Nursing Interventions for Enema Administration
April 27, 2010 | In: Nursing Interventions
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- Check the doctor’s order.
- Provide privacy. To prevent feeling of embarrassment.
- Promote relaxation. To relax anal sphincter and facilitate insertion of rectal tube.
- Position the client:
- Adult – left lateral position.
- Infant/Small children – dorsal recumbent position.
- Sizes of rectal tube to be used are as follows:
- Adult – Fr. 22-32
- Children – Fr. 14-18
- Infant – Fr. 12
- Lubricate 5 cm (2 in) of the rectal tube.
- Allow solution to flow through the connecting tubing and rectal tube to expel air before insertion of rectal tube. This prevents introduction of air into the colon.
- Inset 7-10 cm (3-4 in) of rectal tube gently in rotating motion. To prevent irritation of anal and rectal tissues.
- Introduce solution slowly. To prevent sudden stimulation of peristalsis, and the client can better tolerate introduction of solution.
- Change the position to distribute solution well in the colon (high enema); if low enema, remain in left lateral position.
- If the order is cleansing enema:
- Give the enema 3 times.
- Alternate hypotonic solution with isotonic solution to prevent water intoxication or hypoosmolar fluid imbalance.
- If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution by clamping the tube until peristalsis relaxes.
- After introduction of the solution, press buttocks together to inhibit the urge to defecate.
- Ask the client who is using the toilet not to flush it. The nurse must observe the return flow.
- Do perianal care.
- Make relevant documentation.