ENEMAENEMA

Is a solution introduced into the Is a solution introduced into the rectum and large intestines.rectum and large intestines.

Action: to distend the intestine Action: to distend the intestine and sometimes to irritate the and sometimes to irritate the intestinal mucosa, thereby intestinal mucosa, thereby increasing peristalsis and the increasing peristalsis and the excretion of feces and flatus.excretion of feces and flatus.

The term enema is used to The term enema is used to refer to the process of refer to the process of instilling fluid through the instilling fluid through the anal sphincter into the anal sphincter into the rectum and lower intestine rectum and lower intestine for a therapeutic purpose. for a therapeutic purpose.

An enema administration is An enema administration is performed using a performed using a flexible flexible plastic rectal tube with plastic rectal tube with several large holesseveral large holes in the in the tip. This is connected to tip. This is connected to the tubing from a solution the tubing from a solution bag or container. bag or container.

An enema can also be performed An enema can also be performed using a using a prepackagedprepackaged solution solution that comes in a soft plastic that comes in a soft plastic bottle with a bottle with a pre-lubricated pre-lubricated rectal tip attached. Enema rectal tip attached. Enema solutions are prepared using solutions are prepared using plain tap water or saline, plain tap water or saline, soapsuds solutions, oil solutions, soapsuds solutions, oil solutions, or various medication solutions.or various medication solutions.

PurposesPurposes Relieves abdominal distention, Relieves abdominal distention,

constipation and discomfortconstipation and discomfort Stimulates peristalsisStimulates peristalsis Resumes normal bowel Resumes normal bowel

evacuationevacuation Cleanses and evacuates colonCleanses and evacuates colon

Cleanse the bowel before a Cleanse the bowel before a bowel exam or before bowel bowel exam or before bowel surgery.surgery.

Deliver medication directly Deliver medication directly onto the rectal mucous onto the rectal mucous membranes to be absorbed membranes to be absorbed into the bloodstream. into the bloodstream.

TYPES of EnemasTYPES of Enemas1.1. Cleansing enema-Cleansing enema- intended to intended to

completely remove feces. completely remove feces. Stimulates peristalsis through Stimulates peristalsis through large volumes of solutions.large volumes of solutions.

2.2. Carminative enema-Carminative enema- is given is given primarily to expel flatus. MGW primarily to expel flatus. MGW solution (magnesium 30ml, solution (magnesium 30ml, glycerin 60ml, water 90ml.)glycerin 60ml, water 90ml.)

TYPES of EnemasTYPES of Enemas1.1. Retention enema-Retention enema- introduces oil or introduces oil or

medication into the rectum and sigmoid medication into the rectum and sigmoid colon. The liquid is retained for a relatively colon. The liquid is retained for a relatively long period (e.g. 1-3 hours)long period (e.g. 1-3 hours)

a. Medicated Enema- a. Medicated Enema- contain pharmacological contain pharmacological therapeutic agents.therapeutic agents.

Sodium polystyrene (Kayexalate)- reduce Sodium polystyrene (Kayexalate)- reduce dangerously high serum potassium levels.dangerously high serum potassium levels.

Neomycin enema- reduce bacteria in the colon Neomycin enema- reduce bacteria in the colon before bowel surgery.before bowel surgery.

b. Oil retention enema-b. Oil retention enema- oil-based solution. oil-based solution.

Small volume, absorption of oil softens Small volume, absorption of oil softens stool.stool.

4. 4. Return flow enema –Return flow enema – used occasionally to used occasionally to expel flatus.expel flatus.

*alternating flow of 100 to 200 ml of *alternating flow of 100 to 200 ml of fluid into and out of the rectum and fluid into and out of the rectum and sigmoid colon stimulates peristalsis. This sigmoid colon stimulates peristalsis. This process is repeated five or six times until process is repeated five or six times until the flatus is expelled and abdominal the flatus is expelled and abdominal distention is relieved.distention is relieved.

TYPES of EnemasTYPES of Enemas

5. Tap water (hypotonic) enema-5. Tap water (hypotonic) enema- should not be repeated after first should not be repeated after first installation.installation.

6. Physiological normal saline-6. Physiological normal saline- is is safest. safest.

Used for infants and children. If Used for infants and children. If prepared at home mix 500 ml of tap prepared at home mix 500 ml of tap water with 1 teaspoon table salt.water with 1 teaspoon table salt.

TYPES of EnemasTYPES of Enemas

7. Hypertonic solution-7. Hypertonic solution- useful to patients useful to patients who can’t tolerate large volumes of who can’t tolerate large volumes of fluid. Only 120-180 ml (fleet enema)fluid. Only 120-180 ml (fleet enema)

8. Soapsuds solutions-8. Soapsuds solutions- pure soap added to pure soap added to tap water or normal saline. Use only tap water or normal saline. Use only castile soap. Ratio – 5ml pure soap castile soap. Ratio – 5ml pure soap solution is to 1000ml warm water or solution is to 1000ml warm water or saline. saline.

ADMINISTERING ENEMAADMINISTERING ENEMA

EquipmentsEquipments Two pairs of non sterile glovesTwo pairs of non sterile gloves IV pole and enema set up IV pole and enema set up

(administration bag or bucket (administration bag or bucket with rectal tubing, Castile with rectal tubing, Castile soap, protective plastic linen soap, protective plastic linen saver, packet of water-soluble saver, packet of water-soluble lubricantlubricant

Solution for enema, as Solution for enema, as prescribed by physician:prescribed by physician:

AdultAdult 750-1000 ml750-1000 ml

Children up to Children up to 350 ml350 ml

For infants up to For infants up to 250 ml250 ml ThermometerThermometer Bedpan or bedside commodeBedpan or bedside commode

Disposable waterproof bed Disposable waterproof bed panpan

Basin of warm waterBasin of warm water SoapSoap Wash clothWash cloth TowelTowel Room deodorizerRoom deodorizer

ASSESSMENTASSESSMENT

Assessment should focus on the Assessment should focus on the following:following:

1. Physician’s order for type 1. Physician’s order for type of enemaof enema

2. Agency policy and 2. Agency policy and physician’s order regarding physician’s order regarding performance of procedureperformance of procedure

3. Time of bowel movement and 3. Time of bowel movement and usual bowel evacuation patternusual bowel evacuation pattern

4. Indicators of complications 4. Indicators of complications (ex. lower abdominal pain; (ex. lower abdominal pain; hard small stools)hard small stools)

5. Hx of factors that may 5. Hx of factors that may contraindicate enema or present contraindicate enema or present complications during enema complications during enema administration (ex. Cardiac administration (ex. Cardiac dysrhythmia or bradycardia, dysrhythmia or bradycardia, recent rectal or pelvic surgery, recent rectal or pelvic surgery, spinal cord injury)spinal cord injury)

6. Client’s dietary habits 6. Client’s dietary habits (ex. Intake of liquids and (ex. Intake of liquids and fibers), changes in activity fibers), changes in activity pattern, frequency of use pattern, frequency of use of laxatives or enemasof laxatives or enemas

7. Abdominal status: 7. Abdominal status: presence of bowel soundspresence of bowel sounds

8. Client’s mental status 8. Client’s mental status and any fears associated and any fears associated with procedurewith procedure

9. Status of anus and skin 9. Status of anus and skin surrounding buttocks (ex. surrounding buttocks (ex. Presence of ulcerations, Presence of ulcerations, tears, hemmorhoids, tears, hemmorhoids, excoriation)excoriation)

10. Vital signs, before, 10. Vital signs, before, during and after enemaduring and after enema

11. Client knowledge 11. Client knowledge regarding promotion of regarding promotion of normal bowel evacuationnormal bowel evacuation

12. Client medications 12. Client medications that decrease peristalsis, that decrease peristalsis, such as narcoticssuch as narcotics

NURSING DIAGNOSISNURSING DIAGNOSIS

Nursing diagnosis may include the Nursing diagnosis may include the following:following:

Constipation related to Constipation related to immobility, decreased food, fiber, or immobility, decreased food, fiber, or fluid intake, or surgeryfluid intake, or surgery

Acute abdominal pain related to Acute abdominal pain related to bowel distention from constipation or bowel distention from constipation or from procedurefrom procedure

OUTCOME IDENTIFICATION OUTCOME IDENTIFICATION AND PLANNINGAND PLANNING

Desired OutcomesDesired Outcomes

Sample desired outcomes include the Sample desired outcomes include the following:following:

Client evacuates moderate to Client evacuates moderate to large amount of stoolslarge amount of stools

Client verbalizes pain relief Client verbalizes pain relief within 1 hourwithin 1 hour

IMPLEMENTATIONIMPLEMENTATIONPreparation:Preparation:1. Lubricate about 1. Lubricate about

5 cm (2inch) of 5 cm (2inch) of the rectal tube the rectal tube (some (some commercially commercially prepared enema prepared enema sets already have sets already have lubricated lubricated nozzles)nozzles)

Rationales:Rationales:Lubrication Lubrication facilitates facilitates insertion insertion through the through the sphincters sphincters and and minimizes minimizes traumatrauma

• 2. 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.

Air instilled into the rectum, although not harmful, causes unnecessary distention.

PERFORMANCE/PROCEDUREPERFORMANCE/PROCEDURE1.1. Introduce yourself and Introduce yourself and

verify client’s identity. verify client’s identity. Explain procedure to Explain procedure to the client. the client.

What you are going to What you are going to dodo

Why it is necessaryWhy it is necessary

How he/she can How he/she can cooperatecooperate

Discuss how the results Discuss how the results will be used in planning will be used in planning further care or further care or treatmentstreatments

Indicate that the client Indicate that the client may experience a feeling may experience a feeling of fullness while the of fullness while the solution is being solution is being administeredadministered

Reduces anxietyReduces anxiety Gain patient’s trust and Gain patient’s trust and

cooperationcooperation

2. Perform 2. Perform handwashinghandwashing

Apply clean glovesApply clean gloves

observe observe appropriate appropriate infection control infection control procedure.procedure.

3. Provide for client 3. Provide for client privacy.privacy.

Reduce the Reduce the transfer of transfer of microorganismmicroorganism

To protect the To protect the patient from patient from embarrassmentembarrassment

4. Assist the adult 4. Assist the adult client to a left client to a left lateral, with lateral, with right leg as right leg as acutely flexed as acutely flexed as possible, and the possible, and the linen –server linen –server pad under the pad under the buttocks.buttocks.

This position This position facilitates the flow of facilitates the flow of solution by gravity solution by gravity into the sigmoid and into the sigmoid and descending colon, descending colon, which are on the left which are on the left sideside

Having the right leg Having the right leg acutely flexed acutely flexed provides adequate provides adequate exposure of the anusexposure of the anus

5. Insert the rectal tube.5. Insert the rectal tube.

Gently spread the Gently spread the buttocks with non buttocks with non dominant handdominant hand

Insert the tube Insert the tube smoothly and slowly smoothly and slowly into the rectum, into the rectum, directing it toward the directing it toward the umbilicus.umbilicus.

the angle follows the the angle follows the normal contour of the normal contour of the rectumrectum

To ensure good To ensure good visualization of the visualization of the anal openinganal opening

Slow insertion Slow insertion prevents spasm of prevents spasm of the sphincter the sphincter muscles, muscles, facilitating entryfacilitating entry

Insert the tube Insert the tube adult adult 7 to 10 cm 7 to 10 cm (3-4 inches)(3-4 inches) because the anal because the anal canal is about 2.5 canal is about 2.5 to 5 cm (1-2 inch) to 5 cm (1-2 inch) longlonginfant (1 to 1.5 infant (1 to 1.5 inches)inches)child (2-3 inches)child (2-3 inches)

Prevents rectal Prevents rectal trauma; places trauma; places tube in far tube in far enough to enough to cleanse coloncleanse colon

If resistance is If resistance is encountered at the encountered at the internal sphincter, internal sphincter, ask the client to take ask the client to take a deep breath, then a deep breath, then run a small amount run a small amount of solution through of solution through the tubethe tube

Never force tube or Never force tube or solution entry. solution entry.

If resistance If resistance persists, end the persists, end the procedure and procedure and report the report the resistance to the resistance to the physician and the physician and the nurse in charge,nurse in charge,

To relax the To relax the internal anal internal anal sphinctersphincter

6. 6. Slowly administer the Slowly administer the enema solution.enema solution.Raise the solution Raise the solution container, and release container, and release the clamp to allow the clamp to allow fluid flow.fluid flow.Administer the fluid Administer the fluid slowly. If the patient slowly. If the patient complains of fullness complains of fullness or pain, lower solution or pain, lower solution container, use the container, use the clamp to stop the flow clamp to stop the flow to 30 seconds and then to 30 seconds and then restart the flow at a restart the flow at a lower ratelower rate

Administering Administering the enema slowly the enema slowly and stopping the and stopping the flow momentarily flow momentarily decrease the decrease the likelihood of likelihood of intestinal spasm intestinal spasm and premature and premature ejection of the ejection of the solution.solution.

Administer all Administer all solution or as solution or as much as client much as client can tolerate; be can tolerate; be sure to clamp sure to clamp tubing just tubing just before all of the before all of the solution clears solution clears the tubingthe tubing

Delivers Delivers enough enough solution for solution for proper effect; proper effect; prevents prevents infusion of airinfusion of air

7. Slowly 7. Slowly remove remove rectal tubing rectal tubing while gently while gently holding holding buttocks buttocks togethertogether

Prevents Prevents accidental accidental evacuation of evacuation of solutionsolution

Remind client to Remind client to hold solution for hold solution for amount of time amount of time appropriate for appropriate for type of enematype of enema

-reposition -reposition client for comfortclient for comfort

-place call light -place call light and bedpan or bed and bedpan or bed side commode side commode within easy reachwithin easy reach

Ensures optimal Ensures optimal effecteffect

Facilitates comfortFacilitates comfort

Provides means of Provides means of contacting nurse; contacting nurse; provides receptacle provides receptacle for enema solutionfor enema solution

Discard or restore Discard or restore equipment equipment appropriatelyappropriately

Discard gloves and Discard gloves and perform hand perform hand hygienehygiene

Check client every Check client every 5-10 minutes to 5-10 minutes to assess if client is still assess if client is still able to retain able to retain enemaenema

Promotes clean Promotes clean environmentenvironment

Reduces Reduces microorganism microorganism transfertransfer

Reassess client’s Reassess client’s condition and condition and retention of enemaretention of enema

8. Assist the client to 8. Assist the client to defecatedefecateAssist the client to a Assist the client to a sitting position on the sitting position on the bedpan, commode or bedpan, commode or toilet after retention toilet after retention time have expired or time have expired or when client can no when client can no longer retain enema. longer retain enema. Ask the client who is Ask the client who is using the toilet not to using the toilet not to flush it. flush it. If a specimen of feces is If a specimen of feces is require, ask the client to require, ask the client to use a bedpan or use a bedpan or commodecommode

A sitting position A sitting position facilitates the facilitates the act of defecationact of defecation

The nurse needs The nurse needs to observe the to observe the fecesfeces

9. Apply glove 9. Apply glove and perform and perform perineal care perineal care with soap and with soap and water. Spray water. Spray room room deodorizer after deodorizer after evacuationevacuation

Perform hand Perform hand washingwashing

Removes Removes residual stool residual stool spoilage; spoilage; eliminates odoreliminates odor

Reduces Reduces microorganism microorganism transfertransfer

10. Document the following: 10. Document the following:

Type and amount of solution Type and amount of solution usedusedProcedure completion with date Procedure completion with date and time and color, consistency and time and color, consistency and amount of stool expelledand amount of stool expelledCondition of anus and Condition of anus and surrounding area before and surrounding area before and after procedureafter procedure

Vital signs before and after enemaVital signs before and after enema

Description of and interventions Description of and interventions for any adverse reactions for any adverse reactions experienced during the procedureexperienced during the procedure

Abdominal assessment before and Abdominal assessment before and after enemaafter enema

Client teaching regarding Client teaching regarding prevention of constipationprevention of constipation

EVALUATIONEVALUATION

Were desired outcomes achieved? Were desired outcomes achieved? Example of evaluation include:Example of evaluation include:

Desired outcome met. After enema Desired outcome met. After enema the rectum was free of hard stool, the rectum was free of hard stool, client expelled gas, and abdomen is client expelled gas, and abdomen is now soft.now soft.

Desired outcome met: Client states Desired outcome met: Client states abdominal pain relieved after enemaabdominal pain relieved after enema

Example: Example: Date: June 17, 2010Date: June 17, 2010Time: 8:00amTime: 8:00amSoap suds enema (750 ml) given. Anus intact Soap suds enema (750 ml) given. Anus intact

without irritation. Large amount of dark without irritation. Large amount of dark brown stool returned after enema. No brown stool returned after enema. No signs of adverse effects. Bowel sounds signs of adverse effects. Bowel sounds auscultated in four quadrants before and auscultated in four quadrants before and after procedure. Abdomen soft and non after procedure. Abdomen soft and non distended. Vital signs stable before and distended. Vital signs stable before and after enema. Client verbalized measures after enema. Client verbalized measures for promoting normal bowel evacuation.for promoting normal bowel evacuation.