— 生理適應 · MEDIUM · MCQ —
護理師照護一位放置胸管的病人，哪項發現應立即通報醫師？
A nurse is caring for a client with a chest tube. Which finding should be reported to the provider immediately?
- ASmall amount of sanguineous drainage少量血性引流液
- BOscillation of the fluid in the water seal chamber水封瓶內液面隨呼吸波動
- CContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- DSubcutaneous emphysema at the insertion site置管處出現皮下氣腫
— Explanation · 中文詳解 —
胸管水封瓶出現持續氣泡（Continuous bubbling）代表胸膜腔存在持續性漏氣，通常指向肺部有破口或連接處密合不良。波動（Oscillation）是正常呼吸現象，少量血性引流常見於術後，皮下氣腫需監測但非立即致命，持續氣泡代表系統失效或肺損害惡化。
Continuous bubbling in the water seal chamber indicates a persistent air leak within the system or from the lung, requiring immediate intervention. In contrast, tidaling and small amounts of drainage are normal postoperative findings.
✦ 台美臨床差異
美國護理師在胸管照護的判讀上擁有較高權限；台灣護理師多需醫師確認管路位置後才進行後續處理。