— 生理適應 · HARD · SATA —
護理師照顧使用胸管引流的病人。下列哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings require immediate action by the nurse? (Select all that apply.)
- AConstant bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BDrainage of 200 mL of bright red blood in one hour✓ 正解一小時內引流 200 mL 鮮紅色血液
- CSubcutaneous emphysema noted around the insertion site✓ 正解插管處周圍發現皮下氣腫
- DTidaling in the water seal chamber水封瓶內出現潮汐現象
- EFluctuation of the fluid level with respiration液面隨呼吸波動
— Explanation · 中文詳解 —
胸管水封瓶持續冒泡（A）表示系統漏氣；一小時內超過 100-200 mL 的血性引流（B）暗示活動性出血；皮下氣腫（C）代表空氣滲入皮下組織，均為緊急警訊。Tidaling（D）與呼吸時的波動（E）為正常水封瓶運作現象，表示管路通暢，無需特別介入。
Constant bubbling in the water seal chamber indicates an air leak, excessive bright red drainage suggests active hemorrhage, and subcutaneous emphysema signals air leakage into tissues; all require immediate nursing intervention. In contrast, tidaling and fluctuation with respiration are normal findings indicating system patency.
✦ 台美臨床差異
美國護理師對於胸管脫落或漏氣有明確的緊急處理流程，台灣護理師通常會儘速呼叫醫師協助處理。