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:
distend the intestine To
sometimes to irritate the and
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.Cleansing
Enema
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
ADMINISTRATIO
N
 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
(pressure)
force 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
1teaspoon of table salt
with 500 mL of tap water.
Use enemas only as directed. Do
notrely on them for regular
bowel evacuation.
Prior to administration,
makesure 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
enema.
Change In low enema, the client should remain in left lateral
position
position
If the order is cleansing enema: give the enema 3 times
to
Alternate hypotonic solution( soap suds, tap water) with isotonic
solution (normal saline solution) to prevent water intoxication.
distribut
Water intoxication may cause increased ICP
e
solution
well
in
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 child ren 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
AFTERADMINISTERING
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 aspecimen 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!