A licensed practical nurse is preparing to administer a prescribed large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.
- 1Assist the client into the left lateral Sims position.
- 2Apply a water-soluble lubricant to the tip of the enema tubing.
- 3Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the client's rectum.
- 4Open the clamp on the tubing and allow the solution to flow slowly.
Answer
The correct sequence is to first position the client in the left lateral Sims position, then lubricate the tip of the tubing, gently insert the tubing into the rectum, and finally open the clamp to allow the solution to flow.
The correct sequential order for administering an enema ensures client safety, promotes comfort, and maximizes the procedure's efficacy. Positioning the client properly in the left lateral Sims position must always come first to physically prepare the client and utilize gravity for the bowel's anatomical curve. Next, lubricating the tube is an essential safety measure that must be completed immediately before any contact is made with the body to prevent mucosal damage. After lubrication, the tube is safely and gently inserted 3 to 4 inches into the rectum. Finally, only once the tube is correctly placed and secured by the nurse's hand, the clamp is opened to begin the instillation of the fluid.
Step-by-Step Solution
Key Concept
Basic Care and Comfort: Enema Administration Sequence