What must accompany the use of restraints to ensure safety?

• A. A one-time initial assessment
• B. Weekly evaluation
• C. Ongoing assessment and reevaluation every 24 hours
• D. No assessment required

Answer: (C)

Ongoing assessment and reevaluation are essential whenever restraints are used. Allowing restraints to stay in place without regular review can hide evolving problems and delay needed interventions, placing the patient at risk for injury. The patient must be continually monitored for both safety and potential complications, and the plan should be updated as the situation changes.

Clinically, this means performing regular checks of circulation, sensation, and movement in the restrained limbs; monitor skin integrity for pressure or chafing; look for signs of reduced perfusion such as cool or pale extremities, swelling, or numbness. Also track vital signs, respiratory status, pain, and comfort; ensure the patient can maintain hydration and toileting as feasible; and verify that the restraint remains properly fitted and not too tight, with a two-finger clearance when appropriate. Documentation should reflect findings, actions taken, and whether the restraint continues to be medically necessary.

Reevaluation every 24 hours allows the healthcare team to determine if the restraint is still required, whether a less restrictive option is possible, and when it’s safest to remove it. This approach reduces risks of injury and supports timely de-escalation and recovery.