ROBERT A. CABAÑES, MANClinical instructor

Enema

An enema is the insertion of a solution into the rectum and lower intestine.

The instilled solution distends the intestine and may irritate the intestinal mucosa, thus increasing persistalsis.

Classification of Enema

Cleansing enemas

Retention enemas

Return-flow enemas

Cleansing enemas are given to remove feces from the colon. They are classified as large-volume and small-volume cleansing enemas. Large-volume enemas are also known as hypotonic or isotonic, depending on the solution used. Small-volume enemas are also known as hypertonic enemas.

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:

Infant: 250 cc or less Toddler and preschooler: 500 cc or less School-aged child: 500–1, 000 cc Adult: 750–1, 000 cc

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.

SOLUTION AMOUNT ACTION TTIME TO TAKE

EFFECT

ADVERSE EFFECTS

Tap Water (Hypotonic)

Normal saline (Isotonic)

Soap

500 – 1000 mL

500 – 1000 ml

500 – 1000 ml (concentrate

at 3 -5 mL/1000 mL)

Distends intestine, increases persistalsis, soften stools

Distends intestine, increases persistalsis, soften stools

Distends intestine, increases persistalsis, soften stools

15 min

15 min

10 – 15 min

Fluid & electrolyte imbalance, water intoxication

Fluid & electrolyte imbalance, sodium retention

Rectal mucosa irritation or damage

SOLUTION AMOUNT ACTION TTIME TO TAKE

EFFECT

ADVERSE EFFECTS

Hypertonic

Oil (mineral, olive or cottonseed oil)

70 – 130 mL

150 – 200 mL

Distends intestine, irritates intestinal mucosa

Lubricates stool and intestinal mucosa

5 – 10 min

30 min

Sodium retention

Retention enemas are retained in the bowel for a prolonged period for different reasons.

Carminative enemas help to expel flatus from the rectum and provide relief from gaseous distention. Common solutions include the milk-and-molasses (equal parts) and the magnesium-sulfate-glycerin water (MGW) enema.

Medicated enemas provide medications that are absorbed through the rectal mucosa.

Antihelmintic enemas destroy intestinal parasites.

Nutritive enemas, administer fluids and nutrition rectally.

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.

Return-Flow Enemas or Harris flush enemas are occasionally prescribed to expel flatus. For an adult 100 to 200 mL of a solution is instilled into the rectum and sigmoid colon, and then the solution container is lowered so that the solution flows back into the container. This process is repeated 5 or 6 times, & the alternating flow of the solution stimulates peristalsis and aids in expelling flatus.

ADMINISTERING A

CLEANSING ENEMA

Equipment

Solution as ordered by the physician at a temperature of 105° to 110°F (40° to 43°C) for adults in the appropriate amount (amount will vary depending on type of solution, patient’s age, and patient’s ability to retain the solution. Average cleansing enema for an adult may range from 750 to 1,000 mL.)

Disposable enema set Water-soluble lubricant IV pole Necessary additives as ordered (eg, soap, salt) Waterproof pad Bath thermometer (if available) Bath blanket Bedpan and toilet tissue Disposable gloves Paper towel Washcloth, soap, and towel

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.

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.

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.

SSESSMENT

Assess the patient’s abdomen, including auscultating for bowel sounds, percussing, and palpating. Since the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, the nurse will assess the abdomen before and after the enema. Inspect the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If any of these are noted, added care should be taken while administering enema.

Check the results of the patient’s laboratory work, specifically the platelet count and white blood cell (WBC) count. A normal platelet count ranges from 150,000 to 400,000/mm3. A platelet count of less than 20,000 may seriously compromise the patient’s ability to clot blood. Therefore, any unnecessary procedures that would place patient at risk for bleeding or infection should not be performed. A low WBC count places the patient at risk for infection.

NURSING DIAGNOSES

Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include:

Acute Pain Constipation Risk for Constipation Risk for Injury

Outcome Identification and Planning

The expected outcome to be met when administering a cleansing enema is that the patient expels feces and reports a decrease in pain and discomfort. In addition, the patient remains free of any evidence of trauma to the rectal mucosa.

IMPLEMENTATION

(Cleansing Enema)

Action 1. Verify physician’s orders, gather necessary equipment, and explain procedure to patient, including where he or she will defecate. Have a bedpan, commode, or nearby bathroom ready for use.

Rationale 1. Verifying the physician’s order is crucial to ensuring that the proper enema is administered to the right patient. Organization facilitates performance of tasks. Explanation helps to minimize anxiety. The patient is better able to relax and cooperate if he or she is familiar with the procedure and knows everything is in readiness when the urge to defecate is felt. Defecation usually occurs within 5 to 15 minutes.

Action 2. Warm solution in amount ordered, and check temperature with a bath thermometer if available. (If bath thermometer is not available, warm to room temperature or slightly higher, and test on inner wrist.) If tap water is used, adjust temperature as it flows from faucet.

Rationale 2. Warming the solution prevents chilling the patient, adding to the discomfort of the procedure.

Action 3. Perform hand hygiene.

Rationale 3. Hand hygiene deters the spread of microorganisms.

Action 4. Add enema solution to container. Release clamp and allow fluid to progress through tube before reclamping.

Rationale 4. This causes any air to be expelled from the tubing. Although allowing air to enter the intestine is not harmful, it may further distend the intestine.

Action 5. Position waterproof pad under patient.

Rationale 5. The waterproof pad protects bed linen.

Action 6. Provide for privacy. Position and drape the patient on the left side (Sims position) with anus exposed on the back, as dictated by patient comfort and condition.

Rationale 6. The patient’s comfort and warmth help him or her relax. The exact position of the patient has not been found to alter the results of an enema significantly.

Action 7. Put on nonsterile gloves.Rationale 7. Gloves protect nurse from

microorganisms in feces.

Action 8. Elevate solution so that it is no higher than 45 cm (18) above level of anus. Plan to give the solution slowly over a period of 5 to 10 minutes. The container may be hung on an IV pole or held in the nurse’s hands at the proper height.

Rationale 8. Gravity forces the solution to enter the intestine. The amount of pressure determines the rate of flow and pressure exerted on the intestinal wall. Giving the solution too quickly causes rapid distention and pressure, poor defecation, or damage to the mucous membrane.

Action 9. Generously lubricate end of rectal tube for 5 to 7 cm (2 to 3). A disposable enema set may have a prelubricated rectal tube.

Rationale 9. Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa.

Action 10. Lift buttock to expose anus. Slowly and gently insert the enema tube 7 to 10 cm (3 to 4). Direct it at an angle pointing toward the spine, not bladder. Ask patient to take several deep breaths.

Rationale 10. Good visualization of the anus helps prevent injury to tissues. The anal canal is about 2.5 to 5 cm (1 to 2) long. The tube should be inserted past the external and internal sphincter, but further insertion may damage intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus will help to prevent perforation of the bowel. Slow insertion of the tube minimizes spasms of the intestinal wall and sphincters. Deep breathing helps relax he anal sphincter.

Action 11. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of the tube. Ask patient to take several deep breaths.

Rationale 11. Resistance may be due to spasms of the intestine or failure of the internal sphincter to open. The solution may help to reduce spasms and relax the sphincter, thus making continued insertion of the tube safe. Forcing a tube may injure the intestinal mucosa wall. Taking deep breaths helps relax the anal sphincter.

Action 12. Introduce solution slowly over a period of 5 to 10 minutes. Hold tubing all the time that solution is being instilled.

Rationale 12. Introducing the solution slowly helps prevent rapid distention of the intestine and a desire to defecate.

Action 13. Clamp tubing or lower container if patient has desire to defecate or cramping occurs. Patient also may be instructed to take small, fast breaths or to pant.

Rationale 13. These techniques help relax muscles and prevent premature expulsion of the solution.

Action 14. After solution has been given, clamp tubing and remove tube. Have paper towel ready to receive tube as it is withdrawn. Have patient retain solution until urge to defecate becomes strong, usually in about 5 to 15 minutes.

Rationale 14. This amount of time usually allows muscle contractions to become sufficient to produce good results.

Action 15. Remove nonsterile gloves from inside out and discard.

Rationale 15. This protects nurse from contact with any microorganisms.

Action 16. When patient has a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom. Stay with patient or have call light readily accessible.

Rationale 16. The sitting position is most natural and facilitates defecation. Fall prevention is a high priority due to the urgency of reaching the commode.

Action 17. Record character of stool and patient’s reaction to enema. Remind patient not to flush commode before nurse inspects results of enema.

Rationale 17. The nurse needs to observe and record the results. Additional enemas may be necessary if physician has ordered enemas “until clear.”

Action 18. Assist patient if necessary with cleaning of anal area. Offer washcloths, soap, and water for handwashing.

Rationale 18. Cleaning the anal area and proper hygiene deter the spread of microorganisms.

Action 19. Leave the patient clean and comfortable. Care for equipment properly.

Rationale 19. Bacteria that grow in the intestine can be spread to others if equipment is not properly cleaned.

Action 20. Perform hand hygiene.Rationale 20. Hand hygiene deters the

spread of microorganisms.

Action 21. Document the following: amount and type of enema solution used; amount, consistency, and color of stool; pain assessment rating; assessment of perineal area for any irritation, tears, or bleeding; and patient’s reaction to procedure.

Rationale 21. Proper documentation facilitates continuity of care and ensures communication.

Evaluation

The expected outcome is met when peristalsis is increased so that the patient expels feces and reports a decrease in pain and discomfort. In addition, the patient exhibits no evidence of trauma to the rectal mucosa.

Unexpected Situations

and Associated

Interventions

Solution does not flow into rectum: Reposition rectal tube. If solution will still not flow, remove tube and check for any fecal contents.

Patient cannot retain enema solution for adequate amount of time: Patient may need to be placed on bedpan in the supine position while receiving enema. The head of the bed may be elevated 30 degrees for the patient’s comfort.

Patient cannot tolerate large amount of enema solution: Amount and length of administration may have to be modified if patient begins to complain of pain.

Patient complains of severe cramping with introduction of enema solution: Lower solution container and check temperature and flow rate. If the solution is too cold or flow rate too fast, severe cramping may occur.

Special Considerations

If enema has been ordered to be given “until clear,” check with the physician before administering more than three enemas. Severe fluid and electrolyte imbalances may occur if the patient receives more than three cleansing enemas. Results are considered clear whenever there are no more pieces of stool in enema return. The solution may be colored but still considered a clear return.

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