Document Code NSG-F0-00__

Revision 00
Effectivity Date 2022/07/01
SCHOOL OF HEALTH AND NATURAL SCIENCES Page/s 1 of 2

Name of student: __________________________________ Year/Clinical Group: ______________________

PERFORMANCE EVALUATION TOOL IN ADMINISTERING ENEMA

DIRECTIONS: Below is a list of criteria to evaluate the student’s skill in administering enema. Please indicate your evaluation
by placing the number of scores on the appropriate column using the following descriptive scale.

0- Not Done 1- Done Correctly

Preparation RATING Comments

1. Assess:
 When the client last had a bowel movement, and the amount, color, and
consistency of the feces
 Presence of abdominal distention
 Whether the client has sphincter control
 Whether the client can use a toilet or commode, or must remain in bed and use a
bedpan
2. Determine:
 Whether a primary care provider’s order is required
 The presence of kidney or cardiac disease that contraindicates the use of a
hypotonic solution
3. Assemble equipment:
 Disposable linen-saver pad
 Bath blanket
 Bedpan or commode
 Clean gloves
 Water-soluble lubricant, if tubing not prelubricated
 Paper towel
Large-volume enema
 Solution container, with tubing of correct size and tubing clamp
 Correct solution, amount, and temperature
Small-volume enema
 Prepackaged container of enema solution with lubricated tip
4. Lubricate about 5 cm (2 inches) of the rectal tube.
5. 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.
1. Introduce yourself and verify client’s identity. Explain to the client what you are
going to do, why it is necessary, and how the client can cooperate. Indicate that
the client might experience a feeling of fullness while the solution is being
administered.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Assist the adult client to a left lateral position, with the right leg as acutely
flexed as possible and the linen-saver pad under the buttocks.
5 For clients in left lateral position, left the upper buttock.
Insert the tube smoothly and slowly into the rectum, directing it toward the
umbilicus.
Insert the tube 7-10 cm (3-4 inches).
If resistance occurs at the internal sphincter, ask the client to take a deep breath, then
run a small amount of solution into the tube.
Never force tube or solution entry. If instilling a small amount of solution does not
permit the tube to be advanced, or the solution to flow freely, withdraw the tube.
Check for any stool that might have blocked the tube during insertion. If present, flush
it and retry the procedure. You may also perform a digital rectal examination, to
determine if there is an impaction or other mechanical blockage. If the resistance
persists, end the procedure and report the resistance to primary care provider and
nurse in charge.
Raise the solution container, and open the clamp to allow fluid flow;or
Compress a pliable container by hand.
During most low enemas, hold or hang the solution container no higher than 30 cm
 (12 inches) above the rectum. During a high enema, hang the solution container
approximately 45 cm (18 inches) above the rectum.
Administer the fluid slowly. If the client complains of fullness or pain, lower the
container or use the clamp to stop the flow for 30 seconds, and then restart the flow at
a slower rate.
If you are using a plastic commercial container, roll it up as the fluid is instilled.
After all the solution has been instilled, or when the client cannot hold anymore and
feel the desire to defecate, close the clamp, and remove the rectal tube from the anus.
Place the 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 – for
example, 5-10 minutes for a cleansing enema, or at least 30 minutes for a retention
enema.
Assist the client to a sitting position on the bedpan, commode, or toilet.
Ask the client who is using the toilet not to flush it. The nurse needs to assess the
feces.
If a specimen of feces is required, ask the client to use a bedpan, or commode.
6 After the rectal tube is inserted, have the client to assume a supine position on a
bedpan. The head of the bed can be elevated slightly, to 30 degrees, if necessary, for
easier breathing. Use pillows to support the client’s head and back.
7 For a return-flow enema, the solution (100-200 mL for an adult) is instilled to the
client’s rectum and sigmoid colon. Then the solution container is lowered so that the
fluid flows back out through the rectal tube into the container, pulling the flatus with
it. The inflow-outflow process is repeated five or six times, and the solution is
replaced several times during the procedure if it becomes thick with feces.
Document:
 The type and volume if appropriate of enema given
8  The 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 on the
client record.
TOTAL/AVERA
GE

Comments:____________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________

Student’s signature over printed name/Date/Time: _________________________________________________

Clinical Instructor’s signature over printed name/ Date/Time: _______________________________________