— 基本照護與舒適 · MEDIUM · SATA —
病人有約束醫囑，護理師應採取哪些行動？（選所有適合的）
A client has an order for restraints. Which nursing actions are required? (Select all that apply.)
- ACheck for circulation and skin integrity every 1-2 hours✓ 正解每 1-2 小時檢查循環與皮膚完整性
- BAttach restraints to a non-movable part of the bed frame✓ 正解將約束帶固定在床架不可移動的部分
- CUse a slip knot for easy release✓ 正解使用活結以便快速解開
- DCheck the client's needs for toileting and nutrition✓ 正解檢查客戶如廁與營養需求
- EApply restraints as tightly as possible to ensure safety盡可能緊密地施加約束以確保安全
— Explanation · 中文詳解 —
約束（Restraints）是限制病人自由的最後手段，必須嚴格執行安全監測。護理師需定期評估約束部位的血液循環（Neurovascular check）與皮膚完整性，約束物必須綁在床架不可移動部位以防拉傷，且需使用快拆結（Slip knot）以便緊急時迅速移除。此外，必須定時提供如廁、水分與營養需求，以維護基本人權。
Required nursing actions include checking circulation and skin integrity every 1-2 hours, attaching restraints to non-movable bed frames, using a slip knot for quick release, and monitoring basic needs like toileting. Restraints should never be applied tightly, as this risks skin breakdown and ischemia.
✦ 台美臨床差異
在美國，約束使用受到極其嚴格的法律規範（JCAHO/CMS），醫囑必須是「Time-limited」（通常每24小時重開），且必須詳細記載「Least Restrictive Environment」（最少限制環境）的評估過程。