NCM 109

ENEMA

ALL NCM 109 INSTRUCTORS

PREPARED BY:
At the end of the lesson, the second year nursing
students will be able to:
1.Define enema and other related terms.
2. Explain the indications and purposes of enema
3. Describe the different types or classifications of enema
4. Enumerate the equipment used in enema administration
5. Discuss the nursing considerations and interventions when administering
enema among children, adults and geriatric patients
6. Summarize the nursing responsibilities/interventions before, during and
after an enema administration.
7. Perform the steps in enema administration
8. Discuss the contraindications of enema
9. Explain the importance of barium enema as a diagnostic procedure
10. Formulate a nursing care plan for a patient who requires enema
administration
WHAT IS ENEMA?
An enema is a solution introduced
into the rectum and large
intestine.
It is a technique used to stimulate
stool evacuation.
 Action of an enema: To distend the
intestine and sometimes to irritate the
intestinal mucosa, thereby increasing
peristalsis and the excretion of feces
and flatus.
PURPOSES OF ENEMAS
To relieve constipation
To relieve flatulence
To administer medications
To lower body temperature
To evacuate feces in preparation for diagnostic
procedure or surgery
CLASSIFICATION OF
ENEMA
I. CleansingEnema
An injection of water-based solution into the rectum or colon
with the purpose of stimulating a bowel movement to remove
feces.
They are given chiefly to:
Prevent the escape of feces during surgery.
Prepare the intestine for certain diagnostic tests such as x-ray or
visualization tests (e.g., colonoscopy).
Remove feces in instances of constipation or impaction.
A.HIGH ENEMA
Given to cleanse as much of the colon as possible.
Amount of solution: 1,000 ml
Position Changes during administration: from left lateral
position to dorsal recumbent position and then to right
lateral position so that the solution can follow the large
intestine.
B. LOW ENEMA
It is used to clean the rectum and sigmoid colon
only.
Amount of solution: 500 ml
Position: maintains a left lateral position during
administration.
C. LARGE VOLUME ENEMA
Purpose: to clean as much of the colon as possible of feces, as an
intervention for constipation as well as “bowel prep” before a
diagnostic procedure.
Amount used: 500-1000 ml
Height of administration: bag is raised as high as 18 inches above
the anal opening
LARGE VOLUME ENEMA
The amount of solution administered will depend on the age and medical
condition of the individual.
For example, clients with certain cardiac or renal diseases--------- significant
fluid retention
LARGE VOLUME ENEMA IN CHILDREN (VOLUME OF SOLUTION)
Children less than 18 months old: 50 to 200 mL
Children 18 months to 5 years; 200 to 300 mL
Children 5 to 12 years old: 300 to 500 mL
D. LOW VOLUME ENEMA
Itis used to clean the lower portion of the colon or the sigmoid.
This type of cleansing enema is often used for the patient who is
constipated but does not need cleansing of the higher colon.
The amount used: less than 500 ml (90 to 120 ml)
Height of administration: the bag is raised no higher than 12
inches.
II. RETURN FLOW ENEMA
also called a Harris flush, is occasionally used to expel
flatus.
This type of enema provides an alternating flow of
enema solutions between 100 and 200 mL into and
out of the patient’s sigmoid colon and rectum
Purpose: to stimulate peristalsis to propel food along
the normal process.
This process is repeated five or six times until the
flatus is expelled and abdominal distention is relieved.
III. RETENTION ENEMA
It introduces oil or medication into the rectum and sigmoid colon.
Types of oil and medications:
Antibiotic enemas: to treat infections locally
Anthelmintic enemas: to kill helminths such as worms and
intestinal parasites
Nutritive enemas: to administer fluids and nutrients to the
rectum.
RETENTION ENEMA
Time of retention: 1 to 3 hours
Purpose: To soften the feces and to lubricate the rectum
and anal canal, thus facilitating passage of the feces
Other Solutions: carminative enema (60 to 80 mL ), oil (90-
120 ml)
Height: 12 inches above the anus
Temperature of solution: 105 to 110 F
CARMINATIVE ENEMA (RETENTION ENEMA)
It is given primarily to expel flatus and to release tension
or swelling in the colon and rectum.
The solution instilled into the rectum releases gas, which
in turn distends the rectum and the colon, thus stimulating
peristalsis.
This type of enema allows wastes and toxins to leave the
body.
IV. NON-RETENTION ENEMA
Solutions
Hypotonic solutions (TAP WATER)- 500 to 1000 ml
Isotonic solutions
 (NSS) --- 9 ml of NaCl to 1,000 ml of water
 SOAP SUDS: 20 ml of castile soap in 500- 100 ml of water
Hypertonic solutions: fleet (90 ml- 120 ml)
NON-RETENTION ENEMA
Height of solution for non-retention: 18
inches above the rectum
Temperature: 115 to 125
Time of retention: 5 to 10 mins
A. Hypertonic Solutions
Solutions that have a higher solute concentration than
that of the cell.
Solutions that exert osmotic pressure, which draws
fluid from the interstitial space into the colon.
The increased volume in the colon stimulates
peristalsis and hence defecation.
B. Hypotonic Solutions
Solutions that have lower solute concentrations, such as salt and electrolytes,
than the cells inside of them.
These solutions exert a lower osmotic pressure than the surrounding interstitial
fluid, causing water to move from the colon into the interstitial space.
Before the water moves from the colon, it stimulates peristalsis and defecation.
C. Isotonic Solutions
A solution that has the same solute concentration as cells.
Isotonic solutions, such as physiological (normal) saline,
are considered the safest enema solutions to use.
They exert the same osmotic pressure as the interstitial
fluid surrounding the colon. Therefore, there is no fluid
movement into or out of the colon.
Soapsuds enemas:
 stimulate peristalsis by increasing the volume
in the colon and irritating the mucosa.
Only pure soap (i.e., Castile soap) should be
used in order to minimize mucosa irritation.
 SUMMARY OF Commonly Used Enema Solutions
Solution: Hypertonic
Constituents: 90–120 mL of solution (e.g., sodium
phosphate [Fleet])
Action: Draws water into the colon
Time to Take Effect : 5–10 min
Adverse Effects: Retention of sodium
 Commonly Used Enema Solutions
Solution: Hypotonic
Constituents: 500–1,000 mL of tap water
Action: Distends colon, stimulates peristalsis, and softens
feces
Time to Take Effect : 15–20 min
Adverse Effects: Fluid and electrolyte imbalance; water
intoxication
 Commonly Used Enema Solutions
Solution: Isotonic
Constituents: 500–1,000 mL of normal saline
Action: Distends colon, stimulates peristalsis, and softens
feces.
Time to Take Effect : 15–20 min
Adverse Effects: Possible sodium retention
 Commonly Used Enema Solutions
Solution: Soapsuds
Constituents: 500–1,000 mL (3–5 mL soap to 1,000
mL water)
• Action: Irritates mucosa, distends colon.
• Time to Take Effect : 10–15 min
• Adverse Effects: Irritates and may damage mucosa
 Commonly Used Enema Solutions
Solution: Oil
Constituents: (mineral, olive, cottonseed) 90–120
mL
Action: Lubricates the feces and the colonic
mucosa
Time to Take Effect : 0.5–3 h
 PRINCIPLES INVOLVED IN ADMINISTERING ENEMA
Physics - solution to be administered should be held at high
position
 Psychology
provide privacy by draping the patient
explain the procedure to the before inserting the tube in the rectum
Time and Energy - materials to be used must be prepared before
performing the procedure
 GENERAL
NURSING
CONSIDERATIONS
AND
INTERVENTIONS
IN ENEMA
ADMINISTRATION
 HOLISTIC APPROACH IN ENEMA ADMINISTRATION
It is important for the nurse to remember that clients may perceive this type
of procedure as a significant violation of personal space.
Consider cultural sensitivity pertaining to personal space, gender of the
caregiver, and the potential meaning of the structures and fluids found in
this private area of the body.
Keep in mind the client’s potential discomfort with the gender of the
caregiver and try to accommodate the client’s preferences whenever
possible.
 HOLISTIC APPROACH IN ENEMA ADMINISTRATION
When it is not possible to honor the client’s wishes, respectfully explain the
circumstances.
A gentle, matter- of-fact approach is often most helpful.
Insertion of anything foreign into an orifice of a client’s body may trigger
memories of past abuse.
Monitor the client for emotional responses to the procedure (both subtle and
extreme)---------this could indicate a history of trauma and require
appropriate referral for counseling.
Simply asking the client to describe the experience will give the nurse more
information for possible referral.
The nurse considers the force of flow of
the solution
(a) the height of the solution container,
(b) size of the tubing,
(c) viscosity of the fluid
(d) resistance of the rectum.
RECOMMENDED Position:
Adult: left lateral
Infants/small children: dorsal recumbent
NOTE:
 The higher the solution container is held above the rectum, the
faster the flow and the greater the force (pressure) in the rectum.
 During most adult enemas, the solution container should be no
higher than 30 cm (12 in.) above the rectum.
 During a high cleansing enema, the solution container is usually
held farther to clean the entire bowel.
 To make a saline solution, mix 1 teaspoon of table salt with 500
mL of tap water.
 Use enemas only as directed. Do not rely on them for regular
bowel evacuation.
 Prior to administration, make sure a bedpan, commode, or toilet
is nearby.
Allow solution to flow through the connecting tubing
and rectal tube to expel air. –To prevent flatulence
Lubricate 5cm or 2 inches of the rectal tube—to
prevent trauma to the anorectal mucosa
Promotes relaxation- to prevent feelings of
embarrassment
Introduce solution slowly– to prevent sudden stimulation of
peristalsis
Change position to distribute solution well in the colon in high
enema. In low enema, the client should remain in left lateral
position
If the order is cleansing enema: give the enema 3 times
Alternate hypotonic solution( soap suds, tap water) with isotonic
solution (normal saline solution) to prevent water intoxication.
Water intoxication may cause increased ICP
If abdominal cramps occur during introduction of solution, temporarily stop
the flow by clamping the tubing until peristalsis returns
After introduction of the solution, press buttocks together to inhibit the urge
to defecate--- to retain the solution for few minutes for better cleansing
effect of the solution
Ask the client who is using the toilet not to flush it. The nurse should
actually assess the return flow of the solution.
Do perinea care after the procedure for cleanliness and comfort
Make relevant documentation
Other Important Considerations in Enema Administration
Patients who have had recent surgery, or who have arthritis, a cast, lower limb
amputations, or fractured pelvis--------- may need additional time for the
procedure, owing to limited physical mobility.
Patients with spinal cord injury, high blood pressure and heart and blood vessel
disease should be cautioned to avoid excessive straining (Valsalva maneuvre)
during defecation------------ at risk for complications from vagal stimulation
(bradycardia, syncope, n/v)
An enema should not be administered to a patient with rectal bleeding,
abdominal pain, prolapsed rectal tissue, myocardial infarction, or arrhythmias.
 GENERAL NURSING
CONSIDERATIONS
AND INTERVENTIONS
WHEN
ADMINISTERING
ENEMAS ON INFANTS
AND CHILDREN
HOLISTIC APPROACH IN ADMINISTERING ENEMA TO
PEDIATRIC CLIENTS
Provide a careful explanation to the parents and child before
the procedure.
Parents should be allowed to comfort infants and children
and participate in the procedure.
An enema is an intrusive procedure and therefore threatening
to the child.
Care should be taken in insertion of the enema tube and instillation of the
solution to prevent injury to anus and colon during the procedure.
Insert the tube 5 to 7.5 cm (2 to 3 in.) in the child and only 2.5 to 3.75 cm
(1 to 1.5 in.) in the infant.
Enema temperature should be 37.7°C (100°F) unless otherwise
ordered.
For infants and small children, the dorsal recumbent position is frequently
used.
Infants and small children do not exhibit sphincter control and
need to be assisted in retaining the enema.
Administer the enema while the infant or child is lying with the
buttocks over the bedpan, and the nurse firmly presses the
buttocks together-------- to prevent the immediate expulsion of the
solution.
Place the underpad under the client’s buttocks to protect the bed
linen, and drape the client with the bath blanket.
Older children can usually hold the solution if they
understand what to do and are not required to hold it for
too long a period.
It may be necessary to ensure that the bathroom is
available for an ambulatory child before starting the
procedure or to have a bedpan ready.
GENERAL NURSING
CONSIDERATIONS
AND
INTERVENTIONS
WHEN
ADMINISTERING
ENEMAS ON OLDER
ADULTS
For Geriatric Patients/ Older adults
May need more time and instruction of the procedure for optimal
participation and results.
May fatigue easily.
May be more susceptible to fluid and electrolyte imbalances.
Use tap water enemas with great caution.
 Monitor their tolerance during the procedure, watching for vagal episodes
(e.g., slow pulse) and dysrhythmias.
Protect their skin from prolonged exposure to moisture.
Assist them with perineal care as indicated.
 NURSING
RESPONSIBILITIES BEFORE,
DURING AND AFTER
ADMINISTERING ENEMAS
 NURSING RESPONSIBILITIES BEFORE ADMINISTERING ENEMAS
Check the physicians order
Be familiar with the various kinds of enemas that may be ordered, their
purpose and administration
Verify informed consent; meets patient’s right to be informed; encourages
cooperation and participation.
Assess patient’s ability to participate.
 NURSING RESPONSIBILITIES BEFORE ADMINISTERING ENEMAS
Gather all equipment and place in an easy to access area in patient’s room;
adjust lighting as needed--------Promotes organization of equipment; saves
time; and adjusted lighting enhances visualization for procedure.
Explain to the patient the benefits of relaxing and taking periodic deep
breaths.-------- Reduces anxiety and promotes comfort.
Check patient’s ability to retain fluid and tolerate the activity ordered, their
purpose and administration
Determine the presence of kidney or cardiac disease
 NURSING RESPONSIBILITIES DURING ENEMA ADMINISTRATION
the nurse explains the correct procedure to the patient
The nurse assists the adult client to a left lateral position, with the leg as
acutely flexed as possible
The nurse must see to it that enema is administered to the correct patient
The nurse encourages the patient to retain fluid as long as possible
The nurse assists the patient to the bed pan
 NURSING RESPONSIBILITIES AFTER ENEMA ADMINISTRATION
Record date, time, type, and results of enema administration, as well as
amount and other important characteristics of stool (as required in the
designated area on the patient record).
Record patient’s tolerance of procedure and any complications that
occurred.
Report patient teaching about prevention of constipation.
Instruct patients with cardiovascular disease not to strain when expelling
contents. Avoids creating the Valsalva maneuver, which can lead to sudden
cardiac arrest.
Assist patient with personal hygiene as needed. Provides patient comfort,
and reduces transmission of infectious microorganisms.
 ADMINISTERING ENEMAS AND RELEVANT
NURSING DIAGNOSES
Constipation related to decreased peristalsis
Chronic pain related to abdominal discomfort and distention from bowel
malfunction
Potential for injury related to abdominal distention and trauma to the anus
and colon during the procedure
EXPECTED OUTCOMES
Patient will return to an optimal bowel elimination pattern
Patient is able to assist/participate
Patient will be able to evacuate feces from rectum and colon after the
enema
Patient experiences minimal discomfort during procedure and no injury to
the colon and/or anus
Patient experiences relief and comfort after procedure
 PERFORMANCE
EVALUATION IN
ADMINISTERING ENEMA
(CHECKLIST)
 PREPARATION
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
Assemble equipment:
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.
 Procedure
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. Insert the enema tube.
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.
6. Slowly administer the enema solution.
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.
7. Encourage the client to retain the enema.
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.
8. Assist the client to defecate.
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.
Variation: Administering an
Enema to an Incontinent
Client
Procedure
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.
Variation: Administering a
Return-Flow Enema
Procedure
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 procedure.
9. Document:
The type and volume if appropriate of enema given
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.
 SIPHONING AN ENEMA
This is done when enema solution is not drained adequately
NURSING INTERVENTIONS
Use water at 40C or 105 f
Place client in right side lying position
Height of enema: 10 cm or 4 inches above anus
Quickly lower enema container after introduction of solution
Note amount of liquid siphoned off as well as color, odor, presence of any
feces of abnormal constituents such as blood or mucus
Complications of Enema Administration
Muscle tone loss
Fluid overflow
Bowel irritation
Internal hemorrhaging caused by an imbalance of
electrolytes.
 Barium enema
an X-ray exam that can detect changes or abnormalities in the large
intestine (colon).
The procedure is also called a colon X-ray or lower GI series
Barium sulfate is administered per rectum---coats the lining of the colon.
The barium coating results in a relatively clear silhouette of the colon.
 Barium enema
Client Preparation
Ensure presence of a signed informed consent for the procedure.
Provide or instruct to follow a low residue or clear liquid diet for 24 hours
prior to the test.
All food and fluids may be withheld for 8 hours prior to the test.
Administer or instruct to use laxatives, enemas, or suppositories as
ordered the evening prior to the procedure.
Bowel preparation----- may be ordered for the morning just prior to
the procedure.
After Procedure
A laxative will be given.—barium causes constipation
The stools may be white for the next 1 to 2 days.—expected outcome
Instruct to increase fluid intake – to excrete barium that can cause
constipation
Observe for sign of barium impaction: distended abdomen and
constipation
 REFERENCES
FUNDAMENTALS OF NURSING, KOZIER AND ERB, 10TH EDITION.
BRUNNER AND SUDDHARTS MEDICAL SURGICAL NURSING 12TH
EDITION
MEDICAL SURGICAL NURSING, JOSIE UDAN. 3RD EDITION
MOSBY’S COMPREHENSIVE REVIEW OF NURSING FOR NCLEX, 20TH
EDITION.
SAUNDERS COMPREHENSIVE REVIEW OF NURSING FOR NCLEX,
6TH EDITION.
Thank you!