— 生理適應 · MEDIUM · SATA —
一位裝有胸管引流系統的病人，下列哪些發現需要通知醫師？（選所有適合的）
A nurse is caring for a client with a chest tube drainage system. Which findings warrant notification of the healthcare provider? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BDrainage of 150 mL of bright red blood in one hour✓ 正解一小時內引出150 mL鮮紅色血液
- CFluctuation of the fluid level in the water seal chamber水封瓶內液面隨呼吸波動
- DSubcutaneous emphysema around the insertion site✓ 正解插入部位周圍出現皮下氣腫
- ESpO2 94% on room air在室溫下SpO2為94%
— Explanation · 中文詳解 —
胸管系統（Chest tube system）的監測對於術後病人至關重要，護理師需評估引流物性質、量及氣體漏氣情形。連續氣泡（Continuous bubbling）在水封瓶中，通常代表系統有漏氣；大量的鮮紅血液引流可能暗示活動性出血；皮下氣腫則顯示氣體外洩至皮下組織，皆為危急徵兆。波動（Fluctuation）是隨呼吸變化的正常物理現象；SpO2 94% 在術後初期通常屬於臨床可接受範圍，不需過度驚慌。
Continuous bubbling in the water seal chamber indicates a significant air leak requiring immediate attention, while excessive bright red drainage suggests potential hemorrhage. Subcutaneous emphysema also signals air leakage into tissues, whereas fluctuation and stable oxygen saturation are expected or acceptable findings.