— 生理適應 · HARD · SATA —
護理師照顧一位放置胸管的病人，哪些發現需要立即介入處理？（選所有適合的）
A nurse is caring for a client with a chest tube. Which findings require immediate intervention? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BSubcutaneous emphysema noted around the insertion site插入部位周圍發現皮下氣腫
- C200 mL of bright red blood drainage in the last hour✓ 正解過去一小時內有 200 mL 鮮紅色血液引流
- DThe chest tube has become disconnected from the drainage system✓ 正解胸管與引流系統斷開連接
- EFluctuation of the fluid level in the water seal chamber水封瓶內液面波動
— Explanation · 中文詳解 —
胸管照護首重氣密與引流狀況。水封瓶持續氣泡代表系統有漏氣；一小時內引流量達 200 mL 屬於出血過多，需警覺活動性出血；胸管脫落會導致張力性氣胸。皮下氣腫通常提示漏氣但需觀察，波動現象則是正常的呼吸性胸腔壓力傳遞，不需介入。
Continuous bubbling in the water seal chamber indicates a persistent air leak, excessive bright red drainage suggests active hemorrhage, and disconnection of the chest tube risks tension pneumothorax; all require immediate nursing intervention. In contrast, tidaling (fluctuation) is a normal finding indicating system patency, and minor subcutaneous emphysema typically warrants monitoring rather than emergency action.
✦ 台美臨床差異
台美臨床皆嚴格要求備好無菌生理食鹽水，以備胸管脫落時立即進行水中封閉。