# 一名護理師於開胸術後12小時照顧裝有wet-suction water-seal胸管引流系統的病人。下列何者應立即通知醫師?(複選)

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=zh-tw  
> language: zh-TW  
> subject: Complications of Procedures  
> category: ROR

## 題目

一名護理師於開胸術後12小時照顧裝有wet-suction water-seal胸管引流系統的病人。下列何者應立即通知醫師?(複選)

1

Water-seal室持續冒泡(continuous bubbling)

2

過去1小時250 mL鮮紅色出血引流

3

突發氣泡與tidaling消失合併新發呼吸困難

4

過去1小時60 mL漿液血性引流

5

隨呼吸同步之輕微tidaling

## 解析

Water-seal室持續冒泡顯示系統或肺漏氣 — 應立即查找。氣泡與tidaling消失合併新呼吸困難可能為管阻塞或肺重新膨脹。1小時250 mL鮮紅出血超出正常開胸術後預期,可能胸腔內出血。1小時60 mL漿液血性與呼吸同步tidaling為術後初期正常所見。

## 深入解析

臨床判斷
胸管核心: Tidaling=系統暢通;咳嗽時間歇冒泡=早期正常;持續冒泡=漏氣;Tidaling與冒泡皆消失=阻塞或完全再膨脹。突發鮮紅引流>100 mL/小時或連續數小時>200 mL/小時=外科出血。

記憶口訣
Tidaling正常;持續冒泡異常;Tidaling消失+呼吸困難=查;>100 mL/h鮮紅=外科

韓 vs 美
STS與臺灣胸腔外科醫學會一致: 插入部位密閉敷料、系統低於胸部、不可常規夾管、每小時記錄引流量、每班記錄tidaling與冒泡。兩地皆採用數位式胸引(若可用)。

## 臨床情境

臨床指引
胸管護理:
- 系統低於胸部,絕不舉高過胸
- Tidaling: 自主呼吸者吸氣上升、吐氣下降(機械通氣相反)。確認暢通。
- 冒泡: 咳嗽或活動時間歇=早期正常;持續=漏氣(系統或肺)
- 引流臨界: >100 mL/小時鮮紅或突變需通報
- 漏氣流程: 檢查接頭→依協議於插入端短暫夾管以定位;不可常規夾管
- 意外脫管: 4x4紗布貼三邊(可用凡士林紗布);不可全封閉
- 脫接: 胸管末端浸入無菌水2-4 cm並通報醫師

注意
張力性氣胸發生快速: 呼吸音消失、氣管偏移、低血壓、JVD、嚴重不適。緊急: 於第二肋間鎖骨中線穿刺減壓後置入胸管。

## 重要概念

- **Tidaling** — Water-seal室液面隨自主呼吸吸氣上升、吐氣下降(機械通氣相反)。表示系統暢通且胸膜密合完整。Tidaling消失=阻塞、扭結或肺完全再膨脹。
- **漏氣(持續冒泡)** — Water-seal室持續冒泡顯示空氣進入胸膜腔(肺漏氣)或系統漏氣。依協議於插入處短暫夾管定位;若冒泡停止則為肺源。通報醫師。
- **張力性氣胸** — 單向閥效應使胸膜腔空氣累積、壓力上升、縱膈偏移、循環崩潰之危及生命狀況。徵象: 呼吸音消失、氣管偏向健側對側、低血壓、JVD、嚴重痛苦。急救: 第二肋間鎖骨中線穿刺減壓,後置胸管。

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