— 生理適應 · MEDIUM · SATA —
病人肺葉切除術後置放胸管，護理師應回報哪些發現？（選所有適合的）
A nurse is caring for a client with a chest tube following a lobectomy. Which findings should the nurse report to the provider? (Select all that apply.)
- A200 mL of bright red blood in the drainage system within one hour✓ 正解一小時內引流系統中有200 mL鮮紅色血液
- BContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- CFluctuation of the fluid in the water seal chamber during respiration呼吸時水封瓶內液面波動
- DSubcutaneous emphysema around the insertion site✓ 正解插入部位周圍有皮下氣腫
- EAbsence of tidaling in the water seal chamber after 3 days三天後水封瓶內無潮汐現象
— Explanation · 中文詳解 —
胸管護理重點在於監測出血量、空氣洩漏與閉合完整性。一小時內超過 100-150 mL 的鮮紅色出血代表活動性出血；水封瓶持續冒泡代表有氣胸；皮下氣腫代表空氣外洩至皮下組織。水封瓶波動為正常現象，消失可能代表阻塞。
The nurse should report excessive bright red drainage (over 100-150 mL/hour), continuous bubbling in the water seal indicating an air leak, and subcutaneous emphysema suggesting air leakage into tissues. Tidaling is a normal finding, and its absence after several days may indicate lung re-expansion or tube obstruction rather than an acute emergency requiring immediate reporting in the same manner.
✦ 台美臨床差異
美國護理師常負責胸管引流瓶的維護與評估，台灣則有時由照護團隊醫師共同監測。