— 照護管理 · MEDIUM · SATA —
管理約束病人時，下列哪些措施是正確的？（選所有適合的）
Which actions are appropriate when managing a client in restraints? (Select all that apply.)
- ACheck the client's skin integrity and circulation every 2 hours✓ 正解每2小時檢查個案的皮膚完整性與循環狀況
- BEnsure the restraint is tied to the side rail of the bed確保約束帶綁在床欄上
- CObtain a new provider order every 24 hours✓ 正解每24小時取得新的醫師指示
- DPad the bony prominences to prevent pressure injuries✓ 正解在骨突處墊軟墊以預防壓瘡
- EProvide range of motion exercises during skin checks✓ 正解在檢查皮膚時提供關節活動範圍運動
— Explanation · 中文詳解 —
約束病人需遵守嚴格法規與倫理：必須每 2 小時檢查皮膚與末梢循環（A）；每日需醫師重新評估並開立新醫囑（C）；骨突處加襯墊防壓瘡（D）；檢查時執行關節活動度運動防攣縮（E）。B 選項錯誤：絕對不可將約束帶綁在床欄上，應綁在床架活動部位，避免床欄升降時造成傷害。
Restraints require strict monitoring, including checking skin integrity and circulation every two hours and padding bony prominences to prevent injury. Range-of-motion exercises should be performed during these checks to maintain joint mobility, and orders must be renewed daily per accreditation standards. Restraints must never be tied to side rails, as raising the rail could cause entrapment or injury.
✦ 台美臨床差異
美國對約束評估紀錄極為嚴格（CMS標準）；台灣臨床對此紀錄常因人力缺口而流於形式。