ENEMARODEL A. SAÑO,

RM, RNClinical Instructor

DefinitionA procedure of evacuation or washing out of waste materials (feces or stool) from a person’s lower bowel.

Enema administration involves in stilling a solution into the rectum, colon & large intestines.

Is performed using a flexible plastic rectal tube with several large holes in the tip.

This is connected to the tubing from a solution bag or container.

What is Enema?

ENEMA is a solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus.

ActionAfter introduction of solution, the intestine becomes distended and there will be irritation of intestinal mucosa which results to increase peristalsis. Thus, excretion of feces/flatus.

Types of EnemaCleansingRetention Return FlowCarminative

TYPES OF ENEMAS A. CLEANSING ENEMA = are intended to remove feces. They are given chiefly to:

1. Prevent the escape of feces during surgery.

2. Prepare the intestine for certain diagnostic tests such as x –ray or visualization tests ( e.g. colonoscopy )

3. Remove feces in instances of constipation or impaction.

Cleansing Enema uses a variety of solution :

SOLUTION CONSTITUENTS ACTION

TIME TO

EFFECT

ADVERSE EFFECTS

Hypertonic

90-120ml of solution e.g. sodium phosphate

Draws water into the colon

5-10 mins.

Retention of sodium

Hypotonic 500-1,000 ml of tap water

Distends colon, stimulates peristalsis and softens feces

15-20 mins.

Fluid and electrolyte imbalance, water intoxication

Isotonic 500-1,000 ml of normal saline ( 9 ml to 1,000 ml water)

Distends colon, stimulates peristalsis and softens feces

15-20 mins.

Possible sodium retention

Soapsuds 500-1,000 ml soap to 1,000 ml water

Irritates mucosa, distends colon

10 – 15 mins.

Irritates and may damage mucosa.

Tap water Normal saline solution Soapsuds solution Hypertonic solution

Common solution for cleansing enemas

B. RETENTION ENEMA = introduces oil or medication into the rectum and sigmoid colon. The liquid is retained for a relatively long period. An oil retention enema acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating passage of the feces. Antibiotic enemas are used to treat infections locally, anthelmintic enemas to kill helminths such as worms and intestinal parasites and nutritive enemas to administer fluids and nutrients to the rectum.

Retention enemas are given to:

a. Softens the hardened stool & allow normal elimination

b. Lubricate the inside surface of the lower intestine

c. Soften the stool, if necessary d. Ease the passage of feces without straininge. Provide laxative benefits when oral laxatives

are not allowedf. Soften fecal impaction when straining might

be harmful or painful.

C. RETURN – FLOW ENEMA = is used occasionally to expel flatus Alternating flow of 100 to 200 ml of fluid into and out of the rectum and sigmoid colon stimulates peristalsis. This process is repeated five or six times until the flatus is expelled and abdominal distention is relieved.

D. 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 80 ml. of fluid is instilled.

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PRECAUTIONSEnemas should not be used as a

first-line treatment for constipation.

Frequent use of enemas can lead to fluid overload, bowel irritation, and loss of muscle tone of the bowel and anal sphincter.

Never deliver more than three consecutive enemas to treat a patient.

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A patient with diarrhea may not be able to hold an enema.

Must be used with caution in cardiac patients who have arrhythmias or have had a recent myocardial infarction. Insertion of the enema tube and solution

can stimulate the vagus nerve which may trigger an arrythmias such as bradycardia.

PRECAUTIONS

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Enemas should not be given to patients with undiagnosed abdominal pain because the peristalsis of the bowel can cause an inflamed appendix to rupture.

Should be used cautiously in patients who have had recent surgery on the rectum, bowel, or prostate gland.

If the patient has rectal bleeding or prolapse of rectal tissue from the rectal opening, cancel the enema and consult with the physician before proceeding.

PRECAUTIONS

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Do not force the enema catheter into the rectum against resistance. This can cause trauma to the rectal tissue.

Use only mild castile soap (hard white unperfumed soap made from olive oil and lye) for soapsuds enemas because other soap preparations are too harsh and irritate the rectal tissue.

PRECAUTIONS

Guidelines:Adult Childre

nInfant

Size of rectal tube

Fr. # 22-30 Fr.# 14-18 Fr.# 12

Amount of solution

500-1,000 ml

250-500 ml 250ml or less

Distance of tube

insertion

7.5-10 cm (3-4 in)

5-7.5 cm(2-3 in)

2.5-3.75 cm(1-1.5 in)

Solution temperatu

re

40.5-43 C 37.7 C

Purpose 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.

water enemas can cause cardiovascular overload and electrolyte imbalance. Similarly, repeated saline enemas can cause increased absorption of fluid and electrolytes into the bloodstream, resulting in overload. Individuals receiving frequent enemas should be observed for over-load symptoms that include dizziness, sweating, or vomiting

Soap suds and saline used for cleansing enemas can cause irritation of the lining of the bowel, with repeated use or a solution that is too strong. Only white soap should be used; the bar should not have been previously used, to prevent infusing undesirable organisms into the individual receiving the enema. Common household detergents are considered too strong for the rectum and bowel. The commercially prepared soap is preferred, and should be used in concentration no greater than 5 cc soap to 1, 000 cc of water.

Description 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:

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.

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.

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.

Guidelines:Adult Childre

nInfant

Size of rectal tube

Fr. # 22-30 Fr.# 14-18 Fr.# 12

Amount of solution

500-1,000 ml

250-500 ml 250ml or less

Distance of tube

insertion

7.5-10 cm (3-4 in)

5-7.5 cm(2-3 in)

2.5-3.75 cm(1-1.5 in)

Solution temperatu

re

40.5-43 C 37.7 C

Equipments: 1. A tray containing the following:

Rectal catheter Enema can with tubing Lubricant Pitcher with hot and cold water Solution as ordered by the physician Toilet paper Kidney basin Working gloves

2. Apron or gown to protect the uniform2. Bedpan with cover

3. waterproof underpad 4. irrigation stand or IV stand

Assessment: 1.Assess status of client: last bowel movement, normal versus recent bowel pattern, presence of haemorrhoids, mobility, bowel sounds, presence of abdominal pain. (Determine factors indicating need for enema and influencing the type of enema used. Also establishes baseline for bowel function.)

2.Assess medical records for presence of increased intracranial pressure, glaucoma, or recent rectal or prostate surgery.(Conditions contraindicate use of enemas) 3.Inspect abdomen for presence of distention.(Establishes a baseline for determining effectiveness of enema.)

4.Determining client’s level of understanding of purpose of enema.(Allows nurse to plan fro appropriate teaching measure.) 5.Check client’s medical record to clarify reasons for enema.(Determines purpose of enema administration: preparation for special procedure or relief of constipation.)

6.Review physician’s order for enema.(Order by physician is usually required for hospitalized client. Used to determine how many enemas client will require, type of enema to be given.)

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PREPARATION The patient should be encouraged to empty

both bladder and bowels before the procedure.

Before administering an enema, ensure the patient’s privacy by closing the door of the room.

Have the patient undress completely from the waist down.

Position the patient on the bed on his or her left side with the top knee bent and pulled slightly upward toward the chin.

college of nursing

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ENEMASTEPS RATIONALE

1.Inform client about the procedure

To promote cooperation, to minimize anxiety (Evans-Smith)

STEPS RATIONALE2.Wash hands (medical hand washing)

Hand hygiene deters the spread of microorganism (Evans-smith)

STEPS RATIONALE3.Organize the equipment

For efficiency

STEPS RATIONALE4. Place rubber sheet under patient’s buttocks

The waterproof pad/rubber sheets protects bed linen (Evans-Smith)

STEPS RATIONALE5.Prepare solution, making sure that temperature of solution is lukewarm (about 105-110 F)

Warming the solution prevent chilling of the patient, adding to the discomfort of the procedure (Evans-Smith)

STEPS RATIONALE6.Allow solution to run through the tubing so that air is remove. Clamp tubing

Although allowing air to intestine is not harmful, it may further distend the intestine (Evans-Smith)

STEPS RATIONALE7.Place container on bedside IV stand not more than 18-24 inches above buttocks.

Gravity forces the solution to enter the intestine. The amount of pressure determines the rate of flow and pressure exerted on the intestinal wall (Evans-Smith)

STEPS RATIONALE8.Position the patient on side lying position or Sim’s position with knee flexed

Allows enema solution to flow downward by gravity along natural curve of sigmoid colon and rectum, thus improving retention of solution.

STEPS RATIONALE9.Place bedpan within easy reach.

Place bedpan for the desire to defecate

STEPS RATIONALE10.Wear gloves. Lubricate 4-5 inches of catheter tip rectal tube

Gloves protect nurses from microorganism in feces. Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa (Evans-Smith)

STEPS RATIONALE11. Gently spread the buttocks. Instruct patient to take slow deep breaths through mouth.

To relax the sphincter which will ease catheter insertion by breathing into mouth.

STEPS RATIONALE12.Insert rectal tube into the rectum about 3-4 inches and hold in place

The tube should be inserted past the external and internal sphincters, but further insertion may damage intestinal mucous membrane (Evans-Smith)

STEPS RATIONALE13.Release tubing clamp. Allow solution to flow into colon, observing patient closely

Introducing the solution slowly will help to prevent rapid distention of the intestine anda desire to defecate (Evans-Smith)

STEPS RATIONALE14. If patient complaints of cramping, extreme anxiety or inability to retain solution:a.Lower solution

containerb.Clamp or pinch

tubing for few minutes

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

STEPS RATIONALE15.Administer all solution or as much as patient can tolerate, be sure to clamp tubing just before solution clears tubing

Delivers enough solution for proper effectTo avoid introducing of air into the bowel

STEPS RATIONALE16.Slowly remove rectal tubing while gently holding buttocks together.

This amount of time usually allows muscle contraction to become sufficient to produce good results.

STEPS RATIONALE17. Reposition patient on comfortable position

STEPS RATIONALE18.Documents the results

EVALUATION

Were desired outcomes achieved? Example of evaluation include:Desired outcome met. After enema the rectum was free of hard stool, client expelled gas, and abdomen is now soft.Desired outcome met: Client states abdominal pain relieved after enema

Documentation:The following should be noted on patient’s chart• Type and amount of solution used• Color, consistency and amount of stool return• Condition of anus and surrounding area• Status of vital signs before and after enema• Description of adverse reactions during enema• Abdominal assessment before and after enema• Presence of discomfort after enema• Client teaching regarding prevention of

constipation

Sample documentationDate04/11/2011

Time03:45pm

Soap suds enema (750 ml given. Large, dark brown stool returned from enema. No signs of adverse effects. Bowel sounds auscultated in four quadrants. Abdomen soft and nondistended. Discussed factors for promoting normal bowel evacuation with client. Factors verbalized by client.

Example: Date: 04/11/2011Time: 4:00pmSoap suds enema (750 ml) given. Anus intact

without irritation. Large amount of dark brown stool returned after enema. No signs of adverse effects. Bowel sounds auscultated in four quadrants before and after procedure. Abdomen soft and non distended. Vital signs stable before and after enema. Client verbalized measures for promoting normal bowel evacuation.

AFTERCARE

After administering an enema, remain near the patient in case he or she needs assistance with the bedpan or to get to the bathroom.

Medicated enemas that are expelled immediately may need to be repeated, using fresh solution.

Follow the directions or consult with the physician.

To assist the patient with retaining an enema after instillation, apply gentle pressure to the rectal opening using a 4X4 gauze pad or squeeze the buttocks together.

Tuck a 4X4 gauze pad between the buttocks to collect seepage. This maneuver may help the patient feel more secure.

Cover the patient after the procedure and instruct him or her to lie still for 5 to 10 minutes or longer if a medicated solution or retention enema is administered. This will allow time for the sol’n to take effect.

Wash items that might be reused, such as non-disposable enema bags and tubing, in warm soapy water. Rinse and allow them to air dry.

Place disposable items, gauze pads, & gloves in a trash bag, then seal & discard it.

Assist the patient to the bathroom or with the bedpan after he or she has held the enema solution for the correct amount of time.

Hands should be washed after performing the procedure.

Note the results of the enema (color, consistency, content and amount of feces produced).

COMPLICATIONSComplications of enema administration

are not common but can include irritation, swelling, redness, bleeding, or prolapse of the rectal tissue.

If any of these symptoms are apparent, or if the patient complains of pain or burning during enema instillation, stop the procedure and notify the physician.

Risks Habitual use of enemas as a means

to combat constipation can make the problem even more severe when their use is discontinued. Enemas should be used only as a last resort for treatment of constipation and with a doctor's recommendation. Enemas should not be administered to individuals who have recently had colon or rectal surgery, a heart attack, irregular heart beat.

Both pregnant women and nursing women have safely done enemas. Many of them.  No known risks are associated with clean water enema, but if you are pregnant, you should avoid enema containing herbs.

Can we do an enema in pregnant or nursing a baby?

Giving enemas during labor doesn’t shorten labor or decrease the risk of infection to mother or baby new study has revealed. The study now calls for discouraging the practice of giving enemas during delivery.

Enemas are frequently given to women early in labor so that they empty their back passage. The idea is that this will give more room for the baby as it passes through the pelvis. It is also hoped that it will reduce the chance of the woman leaking fecal material while she is giving birth, a situation that is both embarrassing to the woman and a potential source of infection to mother and child.

Giving Enemas During Delivery to Be Discouraged

Pictures!

ASSEMBLE THE MATERIALS NEEDED

POSITION THE CLIENT IN THE LEFT LATERAL POSITION WITH THE RIGHT LEG SHARPLY FLEXED

PLACE SOLUTION INTO THE BUCKET AND ADD WATER AS NEEDED

LUBRICATE 2 INCHES OF THE RECTAL TUBE WITH LUBRICANT

GENTLY AND SMOOTHLY INSERT THE RECTAL TUBE INTO THE RECTUM

RAISE THE CONTAINER 12 TO 18 INCHES ABOVE THER ECTUM AND INSTILL 200 CC OF SOLUTION

LOWER THE CONTAINER 12 TO 18 INCHES BELOW THE CLIENT’S RECTUM. OBSERVE FOR AIR BUBBLES AS THE SOLUTION RETURNS.

CLEAN THE ANAL AREA TO REMOVE EXCESS LUBRICANT

A COMMERCIAL ENEMA

POSITION THE CLIENT IN THE LEFT LATERAL POSITION WITH THE RIGHT LEG SHARPLY FLEXED

ALTERNATIVELY, YOU MAY POSITION THE CLIENT IN THE KNEE CHEST POSITION

AFTER INSERTING THE NOZZLE INTO THE ANUS, SQUEEZE THE CONTAINER UNTIL ALL THE SOLUTION IS INSTILLED

REMOVE THE NOZZLE AND CONTAINER AND HAVE THE CLIENT CONTINUE TO LIE ON THE LEFT SIDE FOR THE RPESCRIBED LENGTH OF TIME. DISPOSE OF THE EMPTY CONTAINER IN THE TRASH RECEPTACLE

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