— 生理適應 · HARD · SATA —
胸管引流病人出現哪些症狀時，應懷疑是張力性氣胸？（選所有適合的）
Which assessment findings in a client with a chest tube indicate a potential tension pneumothorax? (Select all that apply.)
- ATracheal deviation toward the unaffected side✓ 正解氣管向未受損側偏移
- BAbsence of breath sounds on the affected side✓ 正解患側呼吸音消失
- CDistended neck veins✓ 正解頸靜脈怒張
- DHypotension and tachycardia✓ 正解低血壓與心跳過速
- EIncreased subcutaneous emphysema near the insertion site插入部位附近皮下氣腫增加
— Explanation · 中文詳解 —
張力性氣胸是致命的呼吸系統急症。因為胸膜腔壓力過大，會壓迫縱膈腔導致氣管偏移（偏向健側）、心輸出量減少（低血壓、心搏過速）、靜脈回流受阻（頸靜脈怒張），並出現患側呼吸音消失。皮下氣腫通常與空氣洩漏相關，非張力性氣胸的核心診斷指標。
Tension pneumothorax causes increased intrathoracic pressure that shifts the mediastinum, leading to tracheal deviation away from the affected side. This pressure compresses the lung, causing absent breath sounds, and impedes venous return, resulting in distended neck veins, hypotension, and tachycardia. These signs indicate a life-threatening emergency requiring immediate intervention.
✦ 台美臨床差異
美國 RN 需緊急通知醫師並準備減壓包，台灣護理師需確認是否有管路阻塞或扭曲，並準備針頭減壓。