in the water seal chamber, which indicates an air leak, and subcutaneous emphysema, suggesting air leakage into tissues. Additionally, excessive drainage of bright red blood signals potential hemorrhage, and a disconnected tube risks tension pneumothorax due to loss of negative pressure. Fluctuation with respiration is a normal finding and does not require intervention.
✦ 台美臨床差異
美國醫院針對胸管脫落通常有標準化的緊急夾具包（clamp kits）在床邊；台灣亦有相關規範，但操作流程更強調醫師介入的時效性。