position nurse assist client administering enema Enema administration Nursing

What position should the nurse assist the client to before administering an enema?

  1. The nurse has administered approximately half of an enema solution to a preoperative client when the client complains of pain and cramping. Which nursing action is most appropriate at this time? 
    1. Reassure the client and continue the flow. 
    2. Raise the enema bag so that the solution can be instilled quickly. 
    3. Discontinue the enema and notify the health care provider (HCP). 
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

  2. A female client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? 
    1. High-fiber diet 
    2. Full liquid diet 
    3. Low-fiber diet 
    4. Low-sodium diet

    1. High-fiber diet

  3. The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema?

    1. A 
    2. B 
    3. C 
    4. D

    2. B

  4. The nurse has administered approximately half of an enema solution when the client complains of pain and cramping. Which nursing action is the most appropriate? 
    1. Reassure the client and continue the flow. 
    2. Raise the enema bag so that the solution can be instilled quickly. 
    3. Discontinue the enema and notify the health care provider (HCP). 
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

  5. Before enema administration, which position should the nurse assists the client to assume? 
    1. Right Sims position 
    2. Dorsal recumbent position 
    3. Left lateral position, with the right leg acutely flexed 
    4. Right lateral position, with the left leg acutely flexed

    3. Left lateral position, with the right leg acutely flexed

  6. The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position? 
    1. Left-sided lateral Sims position 
    2. Right-sided lateral Sims position 
    3. Left side-lying, with the head of the bed elevated 45 degrees 
    4. Right side-lying, with the head of the bed elevated 45 degrees

    1. Left-sided lateral Sims position

  7. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? 
    1. Immediately twist the catheter, and then slowly inflate the balloon. 
    2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. 
    3. Insert the catheter until resistance is met, and then inflate the balloon. 
    4. Withdraw the catheter approximately 1 inch, and then inflate the balloon.

    2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.

  8. The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? 
    1. Withdraw the catheter slightly and reinflate the balloon. 
    2. Remove the catheter, and reinsert a new one that is one size smaller. 
    3. Finish inflating the balloon; the discomfort is normal and temporary. 
    4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

    4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

Nurses may have to give an enema as part of their nursing responsibilities. It is important nurses learn how to give an enema properly to prevent too much patient discomfort. Enema administration is virtually painless as long as an experienced nursing professional gives the enema with good nursing skills. The process is important for patients who need to alleviate their bodies of toxins.

What is an Enema?

The process of administering an enema involves inserting fluid into the patient’s rectum to cleanse the lower intestines and colon to remove accumulated toxins and fecal matter. Nurses administer enemas to stimulate bowel movements in most cases, but there are several other reasons, which include colon cleansing, constipation treatment, excessive potassium and ammonia removal, medication delivery, alleviate bowel inflammation, and bowel preparation for surgery. The entire process takes 30 minutes to a couple of hours.

Types of Enema

  • Cleansing Enema – This type of enema prevent the release of feces while the patient is in surgery. The process prepares the intestines of the patient for a colonoscopy or x-ray. This type of enema can be administered as a small volume or large volume cleansing enema.
  • Carminative Enema – This type of enema releases tension or swelling in the colon and rectum. When waste builds and sits in the colon, a carminative enema allows the waste and toxins to leave the body.
  • Retention Enema – This type of enema is used to administer medication and oil into the patient’s rectum. The types of oil and medications include nutritive, antibiotics, and anthelmintics.
  • Return-Flow Enema – This type of enema provides an alternating flow of enema solutions between 100 and 200 mL into and out of the patient’s colon and rectum to stimulate peristalsis to propel food along the normal process.

Steps on How to Give an Enema

  1. Wash the hands thoroughly with soap and warm water for a minimum of 15 seconds before beginning the procedure.
  2. Gather the needed materials (enema bag or bulb, lubricant, gloves, enema solution, ramp clamp, and a towel).
  3. Warm the solution before placing it into an enema bag or bulb to a temperature between 99 and 106 degrees.
  4. Place a towel under the patient to collect any leakage during the procedure. Lay the patient in a position to receive the enema. The ideal positions for enema administration are the right side position, left side position, knee chest position, and on the back. It is advised that the patient remain in one of these positions to receive the enema for one-third of the time.
  5. Lubricate the tip of the enema applicator before inserting it into the rectum of the patient. Ensure that the entire length of the enema tip is lubricated and that the opening of the tip remains free from clogs so that the solution flows freely when the time comes to administer the enema.
  6. Insert the lubricated enema tip into the patient’s rectum and release the enema tubing clamp.
  7. Monitor the patient for cramping as the enema solutions flows comfortably into the patient’s rectum. Signs of cramping may include abdominal muscle tension. If signs of cramping are notices while monitoring the patient, stop the flow and ask the patient to take several deep breaths. Continue the process once the patient becomes comfortable again.
  8. Gently massage the patient’s abdominal area. Massage down the left portion of the patient’s abdomen then massage from left to right across the lower belly button. Continue to massage up the right portion of the abdomen then massage from right to left under the patient’s rib cage.
  9. Remove the tip of the enema from the patient’s rectum once the device is empty. Ask the patient to remain in the current position until he or she has a strong urge for a bowel movement.
  10. The patient may need assistance with walking to the restroom so the nurse should provide this help if needed. Many patients may have the ability to walk to the restroom on their own while the solution is still in the colon.
  11. Ask the patient to massage the abdomen while the enema is being expelled from the body. Tell the patient to massage the area under the belly button from right to left, starting on the right side and from left to right under the patient’s rib cage. The massaging process helps to loosen fecal matter.
  12. Dispose of the gloves used to administer the enema. Wash hands with soap and water after the process is complete.

Video on Enema Administration

Complications of Enema Administration

Complications from enema administration include muscle tone loss, fluid overflow, bowel irritation, internal hemorrhaging caused by an imbalance of electrolytes. An enema should not be administered to a patient with rectal bleeding, abdominal pain, prolapsed rectal tissue, myocardial infarction, or arrhythmias.

Nurses can learn to execute the simple process that can help their patients remove harmful toxins and fecal matter from their bodies safely and comfortably. Patients rely on the specialized care of nursing professionals to make them as comfortable as possible.

What position should a patient be in to receive an enema?

The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon. Although the length of the tube to be inserted is designated as approximately 5-6 cm, do not try to force it but pull it back slightly if any resistance is felt.

What position should be used for the administration of enemas quizlet?

position the patient on his left side in Sims' position or left lateral position with the right knee flexed, which will adequately expose the anus. This position allows the solution to flow downward by gravity along the curve of the sigmoid colon and rectum, thus improving the effectiveness of the enema.

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