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Difficulty: MediumBasic Care and Comfort

A practical nurse (PN) is preparing to administer a large-volume cleansing enema to a client who is experiencing constipation. In what order should the PN perform the following actions? Arrange the steps from first to last.

  1. 1Position the client in the left lateral Sims' position with the right knee flexed.
  2. 2Lubricate the distal 2 to 3 inches of the enema tube tip.
  3. 3Gently insert the tube 3 to 4 inches into the rectum, directing it toward the umbilicus.
  4. 4Elevate the solution container 12 to 18 inches above the level of the anus and unclamp the tubing.
  5. 5Lower the container or clamp the tubing temporarily if the client reports abdominal cramping.

Answer

The correct sequence begins with positioning the client, followed by lubricating the tube, inserting it to the correct depth, initiating the flow at the proper height, and finally monitoring for and managing any discomfort such as cramping.
The procedure follows a logical and safe progression: preparation of the client (positioning), equipment preparation (lubrication), safe execution (insertion and controlled fluid flow), and continuous evaluation (monitoring for and responding to cramps).

Step-by-Step Solution

1
Position the client in the left lateral Sims' position.
The client's anatomy is optimally aligned to receive the fluid.
Gravity and the natural anatomical curve of the descending colon help retain the fluid and allow it to flow deeply into the bowel.
2
Lubricate the enema tip.
The tube surface is smoothed.
Lubrication prevents friction and mucosal tearing during insertion through the anal sphincters.
3
Insert the tube 3 to 4 inches into the rectum.
The tube safely passes the internal and external sphincters.
Ensures the fluid is delivered directly into the rectum and not expelled immediately.
4
Elevate the bag 12 to 18 inches and unclamp.
The solution begins to flow steadily into the bowel.
Provides adequate, safe hydrostatic pressure for fluid instillation without causing excessive force.
5
Monitor for cramping and lower or clamp the bag if it occurs.
The flow is adjusted based on client tolerance.
Rapid bowel distention causes severe pain; clamping or lowering the bag slows the instillation rate and relieves cramping.

Key Concept

Administration of a Cleansing Enema
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Topics

Basic Care and Comfort

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