下列何種評估結果顯示護理師必須重新評估病人的約束裝置？
Which of the following findings indicates the need for a nurse to reassess the client's restraints?
- AThe client is able to move their fingers in the restrained limb病人能在被約束的肢體中活動手指
- BThe restraint is secured to a non-movable part of the bed frame約束帶固定於床架不可移動的部分
- CThe client's peripheral pulses are palpable below the restraint site約束部位下方的周邊脈搏可觸及
- DThe skin beneath the restraint shows localized erythema✓ 正解約束處下方的皮膚出現局部紅斑
約束裝置（Restraints）的使用必須謹慎並定期監測，以預防併發症。核心護理目標在於確保約束部位的血液循環、神經功能及皮膚完整性。當發現皮膚出現紅斑（Erythema）時，這通常是局部壓力過大或摩擦導致的早期組織損害跡象，必須立即介入以防止惡化為壓力性損傷（Pressure Injury）。護理師應重新評估約束的鬆緊度、位置或考慮更換約束類型。
Localized erythema under a restraint indicates early tissue damage from pressure or friction, requiring immediate reassessment of tightness or positioning. While palpable pulses and finger movement suggest intact neurovascular status, skin integrity is paramount. Restraints must be secured to the bed frame, but any sign of skin breakdown necessitates intervention to prevent pressure injuries.
美國對於約束（Restraint）的規範極為嚴格（CMS Guidelines），必須有醫師開立限時醫囑（Time-limited order），且需頻繁進行神經血管評估（Neurovascular check）並詳細記錄，台灣臨床在執行時對醫囑時效與評估頻率的紀錄要求同樣嚴謹，但美國護理師在執行約束前，更強調必須先嘗試所有非約束性的替代方案（Alternatives）。