— 安全與感染控制 · MEDIUM · SATA —
評估中若發現下列哪些跡象，顯示病人可能發生肢體約束帶的併發症？（選所有適合的）
Which assessment findings indicate that a client is experiencing a potential complication of physical restraints? (Select all that apply.)
- ASkin pallor distal to the restraint✓ 正解約束帶遠端皮膚蒼白
- BAbsent pedal pulses✓ 正解足背脈搏消失
- CCapillary refill of 2 seconds毛細血管再充盈時間為 2 秒
- DCool extremities below the restraint✓ 正解約束帶下方肢體末端冰冷
- ENumbness and tingling sensation✓ 正解麻木與刺痛感
— Explanation · 中文詳解 —
肢體約束（Physical Restraints）若過緊會導致末梢血液循環受阻（動脈灌流不足）或神經壓迫。護理師必須定時檢查約束處遠端（Distal）的循環、感覺與運動功能（Neurovascular Status）。若出現蒼白、脈搏消失、溫度下降或感覺異常，皆為嚴重併發症徵兆，需立即鬆開約束帶並評估。
Physical restraints that are too tight can impair distal peripheral circulation (decreased arterial perfusion) or compress nerves. The nurse must routinely check neurovascular status distal to the restraint, including circulation, sensation, and motor function. Pallor, absent pulses, decreased temperature, and abnormal sensation are all signs of serious complications and require immediate release of the restraint and reassessment.