— 降低風險 · HARD · SATA —
護理師照護一位攜帶胸管的病人。下列哪項發現需要立即通知醫師？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings indicate the need for immediate notification of the healthcare provider? (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 level in the water-seal chamber with respirations水封瓶內液面隨呼吸波動
- DSubcutaneous emphysema around the insertion site✓ 正解插管周圍出現皮下氣腫
- EThe chest tube becomes disconnected from the drainage system✓ 正解胸管與引流系統脫離
— Explanation · 中文詳解 —
胸管護理重點在於監測氣漏與引流性質。連續性氣泡表示氣漏（水封瓶應僅有隨呼吸波動的氣泡）。急性大量出血（>100mL/hr）或皮下氣腫擴大均顯示病情惡化。管路脫落則為緊急狀況，需立即執行緊急封閉措施並通知醫師。
Immediate notification is required for continuous bubbling in the water-seal chamber (indicating a significant air leak), drainage of 150 mL of bright red blood in one hour (suggesting hemorrhage), subcutaneous emphysema (indicating tissue air leakage), and disconnection of the chest tube. Tidaling with respiration is a normal finding.
✦ 台美臨床差異
美國護理師常執行「緊急處理後立即回報」；台灣護理師通常會先通知醫師或值班醫師，並準備無菌敷料協助處置。