ENEMA

Definition
A procedure of evacuation or washing out of waste
materials (feces or stool) from a person’s lower
bowel.
Enema administration involves in stilling a solution
into the rectum, colon & large intestines.
Is performed using a flexible plastic rectal tube
with several large holes in the tip.
This is connected to the tubing from a solution bag
or container.
What is Enema?

ENEMA is a solution introduced into the rectum and

large intestine. The action of an enema is to distend the
intestine and sometimes to irritate the intestinal mucosa,
thereby increasing peristalsis and the excretion of feces
and flatus.
Action
After introduction of solution, the intestine
becomes distended and there will be
irritation of intestinal mucosa which results
to increase peristalsis. Thus, excretion of
feces/flatus.
TYPES OF ENEMA

Cleansing

Retention

Return Flow
Carminative
TYPES OF ENEMAS
A. CLEANSING ENEMA = are intended to remove feces.
They are given chiefly to:

1. Prevent the escape of feces during surgery.

2. Prepare the intestine for certain diagnostic tests

such as x –ray or visualization tests ( e.g. colonoscopy )

3. Remove feces in instances of constipation or

impaction.
 Cleansing Enema uses a variety of solution :
TIME TO ADVERSE
SOLUTION CONSTITUENTS ACTION
EFFECT EFFECTS
Hypertonic 90-120ml of Draws water into 5-10 Retention of
solution e.g. the colon mins. sodium
sodium
phosphate
Hypotonic 500-1,000 ml of Distends colon, 15-20 Fluid and
tap water stimulates mins. electrolyte
peristalsis and imbalance,
softens feces water
intoxication
Isotonic 500-1,000 ml of Distends colon, 15-20 Possible sodium
normal saline ( stimulates mins. retention
9 ml to 1,000 peristalsis and
ml water) softens feces
Soapsuds 500-1,000 ml Irritates mucosa, 10 – 15 Irritates and may
soap to 1,000 distends colon mins. damage
ml water mucosa.
Common solution for cleansing enemas

 Tap water
 Normal saline solution
 Soapsuds solution
 Hypertonic solution
B. RETENTION ENEMA = introduces oil or
medication into the rectum and sigmoid colon.
The liquid is retained for a relatively long period.
An oil retention enema acts to soften the feces
and to lubricate the rectum and anal canal, thus
facilitating passage of the feces. Antibiotic
enemas are used to treat infections locally,
anthelmintic enemas to kill helminths such as
worms and intestinal parasites and nutritive
enemas to administer fluids and nutrients to the
rectum.
Retention enemas are given to:

a. Softens the hardened stool & allow normal

elimination
b. Lubricate the inside surface of the lower
intestine
c. Soften the stool, if necessary
d. Ease the passage of feces without straining
e. Provide laxative benefits when oral laxatives
are not allowed
f. Soften fecal impaction when straining might
be harmful or painful.
C. RETURN – FLOW ENEMA = is used
occasionally to expel flatus Alternating flow of
100 to 200 ml of fluid into and out of the rectum
and sigmoid colon stimulates peristalsis. This
process is repeated five or six times until the
flatus is expelled and abdominal distention is
relieved.
D. CARMINATIVE ENEMA = is given primarily to
expel flatus. The solution instilled into the rectum
releases gas, which in turn distends the rectum
and the colon, thus stimulating peristalsis. For an
adult 60 to 80 ml. of fluid is instilled.
PRECAUTIONS
Enemas should not be used as a first-
line treatment for constipation.
Frequent use of enemas can lead to
fluid overload, bowel irritation, and
loss of muscle tone of the bowel and
anal sphincter.
Never deliver more than three
consecutive enemas to treat a
patient. 13
PRECAUTIONS

A patient with diarrhea may not be able

to hold an enema.
 Must be used with caution in cardiac
patients who have arrhythmias or have
had a recent myocardial infarction.
 Insertion of the enema tube and solution
can stimulate the vagus nerve which may
trigger an arrythmias such as bradycardia.
14
PRECAUTIONS

 Enemas should not be given to patients

with undiagnosed abdominal pain
because the peristalsis of the bowel can
cause an inflamed appendix to rupture.
 Should be used cautiously in patients who
have had recent surgery on the rectum,
bowel, or prostate gland.
 If the patient has rectal bleeding or
prolapse of rectal tissue from the rectal
opening, cancel the enema and consult
with the physician before proceeding. 15
PRECAUTIONS

 Do not force the enema catheter into the

rectum against resistance. This can cause
trauma to the rectal tissue.
 Useonly mild castile soap (hard white
unperfumed soap made from olive oil
and lye) for soapsuds enemas because
other soap preparations are too harsh
and irritate the rectal tissue.

16
Guidelines:
Adult Children Infant
Size of Fr. # 22-30 Fr.# 14-18 Fr.# 12
rectal tube
Amount of 500-1,000 ml 250-500 ml 250ml or less
solution
Distance of 7.5-10 cm 5-7.5 cm 2.5-3.75 cm
tube (3-4 in) (2-3 in) (1-1.5 in)
insertion
Solution 40.5-43 C 37.7 C
temperature
Purpose
 Enemas may be given for the following
purposes:
 to remove feces when an individual is
constipated or impacted,
 to remove feces and cleanse the rectum in
preparation for an examination,
 to remove feces prior to a surgical
procedure to prevent contamination of the
surgical area,
 to administer drugs or anesthetic agents.
SPECIAL CONSIDERATIONS
1. water enemas can cause
cardiovascular overload and
electrolyte imbalance. Similarly,
repeated saline enemas can cause
increased absorption of fluid and
electrolytes into the bloodstream,
resulting in overload. Individuals
receiving frequent enemas should be
observed for over-load symptoms that
include dizziness, sweating, or vomiting
SPECIAL CONSIDERATIONS
2. Soap suds and saline used for cleansing
enemas can cause irritation of the lining of
the bowel, with repeated use or a solution
that is too strong. Only white soap should be
used; the bar should not have been
previously used, to prevent infusing
undesirable organisms into the individual
receiving the enema. Common household
detergents are considered too strong for the
rectum and bowel. The commercially
prepared soap is preferred, and should be
used in concentration no greater than 5 cc
soap to 1, 000 cc of water.
Description
 Cleansing enemas act by stimulation of
bowel activity through irritation of the lower
bowel, and by distention with the volume of
fluid instilled. When the enema is
administered, the individual is usually lying on
the left side, which places the sigmoid colon
(lower portion of bowel) below the rectum
and facilitates infusion of fluid. The length of
time it takes to administer an enema
depends on the amount of fluid to be
infused. The amount of fluid administered will
vary depending on the age and size of the
person receiving the enema, however
general guidelines would be:
SPECIAL CONSIDERATIONS
1. Some may differentiate between high and
low enemas. A high enema, given to
cleanse as much of the large bowel as
possible, is usually administered at higher
pressure and with larger volume (1, 000 cc),
and the individual changes position several
times in order for the fluid to flow up into the
bowel. A low enema, intended to cleanse
only the lower bowel, is administered at
lower pressure, using about 500 cc of fluid.
2. Oil retention enemas serve to lubricate the
rectum and lower bowel, and soften the
stool. For adults, about 150–200 cc of oil is
instilled, while in small children, 75–150 cc of
oil is considered adequate. Salad oil or liquid
petrolatum are commonly used at a
temperature of 91°F (32.8°C). There are also
commercially prepared oil retention enemas.
The oil is usually retained for one to three
hours before it is expelled.
3. The rectal tube used for infusion of the
solution, usually made of rubber or plastic, has
two or more openings at the end through which
the solution can flow into the bowel. The
distance to which the tube must be inserted is
dependent upon the age and size of the
patient. For adult, insertion is usually 3–4 in (7.5–
10 cm); for children, approximately 2–3 in (5–7.5
cm); and for infants, only 1–1.5 in (2.5–3.75 cm).
The rectal tube is lubricated before insertion
with a water soluble lubricant to ease insertion
and decrease irritation to the rectal tissues.
4. The higher the container of solution is
placed, the greater the force in which
the fluid flows into the patient.
Routinely, the container should be no
higher than 12 in (30 cm) above the
level of the bed; for a high cleansing
enema, the container may be 12–18 in
(30–45 cm) above the bed level,
because the fluid is to be instilled
higher into the bowel.
Guidelines:
Adult Children Infant
Size of Fr. # 22-30 Fr.# 14-18 Fr.# 12
rectal tube
Amount of 500-1,000 ml 250-500 ml 250ml or less
solution
Distance of 7.5-10 cm 5-7.5 cm 2.5-3.75 cm
tube (3-4 in) (2-3 in) (1-1.5 in)
insertion
Solution 40.5-43 C 37.7 C
temperature
EQUIPMENTS:
 1. A tray containing the following:
 Rectal catheter
 Enema can with tubing
 Lubricant
 Pitcher with hot and cold water
 Solution as ordered by the physician
 Toilet paper
 Kidney basin
 Working gloves
 2. Apron or gown to protect the uniform2. Bedpan with cover
 3. waterproof underpad
 4. irrigation stand or IV stand
Assessment:
1.Assess status of client: last bowel
movement, normal versus recent
bowel pattern, presence of
haemorrhoids, mobility, bowel
sounds, presence of abdominal pain.
(Determine factors indicating need for
enema and influencing the type of
enema used. Also establishes baseline
for bowel function.)
2.Assess medical records for presence of
increased intracranial pressure, glaucoma,
or recent rectal or prostate surgery.
(Conditions contraindicate use of enemas)
3.Inspect abdomen for presence of
distention.
(Establishes a baseline for determining
effectiveness of enema.)
4.Determining client’s level of
understanding of purpose of enema.
(Allows nurse to plan fro appropriate
teaching measure.)
5.Check client’s medical record to
clarify reasons for enema.
(Determines purpose of enema
administration: preparation for special
procedure or relief of constipation.)
6.Review physician’s order for
enema.
(Order by physician is usually required
for hospitalized client. Used to
determine how many enemas client
will require, type of enema to be
given.)
PREPARATION

 The patient should be encouraged to empty both bladder

and bowels before the procedure.
 Before administering an enema, ensure the patient’s
privacy by closing the door of the room.
 Have the patient undress completely from the waist down.
 Position the patient on the bed on his or her left side with
the top knee bent and pulled slightly upward toward the
chin.

32
 33
college of nursing
ENEMA
STEPS RATIONALE
1.Inform client To promote
about the cooperation, to
procedure minimize anxiety
(Evans-Smith)
 STEPS RATIONALE
2.Wash hands Hand hygiene
(medical hand deters the spread
washing) of microorganism
(Evans-smith)
 STEPS RATIONALE
3.Organize the For efficiency
equipment
 STEPS RATIONALE
4. Place rubber The waterproof
sheet under pad/rubber sheets
patient’s buttocks protects bed linen
(Evans-Smith)
 STEPS RATIONALE
5.Prepare solution, Warming the
making sure that solution prevent
temperature of chilling of the
solution is lukewarm patient, adding to
(about 105-110 F) the discomfort of
the procedure
(Evans-Smith)
 STEPS RATIONALE
6.Allow solution to Although allowing
run through the air to intestine is not
tubing so that air is harmful, it may
remove. Clamp further distend the
tubing intestine (Evans-
Smith)
 STEPS RATIONALE
7.Place container Gravity forces the
on bedside IV solution to enter
stand not more the intestine. The
than 18-24 inches amount of pressure
above buttocks. determines the rate
of flow and
pressure exerted on
the intestinal wall
(Evans-Smith)
 STEPS RATIONALE
8.Position the Allows enema
patient on side solution to flow
lying position or downward by
Sim’s position with gravity along
knee flexed natural curve of
sigmoid colon and
rectum, thus
improving retention
of solution.
 STEPS RATIONALE
9.Place bedpan Place bedpan for
within easy reach. the desire to
defecate
 STEPS RATIONALE
10.Wear gloves. Gloves protect
Lubricate 4-5 inches nurses from
of catheter tip microorganism in
rectal tube feces. Lubrication
facilitates passage
of the rectal tube
through the anal
sphincter and
prevents injury to
the mucosa (Evans-
Smith)
 STEPS RATIONALE
11. Gently spread To relax the
the buttocks. sphincter which will
Instruct patient to ease catheter
take slow deep insertion by
breaths through breathing into
mouth. mouth.
 STEPS RATIONALE
12.Insert rectal tube The tube should be
into the rectum inserted past the
about 3-4 inches external and
and hold in place internal sphincters,
but further insertion
may damage
intestinal mucous
membrane (Evans-
Smith)
 STEPS RATIONALE
13.Release tubing Introducing the
clamp. Allow solution slowly will
solution to flow into help to prevent
colon, observing rapid distention of
patient closely the intestine and
a desire to
defecate (Evans-
Smith)
 STEPS RATIONALE
14. If patient These techniques
complaints of help relax muscles
cramping, extreme and prevent
anxiety or inability expulsion of the
to retain solution: solution.
a.Lower solution
container
b.Clamp or pinch
tubing for few
minutes
 STEPS RATIONALE
15.Administer all Delivers enough
solution or as much solution for proper
as patient can effect
tolerate, be sure to To avoid
clamp tubing just introducing of air
before solution into the bowel
clears tubing
 STEPS RATIONALE
16.Slowly remove This amount of time
rectal tubing while usually allows
gently holding muscle contraction
buttocks together. to become
sufficient to
produce good
results.
 STEPS RATIONALE
17. Reposition
patient on
comfortable
position
 STEPS RATIONALE
18.Documents the
results
EVALUATION

 Were
desired outcomes achieved?
Example of evaluation include:
Desired outcome met. After enema
the rectum was free of hard stool,
client expelled gas, and abdomen is
now soft.
Desired outcome met: Client states
abdominal pain relieved after enema
Documentation:
The following should be noted on patient’s chart
• Type and amount of solution used
• Color, consistency and amount of stool return
• Condition of anus and surrounding area
• Status of vital signs before and after enema
• Description of adverse reactions during enema
• Abdominal assessment before and after enema
• Presence of discomfort after enema
• Client teaching regarding prevention of
constipation
Sample documentation
Date Time Soap suds enema (750 ml
04/11/2011 03:45pm
given. Large, dark brown stool
returned from enema. No signs
of adverse effects. Bowel
sounds auscultated in four
quadrants. Abdomen soft and
nondistended. Discussed
factors for promoting normal
bowel evacuation with client.
Factors verbalized by client.
 Example:
 Date: 04/11/2011
 Time: 4:00pm
 Soap suds enema (750 ml) given. Anus intact
without irritation. Large amount of dark brown
stool returned after enema. No signs of adverse
effects. Bowel sounds auscultated in four
quadrants before and after procedure.
Abdomen soft and non distended. Vital signs
stable before and after enema. Client
verbalized measures for promoting normal
bowel evacuation.
AFTERCARE

 Afteradministering an enema, remain

near the patient in case he or she needs
assistance with the bedpan or to get to
the bathroom.
 Medicated enemas that are expelled
immediately may need to be repeated,
using fresh solution.
 Followthe directions or consult with the
physician.
 To assist the patient with retaining an
enema after instillation, apply gentle
pressure to the rectal opening using a 4X4
gauze pad or squeeze the buttocks
together.
 Tuck a 4X4 gauze pad between the
buttocks to collect seepage. This
maneuver may help the patient feel more
secure.
 Cover the patient after the procedure
and instruct him or her to lie still for 5 to 10
minutes or longer if a medicated solution
or retention enema is administered. This
will allow time for the sol’n to take effect.
 Wash items that might be reused, such as
non-disposable enema bags and tubing,
in warm soapy water. Rinse and allow
them to air dry.
 Placedisposable items, gauze pads, &
gloves in a trash bag, then seal & discard
it.
 Assist
the patient to the bathroom or with
the bedpan after he or she has held the
enema solution for the correct amount of
time.
Hands should be washed after
performing the procedure.
Note the results of the enema (color,
consistency, content and amount of
feces produced).
COMPLICATIONS
 Complications of enema administration are
not common but can include irritation,
swelling, redness, bleeding, or prolapse of
the rectal tissue.
 Ifany of these symptoms are apparent, or if
the patient complains of pain or burning
during enema instillation, stop the procedure
and notify the physician.
Risks
 Habitual use of enemas as a means
to combat constipation can make
the problem even more severe when
their use is discontinued. Enemas
should be used only as a last resort
for treatment of constipation and
with a doctor's recommendation.
Enemas should not be administered
to individuals who have recently had
colon or rectal surgery, a heart
attack, irregular heart beat.
Can we do an enema in pregnant or
nursing a baby?

Both pregnant women and nursing

women have safely done enemas.
Many of them. No known risks are
associated with clean water enema,
but if you are pregnant, you should
avoid enema containing herbs.
Giving Enemas During Delivery to Be
Discouraged
 Giving enemas during labor doesn’t
shorten labor or decrease the risk of
infection to mother or baby new study has
revealed. The study now calls for
discouraging the practice of giving
enemas during delivery.
 Enemas are frequently given to women
early in labor so that they empty their back
passage. The idea is that this will give more
room for the baby as it passes through the
pelvis. It is also hoped that it will reduce the
chance of the woman leaking fecal
material while she is giving birth, a situation
that is both embarrassing to the woman
and a potential source of infection to
mother and child.
ASSEMBLE THE MATERIALS NEEDED
POSITION THE CLIENT IN (SIM’S) LEFT LATERAL POSITION
WITH THE RIGHT LEG SHARPLY FLEXED
PLACE SOLUTION INTO THE BUCKET AND ADD WATER AS NEEDED
LUBRICATE
2 INCHES
OF THE
RECTAL
TUBE WITH
LUBRICANT
GENTLY AND SMOOTHLY INSERT THE RECTAL TUBE INTO THE
RECTUM
 RAISE THE
CONTAINER 12
TO 18 INCHES
ABOVE THER
ECTUM AND
INSTILL 200 CC
OF SOLUTION
LOWER THE CONTAINER 12 TO 18 INCHES
BELOW THE CLIENT’S RECTUM. OBSERVE FOR
AIR BUBBLES AS THE SOLUTION RETURNS.
CLEAN THE ANAL AREA TO
REMOVE EXCESS LUBRICANT
A COMMERCIAL ENEMA
POSITION THE CLIENT IN THE LEFT LATERAL POSITION WITH
THE RIGHT LEG SHARPLY FLEXED
ALTERNATIVELY,
YOU MAY POSITION
THE CLIENT IN THE
KNEE CHEST
POSITION
AFTER INSERTING THE
NOZZLE INTO THE ANUS,
SQUEEZE THE CONTAINER
UNTIL ALL THE SOLUTION IS
INSTILLED
REMOVE THE NOZZLE
AND CONTAINER AND
HAVE THE CLIENT
CONTINUE TO LIE ON
THE LEFT SIDE FOR THE
RPESCRIBED LENGTH
OF TIME. DISPOSE OF
THE EMPTY CONTAINER
IN THE TRASH
RECEPTACLE
BINDERS
 DEFINITION:

A type of bandage
applied to large
body areas.
length of cloth or
elasticized material
that encircle the
chest, abdomen or groin.
most binders are made of
elastic cotton, soft muslin,
flannel or a strip of
lightweight canvass material.
Cloth binders are fastened
with safety pins.
Elasticized binders are
fastened with velcro.
A properly applied
binder provides support
and comfort so the
client can resume
normal activities early.
 for support
for immobilization
to hold dressings in
place

PURPOSES:
 TYPES:

 STRAIGHT ABDOMINAL BINDER

- A rectangular material
long enough to encircle
the patient’s abdomen with
some overlap fasten with
safety pins or velcro.
- can be made by any
material- bath blanket or
towel.
 TYPES:

 SCULTETUS OR MANY-TAILED BINDER

- with tails of fabric at
each end; these are
interlaced upward
to give strength
& added support to
the abdomen especially
after abdominal surgery.*
TYPES:

 T-BINDER OR PERINEAL BINDERS

- designed to hold pads or

dressings in the perineal
area or rectal area.
Double T-Binder Single T-Binder
(male) (female)
BREAST BINDER

Reduces Breast
engorgement in
the non
Breastfeeding
mother
ASSESSMENT:
1. Assess the body area to which the binder is
to be applied: Check for swelling,
discoloration, discomfort.
2. Assess the dressing to determine whether it
needs changing or reinforcing, depending
on the physician’s order.
3. Assess the patient’s skin under the binder
for abrasions.
EQUIPMENT

Tape measure
 Binder of appropriate size
and type
 Gloves if necessary
 Safety pins
PREPARATION:
1. Explain the purpose
2. Provide privacy
3. Assist client to a comfortable lying or
sitting position.
4. Raise the bed to its highest position*
PROCEDURE
ACTION EXPLANATION

1.With the patient A binder above

in a supine the waist
position, place the interferes with
binder smoothly respiration, while
under the patient’s one placed too
waist and the low interferes with
lower border at the elimination and
level of gluteal fold walking
PROCEDURE
ACTION EXPLANATION

2. Applying To prevent skin

padding over the surfaces from
iliac crests rubbing together
& becoming
if the patient is
excoriated.
emaciated.
PROCEDURE
ACTION EXPLANATION

3. For straight Place the top pin

abdominal binder, horizontally at the
bring the ends waist to allow
around the comfort when
patient, overlap moving.
them, and secure
them with pins.
 PROCEDURE
ACTION EXPLANATION

4. For a scultetus Each tail should overlap

binder, bring the the preceding one by
tails over the about half of the width
center from of the tail for maximum
support. In thin people
alternate sides. The
the tails may extend
last tail is secured
beyond the other
with a safety pin.
side & will require
folding back.
PROCEDURE
ACTION EXPLANATION

For patients who This provides maximum

have had upward support
abdominal surgery,
lace the tails from
the bottom
upward.
PROCEDURE
ACTION EXPLANATION

For the post- This provides

partum patients, downward pressure on
lace the tails from the uterus
the top downward.
SPECIAL CONSIDERATION:

 For
maximum support, wrap the binder so
that it applies even pressure across the
body section.
 Eliminate
wrinkles and avoid pressure on
bony prominences.
 Becareful not to compress drains, tubes,
catheters.
 Don’tallow binder to interfere with
elimination.
SPECIAL CONSIDERATION:
 Check binder placement every 8 hours.
 Checkthe skin color, palpate for warmth,
check pulses and assess for tingling or
numbness.
 Reapplythe binder when a dressing
needs changing, when the binder
becomes loose or too tight.
…end