ENEMA and Nursing Intervention

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Enema

- A solution introduced into the rectum and sigmoid colon. Its function is to remove feces and/or flatus

Classification

1. Cleansing

2. Carminative

3. Retention

4. Return flow

 

Cleansing enema

• Stimulates peristalsis by irritating the colon and rectum and by distending the intestine with the volume of fluid introduced.

• Cleansing enemas are most effective if held for 5 to 10 min.

Cleansing enema-Types

1. High enema

• To clean as much of the colon as possible.

• Used before diagnostic studies.

• Often about 1liter of solution is administered to an adult.

• The client changes from the left lateral to the dorsal recumbent position and then to the right lateral position during the administration so that the fluid can follow the large intestine

2. The low enema

• Used to clean the rectum and the sigmoid colon only.

• About 0.5 liters of solution is administered to an adult,

• client maintains the left side lying position during its administration.

 

Carminative enema

• A 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 180 ml of fluid is instilled.

 

Retention enema

• A retention enema introduces oil into the rectum and sigmoid colon. The oil is retained for a relatively long period of time (e.g., 1 to 3 hours). It acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating passage of the feces.

 

Return flow enema

• A return flow enema, sometimes referred to as the Harris flush or colonic irrigation, is used to expel flatus.

• Alternating flow of 100-200 ml of fluid into and out of the large intestine stimulates peristalsis and the expulsion of feces.

 

Enemas Commonly Used for Adults


Preparation Name

Constituents

Commercially prepared enema

90-120 ml of a hypertonic solution. E.g. Sodium phosphate

Saline

9 ml of sodium chloride to 1000 ml of water

Tap water

500-1000 ml of tap water

Soap

20 ml of castile soap in 500-1000 ml of water

 Oil, e.g., olive oil

90-120 ml of oil (commercially prepared): mineral, olive, or cotton seed

 

Complications / Risks of Enema

- Enema is a relatively safe procedure.

Main dangers are:

• Irritation of the rectal mucosa by too much soap or an irritating soap.

• Osmosis (fluid drawn into colon from surrounding tissues) if hypertonic solution is used.

• Water intoxication if hypotonic solution is used.

• Electrolyte imbalances.

 

Precautions of Enema

• Given only small amount of fluid.

• Retention only for 5-7 min.

• Not used for children under 2 years unless there are specific instructions.

• More than 3 tap water enemas is not given consecutively. (Even if written enemas until return flow is clear.

 

Guidelines for Administering Enema

• Use appropriate size rectal tube. No, 22-30 Fr, for adults, No. 14-18 for toddler and school age children, No. 12 for infants.

• Rectal tube must be smooth and flexible with one or two openings at the end for the solution to flow. A tube with a sharp or ragged edge should not be used, because it may damage the mucus membranes of the rectum.

• The rectal tube is lubricated with a water soluble lubricant to facilitate insertion and decrease irritation of the rectal mucosa.

• Use the solution at an appropriate temperature. High temperature can injure bowel mucosa and cold temperatures are uncomfortable for the client and may cause spasm of the sphincter muscles.

• Ideal temperatures are:

– Adult 40.5-430 C. (105-1100 F)

– Children 37.70 C. (1000 F)

• The amount of solution to be given depends on the kind of enema, the age and size of the person, the amount of fluid that can be retained.

– Infant 250 ml or less.

– Toddler/preschooler 250-350 ml or less

– School age child 300-500 ml

– Adolescent 500-750 ml.

– Adult 750-1000 ml.

• Position – Left lateral with right leg flexed.

• The length of the tube inserted depends on the age and size of the person.

– Adults 7.5-10 cm (3-4 inches)

– Children 5-7.5 cm (2-3 inches)

– Infants 2.5-3.75 cm (1-1.5 inches)

• The force of flow of the solution is controlled by :

– The height of the solution container. The higher the container is held, the faster the flow. The recommended height are 30 cm (12 inches) for adults for ordinary enema and 30-45 cm (12-18 inches) for high cleansing enema. For infants 7.5 cm (3 inches)

– Size of the tubing.

– Viscosity of the fluid.

– Resistance of the rectum.

• Time taken to administer an enema depends on the amount of fluid. Large volumes take (1000 ml) 10-15 min.

• Time of retention of enema depends on the purpose of the enema and the ability of the client to contract the external sphincter. Oil retention enemas are retained for 30 minutes. Other enemas are retained for 5-10 minutes.

• To retain enema for an unconscious patient, press the buttocks together, providing pressure over the anal area.

• While the enema solution is in the body, the client may have a feeling of fullness and some abdominal discomfort.

• When it is time for the client to defecate, assist the person to a commode or toilet.

• For self administration of an enema, an adult can assume a back-lying position.

 

Technique for Administering Enema

• See the doctor’s order. According to the hospital policy the nurses can give enema at their discretion, if there is a SOS or prn order.

• While giving commercially prepared solutions the nurse must follow the manufacturer’s instructions, unless there are other instructions from the physician or the hospital.

Equipment

• A disposable enema unit or

• An enema set

Enema set

• A container to hold the solution

• A tubing to connect the container to the rectal tube

• A clamp (to compress the tubing & to control the flow)

• Rectal tube of the correct size

• Lubricant

• A bath thermometer to check the temperature of enema.

• Soap, salt or other ingredients.

• Prescribed amount of solution at the correct temperature. Nurse places the solution in the container, check the temperature and adds the soap, salt and other ingredients.

• A bath blanket to drape the patient.

• Tissue wipes.

• A water proof absorbent pad to protect the bed.

• A bedpan or commode

• Gloves

 

Procedure for Administering Enema


Steps

Rationale

Explain the procedure to the client. Inform that there may be a feeling of fullness while the solution is being administered.

Assist adult and school aged clients to a left lateral position, with the right leg acutely flexed and drape with bath blanket.

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

Having the right leg acutely flexed provides for adequate exposure of the anus.

Place a water proof  pad under the clients buttocks.

To protect the bed linen.

Open the clamp and run some solution through the connecting tube and the rectal tube, then close the clamp.

This will expel the air in the tubing. Air instilled into the rectum causes unnecessary distention.

Lubricate 5 cm (2 inches) of the rectal tube if the enema is for an adult and 2.5 cm (1 inch) for children.

Lubrication facilitates insertion through the sphincters and minimizes trauma.

Don gloves, insert the rectal tube smoothly and slowly into the rectum, directing it toward the umbilicus. Insert an appropriate length and note any discomfort or obstruction on insertion.

Inserting the tube towards the umbilicus guides the tube along the length of the rectum. The rectal tube is inserted beyond the internal sphincter.

If resistance is encountered at the internal sphincter, ask the client to take a deep breath, and run a small amount of the solution through the tube. If the resistance persists, withdraw the tube and report the resistance to the nurse in charge/physician.

Deep breathing and inserting a small amount of the solution may relax the sphincter.

If there is no resistance, open the clamp, and raise the solution container to the appropriate height above the rectum.

This height ensures adequate flow and the pressure exerted is not high, so that there is no damage to the lining of the rectum.

Administer fluid slowly. If the client complaints of fullness or pain, stop the flow for 30 sec. Restart the flow at a slower rate. Ask the client to breath slowly through the mouth to assist relaxation. If the nurse is using a plastic commercial container, roll it up as the fluid is instilled.

Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution. Rolling up the container prevents subsequent suctioning of the solution.

After all the solution has been instilled or when the client can not hold more and wants to defecate, close the clamp and remove the rectal tube.

The urge to defecate usually indicates that sufficient fluid has been administered.

Apply firm pressure over the anus with tissue wipes or press buttocks to assist retention of enema. Ask the client to remain lying down. Encourage the client to hold the enema.

Some enemas are more effective if they are retained from 5-10 minutes.

It is easier for a person to retain the enema while lying down than sitting or standing because gravity promotes drainage and peristalsis.

Assist the client to a sitting position on a bed pan, commode or toilet.

A sitting position promotes defecation

Record the procedure, the amount, color, consistency of returns, the presence of unusual constituents ( e.g. worms ) and relief of abdominal distention or flatus and all assessment.

Proper recording enhances accountability.

 

Inserting the rectal tube following the direction of rectum

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Teach the client practices that develop regular and normal defecation.

• Eating a balanced diet with adequate roughage

• Cereals, raw fruits, raw vegetables.

• Adequate fluid intake (1500 ml daily).

• Eating regular meals

• Regular pattern of defecation

• Regular exercises.

 

Administering Enema For An Incontinent Client

• If the patient can not retain the enema even for a few minutes, administer the enema when the client is in supine position on a bedpan. The head end of the bed can be slightly elevated (30º). Support the head and back with pillows.

• Hold the rectal tube with a gloved hand and administer the enema.

• The solution and feces are expelled and flow into the bedpan while administering the fluid.

 

Return flow enema (Harris flush; Colonic irrigation)

• It is a repetitive instillation and drainage of fluid to and from the rectum. It is similar to administering and siphoning an enema.

• Initially the solution (100-200 ml for an adult) is instilled into 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.

• This alternating flow of fluid into and out of the large intestine stimulates peristalsis and the expulsion of the flatus.

• The inflow and out flow process is repeated five or six times, and the solution is replaced several times as it becomes thick with feces.

• A total of 1000 ml. of solution is used for an adult.

 

Siphoning an enema

• Sometimes the client is unable to expel the solution after administration of an enema. In such cases the solution is siphoned out of the rectum and colon using the force of gravity.

EQUIPMENT

• Bedpan

•  A funnel

•Rectal tube

• Lubricant

• A container of water at 40 C

 

Procedure

• Position: Right side-lying (sigmoid colon is upper most, facilitating the drainage of the solution from the rectum and the colon).

• Bring the patient close to the side of the bed.

• Place the bedpan on a chair at the side of the bed near to the patient’s hips. The chair should be lower than the bed.

• The rectal tube is lubricated and attached to the funnel.

• The tube and half of the funnel are filled with solution, then the tube is pinched and gently inserted into the rectum as for an enema.

• Hold the funnel about 10 cm (4 inches) above the anus, release the pinched rectal tube and quickly lower the funnel over the bedpan. This action draws the fluid from the colon and rectum, permitting it to flow through the rectal tube and funnel into the bedpan. Note the color, odor and presence of abnormal substances such as blood and mucus in the return flow.

 

Home administration of enemas

• Teach the patient or care giver, when it is ordered for a specific reason.

• Explain that disposable enema units are available and how to administer an enema by one self.

• Assume a back lying position or left lateral position.

• Use protective bed cover or pad under the buttocks.

• Liberally lubricate the nozzle tip before insertion, never forcefully insert.

• Administer the fluid slowly and retain it for 5-10 minutes, if possible.

• The disposable enema kits contain sodium salts which can be absorbed from colon

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