— 降低風險 · HARD · MCQ —
護理師照護一位放置胸管的病人。下列哪項發現需要立即通知醫師？
A nurse is caring for a client with a chest tube. Which assessment finding requires immediate notification to the provider?
- APresence of subcutaneous emphysema around the site傷口周圍出現皮下氣腫
- BDrainage of 50 mL of serosanguineous fluid in the last hour過去一小時內引流出血清血性液體50 mL
- CFluctuation in the water seal chamber with respiration水封瓶內隨呼吸出現液面波動
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續性冒泡（Continuous bubbling）通常代表系統出現漏氣（Air leak），這意味著胸膜腔持續有空氣進入或系統密封性受損。正常的反應是隨呼吸波動（Tidaling），若是間歇性冒泡則代表空氣正被排除。持續冒泡會影響氣胸的復原，需檢查管路接口並通知醫師。
Continuous bubbling in the water seal chamber indicates an air leak within the chest tube system, which compromises the ability to re-expand the lung and requires immediate assessment. While tidaling is normal and subcutaneous emphysema is monitored, persistent bubbling suggests a breach in system integrity that needs prompt provider notification.
✦ 台美臨床差異
胸管護理在兩地皆屬嚴謹項目，但在美國護理師常需自行嘗試排除氣漏來源，台灣則多交由醫師處理。