護理師為病人執行身體約束時，應採取哪些措施？（選所有適合的）
Which actions should the nurse take when applying a physical restraint to a client? (Select all that apply.)
- ASecure the restraint to the side rail將約束帶固定在床欄上
- BEnsure two fingers can fit under the restraint✓ 正解確保約束帶下能放入兩根手指
- CAssess neurovascular status every 2 hours每2小時評估神經血管狀況
- DObtain a written provider order within the facility timeframe✓ 正解在機構規定時間內取得醫師的書面醫囑
- ETie the restraint using a quick-release knot✓ 正解使用快速解結綁住約束帶
身體約束（Physical Restraint）的使用必須遵循「最少限制（Least Restrictive）」原則，僅在保護病人安全且其他替代方案無效時才可使用。約束的應用必須有醫囑支持，且需定期評估以確保病人安全。正確操作包括確保約束帶鬆緊度（容納兩指）、使用易解結（Quick-release knot）以便緊急情況快速移除，並嚴格遵守機構的醫囑時效規定。臨床上，約束帶必須綁在床架上（bed frame），而非側欄，以避免床體移動時造成病人肢體拉傷或勒傷。
When applying physical restraints, the nurse must ensure a valid provider order is obtained within the facility's timeframe. The restraint should be tied using a quick-release knot and secured to the bed frame, not the side rails, to prevent injury during bed movement. Circulation must be maintained by allowing two fingers to fit under the restraint, and neurovascular status should be assessed frequently, typically every 15 to 30 minutes.
美國醫院對於約束的監控極為嚴格，通常需每小時評估並記錄，且必須在 24 小時內獲得醫師重新確認的醫囑（Renew order），違規即視為嚴重違法行為。