— 降低風險 · MEDIUM · SATA —
胸管引流病人出現哪些徵象時，護理師需立即回報？（選所有適合的）
Which assessment findings should a nurse report immediately for a client with a chest tube? (Select all that apply.)
- AContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
- BClient reports sharp chest pain with inspiration病人主觀深呼吸時感到劇烈胸痛
- CDrainage of 150 mL bright red blood in one hour✓ 正解一小時內引流鮮紅色血液 150 mL
- DFluctuation of water in the water seal tube with breathing水封管內水位隨呼吸波動
- ESubcutaneous emphysema around the insertion site✓ 正解插管周圍出現皮下氣腫
— Explanation · 中文詳解 —
胸管系統需監測異常徵象：水封瓶持續氣泡代表氣胸未癒或系統漏氣；每小時超過 100-150 mL 的鮮紅色出血暗示出血性休克；皮下氣腫擴大則代表氣體滲漏至組織間隙。胸痛與水封瓶隨呼吸波動屬於常見臨床觀察項目。
Continuous bubbling in the water seal chamber indicates a system leak or persistent air leak, while excessive bright red drainage suggests hemorrhage. Subcutaneous emphysema can also signal a significant air leak that may compromise the airway if it spreads. These findings require immediate intervention.
✦ 台美臨床差異
台美護理師對於胸管照護的規範相似，重點均在於維持密閉系統與監測氣胸復發狀況。