Enema

An enema is an instillation of a preparation into rectum and sigmoid colon (Potter

and Perry, 2007).

Purposes

• To remove fecal matter.

• To relieve constipation and gaseous distention.

• To prevent involuntary defecation during surgery.

• To promote visualization of lower gastro intestinal tract during X ray or

endoscopic examination.

• To establish normal bowel function during bowel training programme.

• To reduce fever and cerebral edema.

• To remove contrast medium used following upper or lower gastro intestinal X

rays.

• To administer nutrients or medications.

• To relieve retention of urine by reflex stimulation of bladder.

Contra indications

• Infections

• Injury

• Obstetrical and gynecological contraindications

• Acute renal failure

• Appendicitis.

• Acute myocardial infarction and cardiac problems.

Types of enema:Cleansing enema: 30 cm. Promotes complete evacuation of

feces from colon.
Infusion of large volume of solution

Irritates colon’s mucosa

Stimulation of peristalsis
High enema: 30-45cm.After infusion, the patient is instructed to change left lateral
to dorsal recumbent and then to right lateral so that the infusion reaches the large
intestine.
Low enema: 7.5 cm.Cleanses only rectum and colon.
Tap water enema: Escape of water from bowel lumen into the interstitial spaces
stimulating defecation.
Causes water toxicity or circulatory overload.
Normal saline: Safest method.
Hypertonic enema: Infusion exerts osmotic pressure that pulls fluids out of
interstitial spaces. Amount 120 – 180 ml is effective.
Soap enema: Use only pure castile soap.
Oil retention enema: They lubricate rectum and colon.Feces absorb oil and
become softer and easier to pass. To enhance the action of oil, the patient retains
the enema for several hours.
Therapeutic enema: Sodium polystyrene sulfonate (Kayexate) – for treatment of
hyperkalemia.

Equipments :

1. Disposable gloves 2. Bowl with water

3. Enema can with tubing and glass 4. Pint measure
connection.
5. Soft soap with spoon or pre 6. Bath thermometer
packed enema container with
rectal tip
7. Artery clamp or screw clamp. 8. Kettle with warm water
9. Water soluble lubricants or 10.Rag pieces
Vaseline.
11.Rectal tube (sterile); Size: Adult 12.Two kidney trays
22-30 Fr; Child 12-18 Fr)
13.Disposable gloves 14.Bed pan
15.Intravenous stand 16.Bath blanket.

17.Clean linen (if needed).

Procedure:

Assessment

Steps Rationale Yes

/No
Assess the status of patient Determine factors indicating need
 Last bowel movement; Normal vs for enema influencing the type of
most recent bowel pattern and enema used. Also establish a
bowel sounds baseline for bowel function.
 Hemorrhoids
 Mobility
 External sphincter control
 Abdominal pain
Review medical record for presence
of increased intra cranial pressure,
Glaucoma or recent rectal or
prostrate surgery.
Inspect abdomen for distention
Determine patients’ level of
understanding of purpose of enema.
They are contraindicated
conditions.
Frequently a full colon or impacted
bowel results in abdominal
distention; assessment of
distention establishes a baseline
for determining effectiveness of
the enema.
Allows planning of appropriate
teaching measures.

Check each patient record to clarify Determine purpose of enema

the rationale of enema. administration. Preparation for
special procedure or relief of
constipation.
Review physician’s order for enema. Enemas require a physician’s
order. Determine number and type
of enema to be given.
Critical decision point: “enema until clear” order mean that repeat enema
till patient passes fluid that is clear of fecal matter. Usually a patient
receives only three enemas consecutively.

Planning

Steps Rationale Yes

/No
Collect appropriate equipment. Information promotes patient
Correctly identify patient and explain co operation and reduces
procedure. anxiety.
Assemble enema bag with appropriate
solution and rectal tube.

Implementation

Steps Rationale Yes

/No
Perform hand hygiene and apply gloves. Reduces transmission of micro
organisms.
Provide privacy by closing curtains Reduces embarrassment for
around bed or closing door. paitent.

Raise bed to appropriate working height Promotes good body mechanics

for nurse. Stand on right side of bed and and patient safety.
raise side rail on opposite side.
Assist patient to left side lying (sim’sPositioning allows enema
position) with right knee flexed. Also solution to flow downward by
place children in dorsal recumbent gravity along natural curve of
position. sigmoid colon and rectum thus
improving retention of solution.
Critical decision point: suspect patient of having poor sphincter control
position on bed pan in a comfortable dorsal recumbent position. Patients
with poor sphincter control are unable to retain all of enema solution.
Administering an enema with patient sitting on the toilet is unsafe
because the curved rectal tubing will scrape the rectal wall.
Administer enema:

Enema bag: Hot water will burn intestinal

Add warmed solution to enema bag/can.
Warm tap water. Place saline container
in a basin of hot water before adding
saline to enema bag and check
temperature of solution by pouring
smells amount of solution by pouring
small amount of solution over inner
wrist.
Raise container then release clamp and
allow solution to flow long enough to fill
tubing.
Reclamp tubing.
Lubricate 6 –8cm of tip of rectal tube
with lubricating jelly.
Place water proof pad under hips and
buttocks.
Cover patient with bath blanket exposing
only rectal area clearly visualizing anus.
Separate buttocks and examine perianal
areas for any abnormalities
(hemorrhoids, fissures or rectal prolapse)
Place bed pan or commode in easily
accessible position. If patient will be
using a toilet ensure it remains free.
Gently separate buttocks and locate
anus. Instruct patient to relax by
breathing out slowly through mouth.
Insert tip of rectal tube slowly by
pointing tip in direction of patients’
umbilicus.
LENGTH OF INSERTION:
Adults 7.5 – 10 cm; Children 5-7.5
cm ; Infants 2.5- 3.75 cm
mucosa. Cold water causes
abdominal cramping and is
difficult to retain.
Removes air from tubing.
Allows smooth insertion of
rectal tube without risk of
irritation or trauma to mucosa.
Prevents soiling of linen.
Provides warmth; reduces
exposure of body parts and
allows patient to feel more
relaxed and comfortable.
Findings influence approach to
ensure approach of insertion of
enema tip. A prolapsed rectum
is a contra indication.
Use in patients who are unable
to retain enema solution.
Breathing out promotes
relaxation of external sphincter.
Careful insertion prevents
trauma to rectal mucosa from
accidental lodging of tube
against rectal wall. Insertion
beyond proper limit causes
bowel damage.
Hold tubing in rectum constantly until Bowel contraction causes
end of instillation. expulsion of rectal tube.
If tube doesn’t pass easily do not force it; consider allowing a small
amount of fluid to infuse and then try to slowly reinsert the tube. The
instillation will relax the sphincter and provide additional lubrication.
Open the regulating clamp and allow Rapid insertion stimulates
solution to enter slowly with container at evacuation of rectal tube.
patient’s hip level.
Raise height of enema container slowly Allow for continuous sloe
to appropriate level above anus. instillation; raising height of the
container causes rapid
instillation and possible painful
distention of colon.
Instillation time varies depending on the Temporarily stopping instillation
volume of solution administered. prevents cramping which
Lower container or clamp tubing if prevents patient form retaining
patient complaints of cramping or if fluid all fluid altering effectiveness of
escapes around rectal tube. enema.
Clamp tubing after you instill all solution. Prevents entrance of air into
rectum.

PREPACKAGED DISPOSABLE CONTAINER

Remove plastic cap from rectal tip.
Tip is already lubricated; apply more
jelly if required.
Gently separate buttocks and locate
rectum. Instruct patient to relax by
breathing out slowly through mouth.
Lubrication provides for smooth
insertion of rectal tube without
causing rectal irritation or trauma.
Breathing out promotes relaxation
of external rectal sphincter.

Expel any air from enema container.
Insert tip of bottle gently into rectum
towards umbilicus.
Squeeze bottle until all of solution
has entered rectum and colon.
Instruct patient to retain solution until
the urge to defecate occurs usually 2-
5 minutes.
Place layers of toilet tissue around
tube at anus and gently withdraw
rectal tube.
Explain to patient that at a feeling of
distention is normal as well as some
abdominal cramping. Ask patient to
retain solution as long as possible
while lying quietly in bed.
Discard enema container and tubing
Introducing air into colon causes
further distension and discomfort.
Gentle insertion prevents trauma
to rectal mucosa.
Hypertonic solution requires only
small volume to stimulate
defecation.
Provide for patient’s comfort and
cleanliness.
Solution distends bowel. Length of
retention varies with the type of
enema and patients ability to
contract rectal sphincter. Longer
retention promotes more effective
stimulation of peristalsis and
defecation.
Reduces transmission and growth
in proper receptacle and rinse out of micro organisms.
thoroughly with warm soap and water
if container is reusable.
Assist patient to bathroom or help to Normal squatting position
position patient on bed pan. promotes defecation.
Observe character of feces and
solution (caution patient against
flushing toilet before inspection).
Assist patient as needed in washing Fecal contents irritate skin.
anal area with warm soap and water Hygiene promotes patients
(if perineal care is provided use comfort.
gloves).
Remove and discard gloves and
perform hand hygiene.
Evaluation

Steps Rationale Yes

Inspect color, consistency, amount of
stool and fluid passed.
/No
Determine if patient evacuated
stool or retained fluid. Note
abnormalities like presence of
blood or mucous.

Assess condition of abdomen: Determine if distension is relieved.

cramping, rigidity or distention Excess volume distends or
indicates a serious complication. damages the bowel.

Recording and reporting

Record type and volume of enema given, time administered and characteristics of
results.

Record patient’s tolerance of procedure.

Report failure of patient to defecate and any adverse effects to physician.

Unexpected outcomes Nursing actions

Abdominal pain or cramping Slow down the rate of instillation.

Bleeding 1. stop enema

Distension and rigidity. 2. Notify physician
3. Remain with patient
4. Obtain vital signs.