— 降低風險 · HARD · SATA —
護理師照顧一位新置入胸管的病人。哪些發現顯示可能出現併發症？（選所有適合的）
A nurse is caring for a client with a new chest tube. Which findings indicate a potential complication? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSubcutaneous emphysema✓ 正解皮下氣腫
- CFluctuation of the water seal level with respiration水封瓶水位隨呼吸波動
- DSudden decrease in chest tube drainage output✓ 正解胸管引流液突然減少
- ETracheal deviation toward the unaffected side✓ 正解氣管向未受影響側偏移
— Explanation · 中文詳解 —
胸管置入後的併發症監測極為重要。A（水封瓶持續冒泡）提示系統有氣漏；B（皮下氣腫）表示空氣進入皮下組織；D（引流物突然減少）常提示胸管阻塞或扭曲；E（氣管偏移）是張力性氣胸的徵象，屬緊急醫療狀況。C（波動）為正常現象。
Continuous bubbling in the water seal chamber indicates an air leak in the system, while subcutaneous emphysema suggests air has escaped into the tissue. A sudden decrease in drainage may signal tube obstruction, and tracheal deviation toward the unaffected side is a critical sign of tension pneumothorax.
✦ 台美臨床差異
胸管護理在美台兩地均由護理師高度監測；美國護理師常依據 protocol 判斷是否調整抽吸壓力，台灣則多由醫師執行調整。