A general guideline for the assessment of a restrained body part is removal of the restraint:

Question

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Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO],2004).If patient is violent or noncompliant,remove one restraint at a time and/or have staff assistance while removing restraints.Removal provides opportunity to change patient's position,offer nutrients,perform full ROJM,and toilet and exercise patient.
Following application,evaluate patient's condition for signs of injury every 15 minutes.Frequent assessments prevent injury to patient and removal of restraint at earliest possible time.If the patient shows no sign of impaired circulation or other complication,the restraint does not need to be removed at that time.
Following application,evaluate patient's condition for signs of injury every 15 minutes.Frequent assessments prevent injury to patient and removal of restraint at earliest possible time.If the patient shows no sign impaired circulation or other complication,the restraint does not need to be removed at that time.
If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior,this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patient's need for the restraint.

A General Guideline for the Assessment of a Restrained Body