«Enemas»

Theme: «Enemas»

CONTROL QUESTION
• Enema, definition.
• Classification enemas.
• Cleansing enema. Purpose. Mechanism of action. Indication. Type. Used solution.
• Methods used in given a large-volume cleansing enema.
• Retention enema. Purpose. Mechanism of action. Indication. Type. Used solution.
• Carminative enema. Return flow enema. Purpose. Mechanism of action.
• The contraindications for cleansing enema.
• General instruction for Giving Enema.
 
PRACTICAL SKILLS
• Cleansing enema.
• Retention (oil) enema.
• Application of colonic tube (flatus tube).
 Learning objectives

On completion of this practical lesson the learner will be

able to do the following:
• Define key terms used.
• Explain constipation, its etiology, management and
nursing care.
• Enumerate diarrhoea, its causes and nursing care.
• Describe the various treatments of the colon.
• Perform practical skill: Cleansing enema.
• Perform practical skill: Retention (oil) enema.
• Perform practical skill: Application of colonic tube
(flatus tube).
• Enema - a medical manipulation, the essence of which is the
introduction of the liquid into a direct or colon through the
anus.
• Enema is a procedure of administration different fluids in
lower section of colon for therapeutic and diagnostic purpose.
• For therapeutic purposes enemas are used for a very long time.
In ancient Indian manuscripts are described prominately
enema.
• There are records of such treatment and in the Egyptian
sources. Hippocrates developed the method of cleansing
enemas from harmful juices by gastric lavage, laxatives and
cleansing enemas.
• Especially the widespread use of enemas in the treatment
received in 16 - 18 centuries, when patients put sometimes up
to 10 enemas in a row.
 Purpose
1. Cleanse the lower bowel. (most common reason)
2. Soften feces.
3. Expel flatus.
4. Administer medications (worm and parasite infestations,
corticosteroids)
5. Outline the colon during diagnosis x-ray.
Enemas are classified into four groups according to their
action:
• cleansing,
• carminative,
• retention,
• return-flow enemas.
 CLEANSING ENEMAS
A cleansing enema is probably the most common
type of enema.
Purpose. Cleansing enemas are intended to remove feces.
Mechanism of action. This type of enema stimulates peristalsis
via irritation of the colon/rectum and by causing intestinal
distention with fluid.
They are given chiefly to (indication):
• Remove feces in instances of constipation.
• Prepare the intestine for certain diagnostic tests such as x-ray
or visualization tests (e.g., colonoscopy)
• Prepare the patient for surgery (prevent the escape of feces
during surgery).
• There are two general types of cleansing enemas:
the large-volume enema
the small volume enema.
• A large-volume enema is designed to clean the colon of as
much feces as possible. In a large-volume enema between 500
and 1000 ml of fluid is instilled into the rectum/colon and the
patient is asked to retain the fluid as long as possible. This
allows the fluid to soften and loosen the feces.
The large volume of fluid also distends the bowel, stimulating
peristalsis.
Methods used in given a large-volume

cleansing enema:
• enema bag • enema set (the rectal tip,
enema bag, tubing)
 Skill 1. CLEANSING ENEMA

Purpose: Emptying of the lower part of the colon from feces and gases.
 Indications:
• Remove feces in instances of constipation.
• Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy)
• Prepare the patient for surgery (prevent the escape of feces during surgery).
Counter-indications:
• GI bleeding
• Acute inflammatory and ulcerous processes in a colon or anus
• Anal fissure
• Rectal cancer
• Bleeding hemorrhoids
• The first days after operation on organs of the digestive system
Equipment. Sterile: enema bag, tubing, rectal tube (or enema set), gauze napkins, spatula, Vaseline, tray.
• Unsterile: stand, oilcloth and diaper (or absorbent pad), container with water (volume 1 liters), basin (or bedpan), screen, oilcloth apron, disposable latex gloves, container with disinfectant solution.
Algorithm of action:
1. Explain to the patient the purpose and procedure course. Obtain patient’s consent.
• Conduct hygienic washing hand and processing hand. Put the gloves on.
• Prepare the equipment.
• Isolate the patient with a screen.
• Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
• Wear an apron.
• Prepare the enema set: Attach a rectal tube to the tubing. Close the clamp of enema bag. Prepare the solution at the required temperature. Enemas administered to adults are usually given at 105°–
110°F (40.5°–43°C). Hang the enema bag with the solution on the stand. The solution should be 30–45 cm above the rectum for an adult. Fill the enema bag with a solution. Loosen the clamp and let
a small amount of fluid to run into the kidney tray. Close the clamp.
• Take the Vaseline with spatula. Lubricate rectal tube with Vaseline.
• Spread patient buttocks with thumb and forefinger of the left hand.
• Insert the rectal tube 7 to 10 cm slowly into the rectum, directing it toward the umbilicus.
• Open the clamp of enema bag.
• Slowly enter the about 500 to 1000 ml of fluid in the rectum.
• Control for patients condition. Ask the patient to breath by abdomen.
• Clamp the tubing.
• Gently remove the rectal tube by pulling it through 3 to 4 layers of rag pieces.
• Offer to the patient to take the water in the intestine during 10-15 minutes.
1. Empty the intestine in bedpan or toilet pan.
• Conduct disinfection used material. Take the gloves off and put them in the container for disinfection.
• Wash hands.
• Record the type of enema. The result.
 • Small-volume enemas are
designed to clear the rectum and
the sigmoid colon of fecal matter.
Small volume enemas can be
delivered with the traditional
enema kit using 50 to 200 ml of
solution.
• But most frequently small-volume
enemas are administered using a
prepackaged disposable enema.
Prepackaged enemas (Fleet
enema) are easily administered
and available over the counter in
most drug stores.
Cleansing enemas. Solution used:

large-volume enema:
• Hypotonic (Tap water)
• Isotonic solution (Norman saline)
• Soapsuds (3-5 ml soap and 1000 ml water
Small-volume enemas:
• Hypertonic solution
 Retention enema.
• Retention enema introduces oil or medication
into the rectum and sigmoid colon. The liquid is
retained for a relatively long period of time,
usually 1 to 3 hours. It acts to soften the feces and
to lubricate the rectum and anal canal, thus
facilitating the passage of feces.
The effect in 3-6 hours.
• Solution used: oil (olive, cottonseed, castor,
mineral), medication. Temperature of the solution
– 37,7°C.
 Skill 2. RETENTION (OIL) ENEMA

Purpose: emptying of lower section of colon from fecal matter and gases (these are given to soften faecal matter)
Indications:
1. inefficiency the cleansing enema
2. the first days after operation on organs of abdominal cavity
3. after childbirth
Counter-indications:
• Bleeding of intestine
• ulcerous processes in a colon or anus
• rectal prolapse
• rectal growth
• prolapse of the rectum
• Rectal cancer
Equipment. Sterile: colonic tube, Janet's syringe with oil solution in a volume of 50–200 milliliters, Vaseline oil, gauze napkins, tray. Unsterile: gloves, oilcloth and diaper (or absorbent pad), apron, screen, container
with disinfectant solution.
Algorithm of action:
• Explain to the patient the purpose and procedure course. Obtain patient’s consent.
• Conduct hygienic washing hand and processing hand. Put the gloves on.
• Prepare the equipment.
• Isolate the patient with a screen.
• Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
• Wear an apron.
• Moisten the end of the colonic tube on the distance of 20-30 cm by Vaseline.
• The rounded end colonic tube to take as a pen.
• Spread patient buttocks with thumb and forefinger of the left hand.
• Insert the colonic tube 20 to 30 cm slowly into the rectum, directing it toward the umbilicus.
• Attach the Janet's syringe to colonic tube and enter the oil solution.
• Disconnect the Janet's syringe from the tube.
• Fill the Janet's syringe with air, attach to colonic tube and carefully intake the air.
• Gently remove the colonic tube by pulling it through 3 to 4 layers of rag pieces.
• Wipe the anus with napkin.
• Remove the diaper and oilcloth. Take off an apron, gloves and put into container with disinfectant solution.
• Help patient to take a comfortable position. Give him recommendation - to lie during 6- 10 hours. Therefore this procedure should be done for the night.
• Wash hands.
• Record the type of enema. The result.
• Medications can be administered by enema as well. A small-
volume enema can deliver a medicated solution directly to the
rectal mucosa. This method of medication administration is
useful when the rectum is the area to be medicated if the client
is unable to take oral medications or if rapid absorption of the
medication is required.
 Carminative enema
• Carminative enema. This is given primarily to expel flatus.
The solution instilled into the rectum releases gas, which in
turn distends the rectum and the colon, thus causing
peristalsis. 60-180 ml of fluid is introduced.
• An alternative method for flatulence - application of colonic
tube (flatus tube).
 APPLICATION OF COLONIC TUBE (flatus tube)

Purpouse: evacuation gases of intestine

Indications:
1. Meteorism (bloat) - accumulation of gases in intestine.
2. Using for staging of medicinal and oil enemas
Counter-indications:
• Gastric and intestinal bleeding
• Acute inflammatory and ulcerous processes in a colon or anus
• Anal fissure
• Rectal cancer
• Bleeding hemorrhoids
Equipment. Sterile: colonic tube, vaseline, tray, gauze napkins.
• Unsterile: gloves, screen, oilcloth, diaper, apron, bedpan, container with disinfectant solution.
Algorithm of action:
• Explain to the patient the purpose and procedure course. Obtain patient’s consent.
• Conduct hygienic washing hand and processing hand. Wear gloves.
• Prepare the equipment.
• Isolate the patient with a screen.
• Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
• Wear an apron.
• lubricate the end of the colonic tube on the distance of 20-30 cm by Vaseline.
• The rounded end colonic tube to take as a pen.
• Spread patient buttocks with thumb and forefinger of the left hand.
• With a gentle rotatory movement, Insert the colonic tube 4 to 6 cm slowly into the rectum, directing it toward the umbilicus.
• The free end of the tube being kept into the water in the kidney tray (or bedpan).
• Leave the colonic tube on 20 minutes.
• Wear gloves. Remove the colonic tube from the rectum using a napkin.
• Put the colonic tube in container with disinfectant solution. Wipe the anus with napkin. Remove the bedpan, the diaper and the oilcloth. Take off an
apron, gloves and put into container with disinfectant solution.
• Wash hands.
• Record the type of enema. The result.
 
NOTE: The tube can be re-inserted every 3 to 4 hour, if necessary.
• Return flow enema. Return flow enema is used Referred also
as colonic irrigation, this is used to expel flatus. This involves
the alternating flow of fluid into and out of the large intestine
to stimulate peristalsis and the expulsion of feces.
The contraindications for cleansing
enema
• Gastric and intestinal
bleeding
• Acute inflammatory and
ulcerous processes in a
colon or anus
• Rectal cancer
• Cracks in the anus or rectal
prolapse
• The first days after
operation on organs of the
digestive system
• Bleeding hemorrhoids
 General instruction for Giving
Enema
1. Use the appropriate size catheter or rectal tube.
2. The rectal tube needs to be atraumatic.
3. Use lubricant.
4. Follow the temperature of solution.
5. Follow the amount of the solution.
6. Keep the correct patient position.
7. Keep the height of the enema bag.
8. Follow the depth introduction of rectal tube.
9. Follow the time of retention of solution in intestines.
10. Good condition equipment.
11. Follow the flow speed of fluid.
12. Prevent air from entering into the rectum .
13. Observe the patient's condition during the procedure.
 General instruction for Giving
Enema

1. The appropriate size catheter or rectal tube need to be used. For

giving a cleansing enema use no. 22 French for adults, no. 12 French
for an infant and no. 14 to 18 French for the school age child.
2. The rectal tube needs to be smooth and flexible. Any tube with a
sharp or ragged edge should not be used because of the possibility of
damaging the mucus membrane of the rectum.
3. The rectal tube is lubricated with a water soluble lubricant or with
vaseline to facilitate insertion and to decrease irritation of the rectal
mucosa. Use only a small amount to prevent blockage of the tube.
4. The temperature of the solutions needs to be adjusted according to the
purpose of the enema. To give an evacuant enema, the temperature
should be between 105 and 110°F (40.5° to 43° C) for adults and
100°F (37.7°C) for children. A retained enema should be given at the
body temperature.
 5. The amount of the solution to be administered depends upon
the type of the enema and the age and size of the person. For
giving evacuant enema u 500 to 1000 ml for adults, 250 to 500
ml for a child and 250 ml or less for an infant.
• For giving retained enema, the quantity given at a time should
not be more than 100 ml to 150 ml so that the rectum will not
be distended to cause peristaltic movement.
How can we strengthen the mechanical action of an enema?

• The mechanical action of the enema,

the more significant the greater the
amount of liquid.
• With the introduction of water into
the rectum it increases the pressure.
A large amount of water is an irritant
to the intestinal wall. The increasing
pressure and irritating effects of
water leads to increased peristalsis.
Intensive reduction of the walls of
the intestine lead to washing of their
inner surface and cleaned of residue
content.
 6. When an enema is administered, the patient usually
assumes a left lateral position. In this position, the
position of the sigmoid colon is below the rectum, thus
facilitating instillation of the fluid. For a high cleansing
enema, the patient changes position during the
administration of the enema from left lateral to dorsal
recumbent and then to right lateral. In this way the entire
colon will be reached by fluid. For an evacuant enema the
bed should be made flat and for a retained enema the foot
end should be raised.
 • If the patient is
contraindicated movement,
an enema can be put in the
position of the patient on his
back, placing it on the ship.
7. The height of the enema bag
should be adjusted to regulate the
flow of the solution according to
the type of the enema administered.
For cleansing enemas, the height of the
can should not be above 18 inches
(45 cm) from the anus and for
retention enemas, it should not be
above 8 inches (20 cm) the from
the anus.
The higher the container, the greater is
the force with which the solution
flows into the rectum. There inches
an increase of 0,5 lb of pressure for
every 12 inches of elevation.
the water does not go into
the intestine?
8. The distance to which the
tube is inserted depends
upon the age and the size
of the patient. For an adult
it is normally inserted 7.5
to 10 cm (3 to 4 inches),
for children it is inserted
only 2.5 to 3.75 cm (1 to
1.5 inches). If any
obstruction is
encountered, it should be
withdrawn and reported.
• If the water does not go into the
intestine can raise a mug Esmarch
above or change the position of
the tip, pulling it back to 1-2 cm;
• If water still does not enter the
intestine, remove the tip and
replace it ( as it can be hammered
feces).
• If the rectum is impacted, attempt
to remove the faecal matter with a
gloved finger. The bowels should
be cleaned out by a simple enema
before giving retention enema.
 9. The length of time that the enema
solution is retained will depend upon
the purpose of enema and the ability
of the patient to contract the external
sphincter to retain the solution. Oil
retention enemas are usually retained
for 2 to 3 hours. Other cleansing
enemas are normally retained 5 to 10
minutes. To assist a baby to retain the
solution, the nurse can press the
baby's buttocks together, thus
providing pressure over the anal area.
10. Make sure the whole apparatus used
for the administration of enemas is in
a good working condition.
11. Regulate the flow of fluid according
to the type of the enema: give
retention enemas very slowly, usually
by Murphy drip. Before giving
cleaning enemas, regulate the flow of
fluid and pinch the tube before the
tube is inserted into the rectum.
12. Prevent air from entering into the
rectum:
• By removing the froth from the
solution
• By expelling air from the tube
• By not letting the fluid run in
completely from tube.
• If the patient appeared abdominal
pain, you should immediately stop 13. Listen to the complaints
the procedure and wait until the pain of the client and should
goes.
• If the pain does not subside remove not ignore any discomfort
the tip and report to the doctor. however small they are.
• With the introduction of the tip
should not be in pain. In this case, • Tell us what you will do
you should remove the tip and try to if the patient felt pain?
enter it in the right direction.
• With the introduction of water
should not experience sharp pain,
sharp or cutting. There should be no
pain in the abdominal wall and
ligaments, navel, perineum and
scrotum. When such sensations
procedure should be stopped
immediately.
14. Prepacked enemas will
have their own instruction
which need to be followed
unless there are other
instructions from the
physician.
 Dictionary
• Bedpan • Umbilicus
• Intestine
• Indication
• Colon
• Counter-indications • Rectum
• Fluid • Sigmoid colon
• Large volume of Fluid • Feces
• Small volume of Fluid • Stool
• Constipation
• Explain to the patient
• Enema
• Obtain patient’s consent • Cleansing enema
• Lubricate rectal tube • Return-flow enemas
• Slowly enter • Oil enema
• Tubing
• Gently remove
• Rectal tube
• Colonic tube