Assisting with Elimination
Administering a Cleansing Enema
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Safety
- When handling fecal matter, always use standard precautions.
- Reduce the transmission of C. difficile spores by using a bowel management system if not contraindicated.
- Answer the call light promptly to prevent the patient from trying to get out of bed without assistance.
- To avoid water toxicity or circulatory overload, do not repeat a tap water (hypotonic) enema after the first installation.
- Give no more than three consecutive enemas, to avoid the disruption of fluid and electrolyte balance. Observe the contents of the solution passed.
- Administering an enema with the patient sitting on a toilet is unsafe because the curved rectal tubing can abrade the rectal wall.
- Use a warmed solution—not hot or cold water—when providing an enema.
- To avoid rapid instillation of fluid, do not raise an enema container too high. Lower the container or clamp the tubing if the patient complains of cramping or if fluid escapes around the rectal tube.
- If the tube does not pass easily, do not force it. If you feel resistance or if severe abdominal cramping, bleeding, or sudden abdominal pain develops, stop the enema and notify the health care provider.
Equipment
(Roll cursor over items to see labels)
Enema container with tubing and clamp
Basin
Bedside commode
Bedpan
Waterproof absorbent pads
Towel and washcloth
Clean gloves
Toilet tissue
Rectal tube
Enema solution mix
Prepackaged enema container with lubricated rectal tip (optional)
Soap
Water-soluble lubricant
PrintableDelegation
The skill of enema administration can be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:
- Review proper positioning of patients who have mobility restrictions or therapeutic equipment, such as drains, intravenous catheters, or traction.
- Explain that if the patient has any abdominal pain or rectal bleeding, it must be reported to you immediately. An exception is if the patient reports cramping.
- Emphasize that if the patient has any blood in the stool or around the rectal area or if there is any change in the patient’s vital signs, the information must be reported to you immediately.
Preparation
- Review the health care provider’s order for an enema, and clarify the reason for administration.
- Assess the patient’s status: last bowel movement, normal versus most recent bowel pattern, presence of hemorrhoids, mobility, and presence of abdominal pain.
- Inspect the patient’s abdomen for the presence of any distention, and auscultate for bowel sounds.
- Determine the patient’s level of understanding regarding the purpose of the enema.
- Determine the need for an enema and the type of enema to be used. Identify a baseline for bowel functioning.
- Establish a baseline for determining the effectiveness of the enema.
Follow-up
- Inspect the color, consistency, and amount of stool. Note its odor and the amount of fluid passed.
- Assess the patient for abdominal distention.
Documentation
- Record the type, volume of enema given, time of administration, characteristics of the results, and the patient’s tolerance of the procedure.
- Report to the health care provider if the patient fails to defecate or has any adverse effects.
Review Questions
1. Which action would the nurse take to ensure the safety of an older adult patient who has received an enema?
Assess for the presence of external hemorrhoids.
Provide assistance to the bathroom for expulsion of fluid and stool.- Document the patient’s physical response to the enema.
- Instruct the patient to attempt to retain the fluid for 2 to 5 minutes.
INCORRECT. While a patient with hemorrhoids may require special care during insertion of the tip of the rectal tube, this intervention pertains to the patient’s comfort, not to his or her safety.
CORRECT. Assisting an older adult to the bathroom helps ensure the patient’s safety because it may prevent a fall.
INCORRECT. Documenting the patient’s physical response to the enema is appropriate, but this action pertains to recording and reporting, not safety.
INCORRECT. Such instructions may help make the enema more effective, but will not make it safer.
2. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?
- Place the patient in a side-lying position with the right knee flexed.
- Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube.
- Flush the tube with the solution
- Hold the tube in the rectum until all of the fluid has been instilled.
INCORRECT. This position aids in retention of the solution. It does not facilitate insertion of the rectal tube.
CORRECT. This technique facilitates insertion of the rectal tube.
INCORRECT. Flushing the tubing with solution will not facilitate insertion of the rectal tube.
INCORRECT. This technique helps minimize the possibility of expelling the rectal tube. It does not, however, facilitate insertion of the tube.
3. The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow up?
- “I’ll need help to turn her onto her side.”
- “It may take three or four enemas to achieve a clear return.”
- “I’ll test the water temperature on the inside of my own wrist.”
- “The enema will wear her out, so I’ll wait until after she ambulates.”
INCORRECT. This statement requires no follow-up, since more than one person may be required to turn a patient onto her side.
CORRECT. This statement requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas.
INCORRECT. Testing the water temperature on the wrist is appropriate, so this statement requires no follow-up.
INCORRECT. This statement reflects appropriate concern for the patient and requires no follow-up.
4. The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow up?
- “I’ll warm up the solution before instilling it.”
- “I’ll place the patient in the left side-lying position with the right knee bent.”
- “I’ll put a waterproof pad under the patient before I start.”
- “I’ll instill the solution and then check in on my other patients until I get the call signal.”
INCORRECT. Warming the solution is appropriate.
INCORRECT. The patient is placed in a left side-lying position to allow the solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum.
INCORRECT. A waterproof pad may be placed under the patient if necessary.
CORRECT. After instilling the solution, NAP should remain with the patient until he or she is ready to defecate.
5. Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia?
- Lubricate the tip of the rectal tube.
- Pad the patient’s bed thoroughly.
- Perform hand hygiene before donning gloves.
- Help the patient onto a bedpan to expel the enema fluid and stool.
INCORRECT. While this action is appropriate, it pertains to instillation of the enema, not to reducing the risk of infection.
INCORRECT. While this action is appropriate, it pertains to the patient’s comfort, not to reducing the risk of infection.
CORRECT. Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff.
INCORRECT. While this action is appropriate, it pertains to the procedure itself, not to reducing the risk of infection.
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