CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

Performance Evaluation Checklist

Name: ________________________ Date:_______________

Year and Section: _______________

PERFORMING ENEMA

EQUIPMENT
 Clean gloves
 Water-soluble lubricant
 Waterproof, absorbent pads
 Toilet tissue
 Bedpan, bedside commode, or access to toilet
 Basin, washcloths, towel, and soap
 IV pole
 Stethoscope

INSTRUCTION: Rate the nursing skill performance of the student based as follows:

5 = Perfect (91-100)
4 = Very Satisfactory (85-90)
3 = Satisfactory (80-84)
2 = Poor (79-75)
1 = Need Improvement (74 and below)

PROCEDURE 5 4 3 2 1 Comments
1. Identify the patient

2. Verify health care provider order for type of enema

3. Help patient turn onto left side-lying (Sims’) position with
right knee flexed. Encourage him or her to remain in
position until procedure is complete. Children are placed in
dorsal recumbent position.

4. Lower side rail on working side and place waterproof pad,

absorbent side up, under hips and buttocks. Cover patient
with bath blanket, exposing only rectal area, clearly
visualizing anus.

5. Separate buttocks, and examine perianal region for

abnormalities, including hemorrhoids, anal fissure, and
rectal prolapse.

A. Administer enema: a Administer prepackaged disposable

enema:

1. Remove plastic cap from tip of container. Tip may be

already lubricated. Apply more water-soluble lubricant as
needed. causing rectal irritation or trauma. With presence of
hemorrhoids, extra lubricant provides added comfort.

2. Gently separate buttocks, and locate anus. Instruct patient to

 relax by breathing out slowly through mouth.

3. Expel any air from the enema container.

4. Insert lubricated tip of container gently into anal canal

toward the umbilicus

Adult: 7.5 to 10 cm (3 to 4 inches)

Adolescent: 7.5 to 10 cm (3 to 4 inches)

Child: 5 to 7.5 cm (2 to 3 inches)

Infant: 2.5 to 3.75 cm (1 to 112 inches)

5. Roll plastic bottle from bottom to tipuntil all of solution has

entered rectum and colon. Instruct patient to retain solution
until urge to defecate occurs, usually 2 to 5 minutes.

B. Administer enema using enema bag:

1. Add warmed solution to enema bag: Warm tap water as it

flows from faucet, place saline container in basin of warm
water before adding saline to enema bag, and check
temperature of solution by pouring small amount of solution
over inner wrist.

2. If soap suds enema (SSE) is ordered, add castile soap after

water. Prevents bubbles in bag.

3. Raise container, release clamp, and allow solution to flow

long enough to fill tubing.Removes air from tubing.

4. Reclamp tubing

5. Lubricate 6 to 8 cm (2 12 to 3 inches) of tip of rectal tube

with lubricant.

6. Gently separate buttocks, and locate anus. Instruct patient to

relax by breathing out slowly through mouth. Touch
patient’s skin next to anus with tip of rectal tube.

7. Insert tip of rectal tube slowly by pointing it in direction of

patient’s umbilicus. Length of

insertion varies:

Adult: 7.5 to 10 cm (3 to 4 inches)

Adolescent: 7.5 to 10 cm (3 to 4 inches)

Child: 5 to 7.5 cm (2 to 3 inches)

Infant: 2.5 to 3.75 cm (1 to 112 inches)

8. Hold tubing in rectum constantly until end of fluid

instillation.

9. Open regulating clamp and allow solution to enter slowly

with container at patient’s hip level.

10. Raise height of enema container slowly to appropriate level

above anus: You may use an IV pole to hold an enema bag
 once you get a slow flow of fluid established.

11. Instill all solution and clamp tubing. Tell patient that
procedure is completed and that you will be removing
tubing

6. Place layers of toilet tissue around tube at anus and gently

withdraw rectal tube and tip

7. Explain to patient that some distention and abdominal

cramping are normal. Ask patient to retain solution as long
as possible until urge to defecate occurs. This usually takes a
few minutes. Stay at bedside. Have patient lie quietly in bed
if possible.
8. Discard enema container and tubing in proper receptacle.

9. Help patient to bathroom or commode if possible. If using

bedpan, help to as near normal position for evacuation as
possible.

10. Observe characteristics of stool and solution. (Caution

patient against flushing toilet before inspection.)

11. Help patient as needed to wash anal area with warm soap
and water (if nurse administers perineal care, use gloves).

12. Document and Evaluate the patient’s response to procedure.

TOTAL RATING

STUDENT SIGNATURE: __________________________

CLINICAL INSTRUCTORS SIGNATURE: ____________