Republic of the Philippines

Isabela State University

Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:
Year/Group:

SKILL: Administering Enema (commercially prepared)

PREPARATIONS 0 1 2 Comments
1. Check for doctor’s order before administering
enema
2. Assemble equipment:
Disposable linen-saver pad, Bath blanket,
Bedpan or commode, Clean gloves, Water-
soluble lubricant if tubing not prelubricated,
Paper towel
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
PROCEDURE
1. Introduce yourself and verify the client’s
identity. Explain to the client what you are going
to do, why it is necessary, and how the client can
cooperate. It is important to help the client relax
by encouraging the client to take deep breaths
and inform the client about potential sensations
such as feelings of defecation or passing gas.
Indicate that the client may experience a feeling
of fullness while the solution is being
administered. Explain the need to hold the
solution as long as possible.
2. Perform hand hygiene, apply gloves, and
observe other appropriate infection control
procedures.
Apply PPE as needed.
3. Provide for client privacy. Drape the client
appropriately to prevent the exposure of body
parts.
4. Lubricate about 5 cm (2 in.) of the rectal tube
(some commercially prepared enema sets already have
lubricated nozzles).
Rationale: Lubrication facilitates insertion through the
sphincter and minimizes trauma.
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. Rationale: Air
instilled into the rectum, although not harmful, causes
unnecessary distention.
5. Assist the adult client to a left lateral position,
with the right leg as acutely flexed (Sim’s position) as
possible with the linen-saver pad under the buttocks.
Rationale: This position facilitates the flow of solution by
gravity into the sigmoid and descending colon, which are
on the left side. Having the right leg acutely flexed
provides for adequate exposure of the anus.
6. Insert the enema tube. For clients in the left lateral
position, lift the upper buttock.
Rationale: This ensures good visualization of the anus
7. Insert the tube smoothly and slowly into the rectum,
directing it toward the umbilicus. Rationale: The angle
follows the normal contour of the rectum. Slow insertion
prevents spasm of the sphincter.
Insert the tube 7 to 10 cm (3 to 4 in.). Rationale: Because
the anal canal is about 2.5 to 5 cm (1 to 2 in.) long in
the adult, insertion to this point places the tip of the tube
beyond the anal sphincter into the rectum.
If resistance is encountered at the internal sphincter, ask
the client to take a deep breath, then run a small amount
of solution through the tube. Rationale: This relaxes the
internal anal sphincter.

8. Slowly administer the enema solution. If you are using

a plastic commercial container, roll it up as the fluid is
instilled. This prevents subsequent suctioning of the
solution. After all the solution has been instilled or when
the client cannot hold any more and feels the desire to
defecate (the urge to defecate usually indicates that
sufficient fluid has been administered), close the clamp,
and remove the enema tube from the anus.
• Place the enema tube in a disposable towel as you
withdraw it.
9. Encourage the client to retain the enema.
• Ask the client to remain lying down. Rationale: It is
easier for the client to retain the enema when lying down
than when sitting or standing, because gravity promotes
drainage and peristalsis. Request that the client retain the
solution for the appropriate amount of time, for example,
5 to 10 minutes for a cleansing enema or at least
30minutes for a retention enema.
10. Assist the client to defecate.
• Assist the client to a sitting position on the bedpan,
commode, or toilet. A sitting position facilitates the act
of defecation.
• Ask the client who is using the toilet not to flush it. The
 nurse needs to observe the feces.
• If a specimen of feces is required, ask the client to use a
bedpan or commode.
• Remove and discard gloves.
• Perform hand hygiene.
11. Document the type and volume, if appropriate, of
enema given. Describe the results.

Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Clinical Instructor

Where: RS = Raw Score Date:

N = Total number of items
 Republic of the Philippines
Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:
Year/Group:

SKILL: Administering Soapsud Enema

PREPARATIONS 0 1 2 Comments
1. Check for doctor’s order before administering enema
2.Assemble equipment:
Enema can and tubing method, A tray containing
Disposable gloves, Water soluble lubricant, Bath
thermometer, Soap and water, Toilet tissues, Enema can,
Tubing and clamp.
Appropriate size rectal tube :
Adult : 22-30 Fr
Child size : 12-18 Fr
IV stand, K . Basin(2),
Solution as ordered, Mackintosh/waterproof under pad,
Bedpan Temperature of solution
Adult : 105-110 F (40-43 C) Child : 100 F(37.1 C)
Amount of solution
Adult :750-1000 ml
Adolescent :500-750 ml
School age :300-500 ml
Toddler :250-300 ml
Infant :150-250 ml
(Prior to administration, make sure a bedpan, commode,
or toilet is nearby).
PROCEDURE
1. Introduce yourself and verify the client’s
identity. Explain to the client what you are going
to do, why it is necessary, and how the client can
cooperate. It is important to help the client relax
by encouraging the client to take deep breaths
and inform the client about potential sensations
such as feelings of defecation or passing gas.
Indicate that the client may experience a feeling
of fullness while the solution is being
administered. Explain the need to hold the
solution as long as possible.
2. Perform hand hygiene, apply gloves, and observe
other appropriate infection control procedures.
 Apply PPE as needed.
3. Provide for client privacy. Drape the client
appropriately to prevent the exposure of body
parts.
4. Raise container, release clamp and allow solution
to flow long enough to fill tubing. Clamp the
tubing, lubricate 6-8 cm of tip of rectal tube with
jelly.

5. Assist the adult client to a left lateral position

(Sim’s Position), with the right leg as acutely flexed as
possible with the linen-saver pad under the buttocks.
Rationale: This position facilitates the flow of solution by
gravity into the sigmoid and descending colon, which are
on the left side. Having the right leg acutely flexed
provides for adequate exposure of the anus.
6. Separate the buttocks and locate the anus.
Instruct patient to relax by breathing out slowly through
mouth. Insert –tip of rectal tube gently by pointing the tip
in the direction of patients umbilicus.
Adult : 7.5-10 cm Child : 5-7.5 cm Infant : 2.5-3.7 cm
Hold the tubing in place with one non- dominant hand.

7. Open regulatory clamp and allow solution to enter

slowly with the container at the patient’s hip level. Raise
the enema can slowly to appropriate level above the anus.
Eg: for the infusion rate 1L in 10 min. Lower container
or clamp tubing for 30seconds.If patient complaints of
cramping or if fluid escapes around rectal tube. Clamp
tubing after all solution is instilled. Inform patient, that
fluid instillation is over and the tube will be removed.
Place layers of toilet tissue around tube at anus and
gently withdraw rectal tube. Explain to patient that
feeling of distention is normal and ask patient to retain
solution as long as possible (5-10 min.) while lying
quietly in bed.
8. Discard the disposable, used items in proper
receptacle. If enema can needs to be reused. Rinse out
thoroughly with soap and warm water.

9. Assist patient to toilet or help to position on bed pan.

Observe the fecal matter and expelled solution. Assist as
needed to wash anal area with soap and water.

10. Remove and discard gloves and wash hands. Assess

condition of patient abdomen may indicate serious
problems.

11. Document the type and volume, if appropriate, of

enema given. Record type and volume of enema given
 and characteristics of return flow. Report failure to
defecate to the physician.

Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Clinical Instructor

Where: RS = Raw Score Date:

N = Total number of items
 ENEMA

Definition- is a 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. It 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.

- 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.

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.

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.
May be given to: a. Lubricate the inside surface of the lower intestine
b. Soften the stool, if necessary to ease the passage of feces
without straining
c. Provide laxative benefits when oral laxatives are not allowed
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.

Commonly Used Cleansing Enema Solutions

Solution Constituents Action Time to Take Adverse Effects

Effect
Hypertonic 90–120 mL of Draws water 5–10 min Retention of
solution (e.g., into the colon. sodium
sodium
phosphate
[Fleet])
Hypotonic 500–1,000 mL Distends colon, 15–20 min Fluid and
of tap water stimulates electrolyte
peristalsis, and imbalance;
softens feces. water
intoxication
Isotonic 500–1,000 mL Distends colon, 15–20 min Possible sodium
of normal stimulates retention
saline peristalsis, and
softens feces.
Soapsuds 500–1,000 mL Irritates mucosa, 10–15 min Irritates and may
(3–5 mL soap distends damage
to 1,000 mL colon. mucosa
water)
Oil (mineral, 90–120 mL Lubricates the 0.5–3 h
olive, feces and the
cottonseed) colonic mucosa.
PRECAUTIONS
 1. Enemas should not be used as a first- line treatment for constipation.
2. Frequent use of enemas can lead to fluid overload, bowel irritation, and loss of muscle
tone of the bowel and anal sphincter.
3. Never deliver more than three consecutive enemas to treat a patient.
4. A patient with diarrhea may not be able to hold an enema.
5. Must be used with caution in cardiac patients who have arrhythmias or have had a recent
myocardial infarction.
6. Insertion of the enema tube and solution can stimulate the vagus nerve which may trigger
arrythmias such as bradycardia.
7. Enemas should not be given to patients with undiagnosed abdominal pain because the
peristalsis of the bowel can cause an inflamed appendix to rupture.
8. Should be used cautiously in patients who have had recent surgery on the rectum, bowel,
or prostate gland.
9. 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.
10. Do not force the enema catheter into the rectum against resistance. This can cause trauma
to the rectal tissue.
11. 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.

Special considerations when giving enema:

 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.
 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.
 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 freely flow, withdraw the tube. Check for any
stool that may 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 resistance persists, end the procedure and
report the resistance to the primary care provider and nurse in charge.

COMPLICATIONS - Complications 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 heartbeat.
 Both pregnant women and nursing women have safely done enemas. No known
risks are associated with clean water enema, but if you are pregnant, you should
avoid enema containing herbs.
 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.
 Special precautions must be used to alert nurses to possible contraindications
when Fleet enemas are prescribed for clients with renal failure. The label on the
Fleet enema warns that using more than one enema every 24 hours can be
harmful. Clients and family may underestimate the risks for a client with
decreased renal function because a Fleet enema can be obtained over the counter
in stores (Cohen, 2012).
 Prepared by:

Melissa L. Bucao, RN
 Republic of the Philippines
Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:
Course/Year/Group:

SKILL: Inserting a Nasogastric tube

PREPARATION 0 1 2 Comments
1. Assess:
 For history of nasal surgery or deviated septum
 Patency of nares
 Presence of gag reflex
 Mental status/ability to cooperate with the
procedure
2. Determine:
 Size of tube to be inserted
3. Assemble equipment and supplies:
 Tube Adhesive tape
 Clean gloves
 Water soluble lubricant
 Facial tissue
 50 ml syringe
 Basin
 Stethoscope
 Towel
4. Assist the client to a high Fowler’s position, if
health permits, and support head on pillow. Place
a towel across client’s chest.
PROCEDURE
1. Introduce yourself and verify the client’s
identity. Explain to the client what you are going
to do, why is it necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other
appropriate infection control procedures.
3. Provide for client privacy.
4. Assess the client’s nares.
5. Prepare the tube.
6. Determine how far insert the tube.
 Measure the distance from the tip of client’s nose
to the tip of the earlobe and then from the tip of
the earlobe to the tip of the xyphoid.
7. Insert the tube.
  Put on gloves
 Lubricate the tip of the tube well, to ease
insertion
 Insert the tube
 Ask client to hyperextend the neck and gently
advance the tube toward the nasopharynx
 If the tube meets resistance, withdraw it, re-
lubricate it, and insert it in the other nostril.
 Once the tube reaches the oropharynx, the client
will feel the tube in the throat and may gag and
retch. Ask the client to tilt head forward, and
encourage the client to swallow.
 Pass the tube 5-10 cm with each swallow until
the indicated length is inserted.
8. Ascertain correct placement of the tube
 Aspirate stomach contents
 Place a stethoscope over the client’s epigastrium,
and inject 10-30 ml of air into the tube while
listening for a whooshing sound.
 If the signs do not indicate placement in the
stomach, advance the tube 2 inches and repeat
test.
9. Secure the tube by taping it to the bridge of the
client’s nose.
10. Attach the tube to a feeding apparatus, as
ordered, or clamp the end of the tubing.
11. Secure the tube to clients gown
12. Document relevant information
13. Establish a plan for providing daily nasogastric
tube care
14. If suction is applied, ensure the patency of
nasogastric tube is maintained.

Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100

N Name and Signature of Professor

Where: RS = Raw Score Date:

 N = Total number of items

Republic of the Philippines

Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:
Course/Year/Group:

SKILL: Administering a Tube Feeding

PREPARATION 0 1 2 Comments
1. Assess:
 For any clinical signs of malnutrition or
dehydration.
 For allergies to any food in the feeding.
 For the presence of bowel sounds.
 For any problems that suggest the tolerance of
previous feedings.
2. Determine:
 Type amount and frequency of feedings.
 Tolerance of previous feedings.
3. Assemble equipment and supplies:
  Correct amount of feeding solution.
 60 ml catheter-tip syringe
 Emesis basin
 Clean gloves
 pH strip or meter
 large syringe or calibrated plastic feeding bag
with label and tubing
 measuring container from which to pour the
feeding
 water at room temperature (60 ml, unless
otherwise specified)
 Feeding pump as required
4. Assist the client to a Fowler’s position in bed, or
a sitting position in a chair. If a sitting position is
contraindicated, a slightly elevated right side-
lying position is acceptable.
PROCEDURE
1. Introduce yourself and verify the client’s identity.
Explain to the client what are you are going to
do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other
appropriate infection control procedures.
3. Provide for client privacy.
4. Assess tube placement:
 Attach the syringe to the open end of the tube,
and aspirate.
 If 100 ml (or more than half of the last feeding) is
withdraw, check with the nurse in charge or refer
to agency policy before proceeding.

Reinstill the gastric contents into the stomach, if this is

the agency policy or the primary care provider’s order.

If the client is on a continuous feeing, check the gastric

residual every 4-6 hours or according to agency protocol.
5. Administer the feeding:
Before administering feeding:
 Check the expiration date of the feeding.
 Warm the feeding to room temperature.
Feeding Bag
 Remove the plunger from the syringe, and
connect the syringe to a pinched or clamped
nasogastric tube.
 Add the feeding to the syringe barrel.
 Permit the feeding to flow in slowly at the
prescribed rate. Raise or lower the syringe to
adjust the flow as needed. Pinch or clamp the
tubing to stop the flow for a minute, if the client
 experiences discomfort.
6. Flush the feeding tube immediately before all of
the formula has run through the tubing.
 Instill 50-100 ml of water through the feeding
tube ore medication port.
 Be sure to add the water before the feeding
solution has drained from the neck of syringe or
from the tubing of an administration set.
7. Clamp the feeding tube.
8. Ensure client comfort and safety.
 Secure the tubing to the client’s gown.
 Ask the client to remain sitting upright in
Fowler’s position or in a slightly elevated right
lateral position for at least 30 minutes.
9. Dispose of equipment appropriately.
 If the equipment is to be refused, wash it
thoroughly with soap and water, so that it is
ready for reuse.
10. Document all relevant information
 Document the feeding, including amount and
kind of solution taken, duration of the feeding,
and assessment of the client.
11. Monitor the client for possible complications.

Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Professor

Where: RS = Raw Score Date:

N = Total number of items
 Republic of the Philippines
Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:
Course/Year/Group:

SKILL: Removing a Nasogastric Tube

PREPARATION 0 1 2 Comments
1. Assess:
 For the presence of bowel sounds.
 For the absence of nausea or vomiting when
the tube is clamped.
2. Assemble equipment:
 Disposable tissue pad or towel
 Tissues
 Clean gloves
 50-ml syringe (optional)
 Plastic trash bag
3. Confirm the primary provider’s order to remove
the tube
4. Assist the client to a sitting position, if health
permits.
5. Place the disposable pad or towel across the
client’s chest.
6. Provide tissues to client to wipe nose and month
after tube removal.
PROCEDURE
1. Introduce yourself and verify the client’s
identify. Explain to the client what you are going
to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other
appropriate infection control procedures.
3. Provide for client privacy.

4. Detach the tube.

 Disconnect the nasogastric tube from the suction
apparatus, if present.
 Unpin the tube from the client’s gown.
 Remove the adhesive tape securing the tube to
the nose.
5. Remove the nasogastric tube.
 Put on clean gloves.
 Optional: Instill 50 ml of air into the tube.
 Ask the client to take a deep breath and to hold it.
 Pinch the tube with the gloved hand.
  Smoothly withdraw the tube.
 Place the tube in the plastic bag.
 Observe the intactness of the tube.
6. Ensure client comfort.
 Provide mouth care, if desired.
 Assist the client as required to blow nose.
7. Dispose of the equipment appropriately.
 Place the pad, bag with tube, and gloves in the
receptacle designated by the agency.
8. Document all relevant information.
 Record the removal of the tube, the amount and
appearance of any drainage, if the tube was
connected to suction, and any relevant
assessment of the client.

Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Professor

Where: RS = Raw Score Date:

N = Total number of items