— 降低風險 · HARD · SATA —
護理師照護一位因氣胸放置胸管的病人，下列哪些發現需立即通報醫師？（選所有適合的）
A nurse is caring for a client with a new chest tube for a pneumothorax. 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
- B200 mL of bright red blood in the drainage chamber within one hour✓ 正解引流瓶內一小時內有 200 mL 鮮紅色血液
- CAbsence of tidaling in the water seal chamber水封瓶內無潮汐波動
- DSubcutaneous emphysema around the insertion site插管周圍有皮下氣腫
- EThe chest tube becomes disconnected from the drainage system✓ 正解胸管與引流系統脫離連接
— Explanation · 中文詳解 —
胸管護理的紅旗警訊包含持續性氣泡（代表空氣外漏，氣胸未改善）、短時間大量出血（可能為活動性出血）、以及管路脫落（造成張力性氣胸）。C 和 D 需視情況評估，但不一定需立即通報，通常代表肺部復張或輕微滲漏。
Continuous bubbling in the water seal chamber indicates a persistent air leak, suggesting the pneumothorax is not resolving. Large volumes of bright red blood (>100 mL/hr) signal active hemorrhage requiring immediate attention. Additionally, a disconnected chest tube is an emergency as it allows atmospheric air to enter the pleural space, potentially causing a tension pneumothorax.
✦ 台美臨床差異
美國護理師常被訓練在胸管脫落時立即採取急救措施；台灣護理作業較傾向依從醫師指示或由醫師操作。