— 降低風險 · MEDIUM · SATA —
胸管引流病人出現下列哪些情況時，護理師應立即通知醫師？（選所有適合的）
Which of the following findings in a client with a chest tube should the nurse report to the 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 one hour✓ 正解一小時內引流 150 mL 鮮紅色血液
- CFluctuation of the fluid in the water seal tube during respiration呼吸時水封管內液面波動
- DSubcutaneous emphysema around the insertion site✓ 正解插管周圍出現皮下氣腫
- EThe client reports mild chest discomfort during deep breathing病人在深呼吸時報告輕微胸部不適
— Explanation · 中文詳解 —
胸管照護的紅旗指標包括：水封瓶持續冒泡（顯示氣胸未癒或管路漏氣）、短時間內大量出血（顯示活動性出血）、皮下氣腫（顯示氣體外漏至皮下組織）。波動（Tidaling）為正常物理現象；輕微不適為術後常見反應。
Continuous bubbling in the water seal chamber, excessive bright red drainage, and subcutaneous emphysema all indicate complications such as air leaks or hemorrhage. These findings require immediate provider notification to prevent further client deterioration.
✦ 台美臨床差異
美國護理師常需自行判斷並排除管路漏氣後回報；台灣護理師通常在發現問題時直接通知醫師處理。