Enema

•      A solution introduced into the rectum and sigmoid colon to remove feces and/or flatus.

Types of enema: Cleansing enema

·         Prevent the escape of feces during surgery. Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g. colonoscopy). Constipation or impaction.

·         Large volume cleansing enema: A total of ___ to ___ml of solution should be administered. Small volume cleansing enema. Amount of solution administered depends on (name 2): 

1.

2.

·         Cleansing enema: (high): Given to cleanse as much of the colon as possible. Left lateral position to the dorsal recumbent position and then to the right lateral position during the administration so that the solution can follow the large intestine. The solution container is usually held 12 to 18 inches above the rectum because the fluid is instilled farther to clean the entire bowel. Cleansing enema (low): Cleanse the rectum and sigmoid colon. Maintains a left lateral position during administration.

Carminative enema:

•      Distends the rectum and colon with gas released from the enema solution. For an adult, 60 to 80 mL is instilled.

Retention enema:

·         Introduces oil or medication into the rectum (types):

1.       Antibiotic:

2.       Anthelmintic:

3.       Nutritive:

Return-flow enema:

·         ______ ______. Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis. Repeated five or six times until the flatus is expelled and abdominal distention is relieved.

Commonly used enema solutions (Table 46-4; p. 1241)

•      Hypertonic: 90 to 120 mL of solution (e.g. sodium phosphate). Example: _____ _________ _____. Action: Draws water into the colon. Effective in 5 to 10 minute.  Adverse effects: Retention of sodium. Critical thinking: Sylvia tells the nurse she routinely uses a Fleets Enema to keep her bowels regular. The nurse asks Sylvia, “Are you taking any vitamin supplements?” Why should Sylvia take vitamin supplements with prolonged use of Fleets enema?

 

•      Hypotonic:  500 to 1,000 mL of tap water. Distends colon, stimulate peristalsis, and softens feces. Effective in 15 to 20 minutes. Fluid and electrolyte imbalance; water intoxication.

•      Isotonic: 500 to 1,000 mL of NS. Distends colon; stimulates peristalsis, and softens feces. Effective in 15 to 20 minute. Adverse effects: Possible sodium retention.

•      Soapsuds: 3-5 mL soap to 1,000 mL water. Irritates mucosa, distends colon. Effective in 10 to 15 minutes. Adverse effects: Irritates and may damage mucosa.

•           Oil: 90 to 120 mL. Name 3 types:  

1.

2.

3.

•      Lubricates the feces and the colonic mucosa. Effective in ½ to 3 hours.

1.       Case Study: You are teaching, Mr. Rose, about the various types of enemas. What type of enema solutions poses the greatest risk for fluid and electrolyte imbalances and water intoxication?

2.       Mr. Rose will be undergoing a sigmoidoscopy requiring visualization of the anus, rectum, and sigmoid colon. What type of enema do you plan to administer?

3.        A fellow nursing student asks you, “What type of enema distends the rectum and colon with gas released from the enema solution?” How would you respond?

•      Clinical alert: Some clients may wish to administer their own enemas. If this is appropriate, validate the client’s knowledge of correct technique and assist as needed.

Administering an Enema

•      Assess:  Last bowel movement (amount, color, and consistency), abdominal distention, and sphincter control. Whether the client uses toilet, commode, or bedpan

Planning

•      Is a physician’s order required? If the client has kidney or cardiac disease that contraindicates the use of a _________solution. Delegation to the UAP. Equipment: Disposable linen-saver pad, bath blanket, bedpan or commode, clean gloves, water-soluble lubricant if tubing not prelubricated, and paper towel.

•      Large Volume enema: Solution container with tubing of correct size and tubing clamps, correct solution, and amount. IV pole. Temperature of the solution is between ____ to ____ degrees.

•      Small volume enema: prepackaged container of enema solution with lubricated tip.

•       

Preparation

•      Lubricate about 2 inches of the rectal tube. Run some solution through the connecting tubing of a large-volume enema set and the rectal tube to expel any air in the tubing; then close the clamp.

Performance

•      Patient education.

•        

•      Wash hands and apply clean gloves. Provide for client privacy. During an enema, the client should be asked to lie in the ____ _______ position. The right leg as acutely flexed as possible and the linen saver pad under the buttocks.

•       

•      For clients in the left lateral position, lift the upper buttock to ensure good visualization of the anus. Insert the tube smoothly and slowly into the rectum, directing it toward the umbilicus.

•       

•      Adult: Insert the tube ___to ___inches. Infant: 1 to 1.5 inches. Child: 2 to 3 inches.  Critical Thinking: You encounter resistance at the internal sphincter during insertion of an enema tube into the Mr. Rose. What should you do?

 

•      Never force tube or solution entry.

•       

•      Raise the solution container, and open the clamp to allow fluid flow OR compress a pliable container by hand. During low enemas hold or hang the solution container no higher than 12 inches and high enema (18 inches).

•       

•           Critical Thinking: During a tap water enema, Mr. Staples complains of abdominal cramping. What should be your first response to the complaint?

 

•      If you are using a plastic commercial container, roll it up as the fluid is instilled. Prevents suctioning of the solution.

•      After all the solution has been instilled or when the client cannot hold any more and feels the desire to defecate, close the clamp, and remove the rectal tube from the anus. Place the rectal tube in a disposable towel as you withdraw it. Ask the client to remain lying down.

•       

•      Request that the client retain the solution for the appropriate amount of time.

•       

•      Assist the client to defecate in a sitting position on the bedpan, commode, or toilet. Ask the client who is using the toilet not to flush it so feces can be observed. If a specimen of feces is required, ask the client to use a bedpan or commode.

Incontinent Client

•      After the rectal tube is inserted, the client assumes a supine position on a bedpan. HOB elevated 30 degrees. Pillows to support the client’s head and back.

Documentation:

•      Type of solution, length of time solution was retained, the amount, color, and consistency of the returns, and the relief of flatus and abdominal distention. Critical Thinking: A nursing student, Shawn Brown, charts the following information after an enema procedure. What information did Shawn forget to document? Enema administered. Pt retained solution for 5 minutes with return of 500 cc light brown liquid stool. Pt reports + relief of flatus and abdominal distention. Shawn Brown, GCSU, SN I.

 

•      (Read Lifespan Considerations, p. 1244). True or False. Tap water enemas are not usually given to children and infants because of the danger of fluid imbalances. ___

•      Items A through G are the steps for enema administration. Number these steps in the order that should be followed.

a.       Lubricate the tip of the tube with a water-soluble lubricant. ___

b.       Reclamp the tube and remove it; instruct the client to retain the solution as long as possible. ___

c.       Position the client in a Sims’ position. ___

d.       Raise the container 18 inches above the anus; allow the solution to flow for 5 to 10 minutes. ___

e.       Provide privacy. ___

f.        Separate the anus and assess the anus area; insert the tube gently while instructing the client to take a deep breath. ___

g.       Open the clamp on the tubing to remove air and reclamp the tubing. ___

•      Answers: a). 4 b). 7 c). 2 d). 6 e). 1 f). 5 g). 3

•      After viewing the 15 minute Bowel Elimination Video, answer the fecal impaction case study.

1.       Mr. Johnson is scheduled to be disimpacted. What type of enema should be given before this procedure?

 

2.       True or False. When removing a fecal impaction, the nurse uses a “hooking motion” of the index finger.

3.       The digital removal of an impaction should be carried out gently because of vagal nerve stimulation that could (decrease or increase) the cardiac rate?