以下哪些護理措施展現了正確使用身體約束的方式？（選所有適合的）
Which of the following nursing interventions demonstrate the correct use of physical restraints? (Select all that apply.)
- AAttaching the restraint to the side rail將約束帶綁在護欄上
- BEnsuring two fingers can fit between the restraint and skin✓ 正解確保約束帶與皮膚之間可放入兩指寬的空間
- CAssessing the client's skin integrity every 2 hours✓ 正解每 2 小時評估病人皮膚完整性
- DSecuring the restraint with a quick-release knot✓ 正解使用快速解開的結固定約束帶
- EDocumenting the reason for the restraint every 24 hours每 24 小時記錄使用約束帶的原因
使用身體約束必須謹慎且符合倫理。正確的操作包括確保約束帶不會過緊（應能放入兩指，以防血液循環受阻）、定期評估皮膚完整性（防止壓瘡與神經損傷），以及使用快速釋放結（quick-release knot），以便在緊急情況下迅速移除。約束帶應固定在床架（bed frame）的活動部分，避免隨床欄升降而對病人造成傷害。
The use of physical restraints must be cautious and ethical. Correct technique includes ensuring that the restraint is not too tight (two fingers should fit between the restraint and skin to prevent compromised circulation), regular assessment of skin integrity (to prevent pressure injury and nerve damage), and use of a quick-release knot for rapid removal in emergencies. The restraint should be tied to a non-moving part of the bed frame to avoid injury when the side rails are raised or lowered.
美國醫院對於身體約束的規範極為嚴格，通常要求護理師每 1-2 小時進行評估（視醫院政策），並詳細紀錄約束的原因與病人的反應。若無醫囑擅自約束或未正確紀錄，在美國法律下屬於非法剝奪人身自由。