— 降低風險 · HARD · SATA —
護理師照護一位放置胸管的病人。下列哪些評估結果應立即回報醫師？（選所有適合的）
A nurse is caring for a client with a chest tube. Which assessment findings should be reported to the provider immediately? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BFluctuation of fluid in the water seal chamber with respiration水封瓶內液體隨呼吸波動
- CSubcutaneous emphysema noted around the insertion site✓ 正解插入部位周圍出現皮下氣腫
- D200 mL of bright red blood drainage in the last hour✓ 正解過去一小時內有 200 mL 鮮紅色引流液
- EAbsence of tidaling in the water seal chamber when the lung has re-expanded肺部復張後水封瓶內無潮汐現象
— Explanation · 中文詳解 —
胸管護理的紅旗警訊包括：水封瓶持續氣泡（代表空氣外漏）、皮下氣腫（代表導管阻塞或氣體滲入組織）、以及短時間內大量鮮紅血液流出（代表活動性出血）。潮汐波動（Tidaling）正常隨呼吸起伏，若肺已擴張則潮汐消失為預期反應。
Continuous bubbling in the water seal chamber indicates a significant air leak, while subcutaneous emphysema suggests air escaping into tissues, and excessive bright red drainage points to active hemorrhage; all require immediate provider notification. Fluctuation (tidaling) is normal with respiration, and its absence is expected once the lung has fully re-expanded.
✦ 台美臨床差異
美國護理師常需自行判斷氣泡來源，台灣護理師則常會同呼吸治療師進行胸管照護與評估。