一位78歲男性因肺炎正插著氣管內管使用呼吸器。隨著鎮靜藥物減量，他變得焦躁不安，並兩度用力抓住氣管內管試圖將其拔出。生命徵象：血壓 145/88 mmHg，心跳 118 次/分，血氧 93%。在嘗試口頭安撫與使用乒乓球手套皆無效後，護理師對其使用了雙側軟式手腕約束帶。護理師必須遵循下列哪一項關於身體約束的法律與安全要求？
A 78-year-old male with pneumonia is intubated on a mechanical ventilator. As sedation is decreased, he becomes agitated and forcefully grasps his endotracheal tube twice in an attempt to pull it out. Vital signs: BP 145/88 mmHg, HR 118 bpm, SpO2 93%. After attempting verbal redirection and applying hand mittens without success, the nurse applies bilateral soft wrist restraints. Which legal and safety requirement regarding physical restraints must the nurse follow?
- ATie the restraint straps firmly in a sturdy square knot directly to the side rails to prevent the patient from sliding down the bed.將約束帶以穩固的平結直接綁在床欄上，以防止病人滑下床
- BEnsure the provider conducts an in-person face-to-face assessment of the patient within 1 to 24 hours of initiating the restraints, depending on facility policy.確保醫師在開始使用約束後的1至24小時內（依機構政策而定）對病人進行面對面的實地評估正確答案
- CObtain a PRN (as-needed) prescription from the provider so restraints can be removed and reapplied at the nurse's discretion over the weekend.取得醫師的PRN（需要時）處方，以便護理師在週末期間自行決定移除和重新綁上約束帶
- DRemove the restraints strictly every 4 hours to assess skin integrity, pulse, and capillary refill of the restrained extremities.嚴格每4小時解除約束帶一次，以評估受約束肢體的皮膚完整性、脈搏及微血管充填時間
- B確保醫師在開始使用約束後的1至24小時內（依機構政策而定）對病人進行面對面的實地評估
本題測驗使用身體約束（Physical Restraints）的聯邦醫療保險中心（CMS）強制法規。約束會侵犯病患人身自由，僅能做為保護其不拔除維生管路的最後手段。法律嚴格禁止針對約束開立長期或「需要時（PRN）」醫囑（選項C錯誤）。當緊急啟動約束後，主治醫師（或授權開單者）必須親自到病床邊進行面對面評估（Face-to-face assessment），以確認約束的必要性，這通常被嚴格規定在約束後的 1 至 24 小時內完成（選項B正確）。在約束期間，護理師必須每 2 小時（而非 4 小時）鬆開約束帶以評估周邊皮膚完整性、脈搏及微血管充血，並提供關節活動（選項D錯誤）。約束帶必須使用能快速解開的單向活結（Quick-release knot），且只能綁在會隨著床頭升降移動的床架結構（Bed frame）上，絕對不可綁在可移動的床欄（Side rails）上，否則升降床欄時會扯斷病患手臂（選項A錯誤）。
- A將約束帶以穩固的平結直接綁在床欄上，以防止病人滑下床
約束帶必須以快速解開的活結綁在床架穩定的結構組件上，絕不可綁在會移動的床欄，那會造成機械性損傷。
- B · 正確答案確保醫師在開始使用約束後的1至24小時內（依機構政策而定）對病人進行面對面的實地評估
聯邦指引嚴格規定在實施約束後，醫師必須進行面對面的評估，以確立這種極端剝奪人身自由的必要性。
- C取得醫師的PRN（需要時）處方，以便護理師在週末期間自行決定移除和重新綁上約束帶
「需要時（PRN）」的約束醫囑被所有監管機構嚴格禁止；每一次使用約束都需要明確的、有時間限制的臨床理由。
- D嚴格每4小時解除約束帶一次，以評估受約束肢體的皮膚完整性、脈搏及微血管充填時間
皮膚完整性、血管灌流以及關節活動度評估，必須至少每 2 小時執行與紀錄一次，而非 4 小時。
台美面臨暴力或拔管風險的處理一致。但美國對於護理紀錄跟醫師開立醫囑（禁開 PRN）的法律追訴嚴苛，病房會針對約束進行嚴謹的跨班次督考；台灣雖然醫院評鑑也有標準，但臨床有時會遇到醫師預先開好護理常規讓護理師全權處理約束的事實落差。實際要求可能受聯邦法、州法、州護理委員會規則與機構政策影響；本題依題幹所示護理原則作答。
English explanation
This question tests the Centers for Medicare and Medicaid Services (CMS) federal regulations regarding the use of physical restraints. Restraints infringe on personal liberty and may be used only as a last resort to prevent the patient from removing life-sustaining devices. Long-standing or 'as needed' (PRN) orders for restraints are strictly prohibited by law (Option C is incorrect). After emergent application of restraints, the provider (or authorized prescriber) must perform a face-to-face assessment at the bedside to validate the necessity of restraint, typically required within 1 to 24 hours after restraint application (Option B correct). During restraint use, the nurse must release the restraints every 2 hours (not every 4 hours) to assess peripheral skin integrity, pulses, and capillary refill, and to provide range-of-motion exercises (Option D incorrect). Restraints must be tied with a quick-release knot and secured only to a stationary structural component of the bed frame that moves with the head of the bed; they must never be tied to movable side rails, because raising or lowering the rails could tear the patient's arm (Option A incorrect).
最近修訂：2026-10-06