Maternal AND CHILD HEALTH NURSING LABORATORY

ENEMA Position: maintains a left lateral position during

◼ And enema is a solution introduced into the rectum administration
and large intestine C. Large volume enema
◼ It is a technique used to stimulate stool evacuation Purpose: to clean as much of the colon as possible of
feces as an intervention for constipation as well as “bowel
Action of an enema prep” before a diagnostic procedure
 To distend the intestine and sometimes to Amount of solution: 500-1000ml
irritate the intestinal mucosa, thereby Height of administration: bad is raised as high as 18
increasing peristalsis and the excretion of inches above the anal opening
feces and flatus ◼ The amount of solution administered will depend on
the age and medical condition of the individual
Purposes ◼ For example, clients with certain cardiac or renal
✓ To relieve constipation diseases-----significant fluid retention
✓ To relieve flatulence
✓ To administer medications Large volume enema in children (volume of solution)
✓ To lower body temperature Children <18 months old: 50 to 200ml
✓ To evacuate feces (bowel preparation) in Children 18 months to 5 years: 200-300ml
preparation for diagnostic procedure or surgery (to Children 5-12 y/o: 300-500ml
have clearer view)
Normal flora in the DS: E.coli D. Low volume enema
◼ It is used to clean the lower portion of the colon or
CLASSIFICATIONS OF ENEMA the sigmoid
I. Cleansing enema ◼ This type of cleansing enema is often used for
◼ An injection of water-based solution into the rectum patient who is constipated but does not need
or colon with the purpose of stimulating a bowel cleansing of the higher colon
movement to remove feces ◼ The amount used: less than 500 ml (90-120ml)
They are given to: ◼ Height of administration: the bag is raised no
➢ Prevent the escape of feces during surgery higher than 12 inches
➢ Prepare the intestine for certain diagnostic tests
such as x-ray or visualization tests (ex. II. Return flow enema
Colonoscopy) ◼ Also called a Harris flush, is occasionally used to
➢ Remove feces in instances of constipation or expel flatus
impaction ◼ This type of enema provides an alternating flow of
enema solutions between 100 and 200 ml into and
A. High enema out of the patient’s sigmoid colon and rectum
◼ Given to cleanse as much of the colon as possible Purpose: to stimulate peristalsis to propel food along the
◼ Amount o solution: 1L normal process
◼ Position changes during administration: from left ◼ This process is repeated five or six times until the
lateral position to dorsal recumbent position and then flatus is expelled and abdominal distention is
to the right lateral position so that the solution can relieved.
follow the large intestine
III. Retention enema
B. Low enema ◼ It introduces oil or medication into the rectum and
Is is used to clean the rectum and sigmoid colon only sigmoid colon
Amount of solution: 500 ml Types of oil and medications:
a. Antibiotic enemas: to treat infections locally

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b. Anthelmintic enemas: to kill helminths such as
worms and intestinal parasites
c. Nutritive enemas: to administer fluids and nutrients
to the rectum
Time of retention: 1-3 hours
Purpose: to often the feces and to lubricate the rectum
and anal canal, thus facilitating passage of the feces
Other solutions: carminative enema (60-80 ml), oil
(90-120ml)
Height: 12 inches above the anus
Temperature of solution: 105-110 F (40.55-43.33 C)
Carminative 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 solution (tap water): 500-1000ml
◼ Isotonic solution
a. NSS: 9ml of NaCl to 1000ml of water
b. Soap suds: 20 ml of castile soap in 500-100 ml
water
◼ Hypertonic solutions: fleet (90ml-120ml)
Height of solution for non-retention:18 inches above
the rectum
Temperature: 115 to 125 F
Time of retention: 5-10 mins
A. Hypertonic solutions
◼ Solutions that have higher solute concentration than
that of the cell (ex.D5LR, D10W, D5NSS)
◼ 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 solution
◼ Solutions that have lower solute concentrations,
such as salt and electrolytes, than the cells inside of
them (Ex. 045% saline. 0.33% saline, 0.225 saline)
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◼ 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 (Ex. Castile soap) should be used in
order to minimize the mucosa irritation
Summary of commonly used enema solutions
Solution: HYPERTONIC
Constituents: 90-120 ml of solution (sodium phosphate
fleet)
Action: draws water into the colon
Time to take effect: 5-10 min
Adverse effects: retention sodium
Solution: HYPOTONIC
Constituents: 500-1000ml tap water
Action: distends colon, stimulates peristalsis and softens
feces
Time to take effect: 10-15 mins
Adverse effects: fluid and electrolyte imbalance; water
intoxication
Solution: ISOTONIC
Constituents: 500-1000ml of normal saline
Action: distends colon, stimulates peristalsis and softens
feces
Time to take effect: 15-20 mins
Adverse effects: possible sodium retention
 Maternal AND CHILD HEALTH NURSING LABORATORY

Solution: SOAPSUDS ◼ Simply asking the client to describe the experience

Constituents: 500-1000ml (3-5 ml soap to 1000ml water) will give the nurse more information for possible
Action: irritates mucosa, distends colon referral
Time to take effect: 10-15 mins The nurse considers the force of flow of the solution
Adverse effects: irritates and may damage mucosa a. The height of the solution container
b. Size of the tubing
Solution: OIL c. Viscosity of the fluid
Constituents: mineral, olive, cottonseed) 90-120ml d. Resistance of the rectum
Action: lubricates the feces and the colonic mucosa Recommended position:
Time to take effect: 30 mins- 3 hours Adult: left lateral
Infants/small children: dorsal recumbent
PRINCIPLES INVOLVED IN ADMINISTERING ENEMA
Physics NOTE!!!
◼ solution to be administered should be held at high  The higher the solution container is held above the
position rectum, the faster the flow and the greater the force
Psychology (pressure) in the rectum
◼ provide privacy by draping the patient  During most adult enemas, the solution container
◼ Explain the procedure to the patient before inserting should be no higher than 30 cm (12 in) above the
the tube in the rectum rectum
Time and energy  During a high cleansing enema, the solution
◼ materials to be used must be prepared before container is usually held farther to clean the entire
performing the procedure bowel
 To make a saline solution, mix 1 tsp of table salt with
GENERAL NURSING INTERVENTION 500 ml of tap water
 Use enemas only as directed. Do not rely on them for
HOLISTIC APPROACH IN ENEMA ADMINISTRATION regular bowel evacuation
◼ It is important for the nurse to remember that clients  Prior to administration, make sure a bedpan,
may perceive this type of procedure as a significant commode, or toilet is nearby
violation of personal space  Allow solution to flow through the connecting tubing
◼ Consider cultural sensitivity pertaining to personal and rectal tube to expel air
space, gender of the caregiver, and the potential Rationale: to prevent flatulence
meaning of the structures and fluids found in this  Lubricate 5cm or 2 inches of the rectal tube
private area of the body Rationale: to prevent trauma to the anorectal mucosa
◼ Keep in minds the client’s potential discomfort with  Promotes relaxation
the gender of the caregiver and try to accommodate Rationale: to prevent feelings of embarrassment
the client’s preferences whenever possible  Introduce solution slowly
◼ When it is not possible to honor the client’s wishes, Rationale: To prevent sudden stimulation of peristalsis
respectfully explain the circumstances  Change position to distribute solution well in the
◼ A gentle, matter of fact approach is often most helpful colon in high enema. In low enema, the client should
◼ Insertion of anything foreign into an orifice of a remain in the left lateral position
client’s body may trigger memories of past abuse  If the order is cleansing enema: give the enema 3
◼ Monitor the client for emotional responses to the times
procedure (both subtle and extreme)--- this could  Alternate hypotonic solution (soap suds, tap water)
indicate a history of trauma and require appropriate with isotonic solution (normal saline solution)
referral for counseling Rationale: To prevent water intoxication. Water
intoxication may cause increased ICP (alteration of LOC)

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 Maternal AND CHILD HEALTH NURSING LABORATORY
 If abdominal cramps occur during introduction of
solution, temporarily stop the flow by clamping the
tubing until peristalsis returns
 After the introduction of the solution, press buttocks
together to inhibit the urge to defecate
Rationale: 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 perineal 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
arthriris, a cast, lower limb amputation, or fractured pelvis
Rationale: may need additional time for the
procedure, owing to limited physical mobility
Patients with spinal cord injury, high BP and heart and
blood vessel disease should be cautioned to avoid
excessive straining (Valsava Maneuver) during defecation
Rationale: 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 arryhtmias
GENERAL NURSING CONSIDERATIONS AND
INTERVENTIONS WHEN ADMINISTERING ON
ENEMAS ON INFANTS AND CHILDREN
PEDIATRIC CLIENTS
 Provide a careful explanation to the parents and child
before the procedure
 Parents should be allowed to comfort infants and
children and participated 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 procedure
 Insert the tube 5-7/5 cm (2-3 in) in the child and only
2.5-3.75 cm (1-1.1.5 in) in the infant
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 Enema temperature should be 37.7 C (100F) unless
otherwise ordered
 For infants and small children, the dorsal recumbent
position is frequently used
 Infants and small children 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
Rationale: 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
 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 (ex. Slow pulse) and
dysrhythmias
 Protect their skin from prolonged exposure to
moisture
 Assist them with perineal case as indicated
Before, during and after enemas
BEFORE
 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
 Maternal AND CHILD HEALTH NURSING LABORATORY

 Gather all equipment and place in an easy to access Potential for injury r/t abdominal distention and trauma to
area in patient’s room; adjust lighting the anus and colon during the procedure
Rationale: promotes organization of equipment; EXPECTED OUTCOMES
saves time and adjusted lighting enhances ✓ Patient will return to optimal bowel elimination
visualization for procedure pattern
 Explain to the patient the benefits of relaxing and ✓ Patient is able to assist/participate
taking periodic deep breaths ✓ Patient will be able to evacuate feces from rectum
Rationale: reduces anxiety and promotes and colon after the enema
comfort ✓ Patient experiences minimal discomfort during
 Check the patients ability to retain fluid and tolerated procedure and no injury to the colon and/ or anus
the activity ordered ✓ Patient experiences relief and comfort after
 Determine the presence of kidney or cardiac disease procedure

DURING PERFORMANCE EVALUATION IN ADMINISTERING

 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
AFTER
 Record date, time, type, and results of enema
administration, as well as the amount and other
important characteristics of stool (As required in the
designated area on the patient’s record)
 Record patient’s tolerance of procedure and any
complications that occurred
 Report patient teaching about prevention
constipation
 Instruct patients with cardiovascular disease not to
strain when expelling contents. Avoids creating the
valsava maneuver, which can lead to sudden cardiac
arrest
 Assist patient with personal hygiene as needed.
Provides patient comfort, and reduces transmission
of infectious microorganisms
NURSING DIAGNOSES
Constipation r/t decreased peristalsis
Chronic pain r/t abdominal discomfort and distention from
bowel malfunction
ENEMA CHECKLIST
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
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
Assemble equipment:
⚫ Disposable linen-saver pad (waterproof rubber
sheet)
⚫ Bath blanket
of ⚫ Bedpan or commode
⚫ Clean gloves (dirty naman ang pwet bhie)
⚫ 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
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.

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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
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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 a specimen of feces is required, ask the client to
use a bedpan, or commode.
Variation: Administering an Enema to an Incontinent
Client
◼ 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
◼ 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.
9. Document the procedure.
 Maternal AND CHILD HEALTH NURSING LABORATORY

Document: ◼ Administer or instruct the use of laxative enemas or

✓ The type and volume if appropriate of enema given suppositories as ordered the evening prior to the
✓ The type of solution; length of time solution was procedure
retained; the amount, color, and consistency of the ◼ Bowel preparation-- may be ordered for the
returns; and the relief of flatus and abdominal morning just prior to the procedure
distention on the client record.
AFTER PROCEDURE
Siphoning an enema ◼ A laxative will be given--barium causes
◼ This is done when enema solution is not drained constipation
adequately ◼ The stools may be white for the next 1 to 2
NURSING INTERVENTIONS days--expected outcome (effect of barium)
1. Use water at 40C or 105 F ◼ Instruct to increase fluid intake--to excrete barium
2. Place client in right side lying position that can cause constipation
3. Height of enema: 10 cm or 4 inches above anus ◼ Observe for sign of barium impaction: distended
4. Quickly lower enema container after introduction of abdomen and constipation
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

o Muscle tone loss
o Fluid overflow
o Bowel irritation
o Internal hemorrhage caused by an imbalance of
electrolytes (misuse of hypotonic and isotonic
solutions)

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 result in a relatively clear
silhouette of the colon

CLIENT PREPARATION
◼ Ensure presence of a signed informed consent for
the procedure
◼ Provide or instruct to follow a low residue (low fiber
diet) 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

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