A practical nurse is preparing to administer a large-volume tap water cleansing enema to an adult client experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.
- 1Position the client in the left lateral Sims' position with the right knee flexed.
- 2Lubricate the distal 2 to 3 inches (5 to 7.5 cm) of the rectal tube with a water-soluble lubricant.
- 3Gently insert the tube 3 to 4 inches (7.5 to 10 cm) into the rectum, directing it toward the umbilicus.
- 4Elevate the enema container 12 to 18 inches (30 to 45 cm) above the client's anus and unclamp the tubing.
- 5Lower the container or temporarily clamp the tubing if the client reports severe abdominal cramping.
Answer
The correct sequence is to first position the client appropriately, lubricate the tube, insert the tube into the rectum, elevate the container to begin the flow, and finally, monitor the client and adjust the flow if cramping occurs.
Administering a large-volume enema requires a systematic approach to ensure safety, effectiveness, and comfort. The nurse must first place the client in the left lateral Sims' position to align with the anatomy of the descending colon. Once positioned, the nurse lubricates the tube to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches, following the direction of the umbilicus. After safe placement, the nurse elevates the container 12 to 18 inches above the anus and unclamps it to initiate the flow. Throughout the procedure, the nurse monitors the client's tolerance, lowering the container or clamping the tube if cramping occurs to allow the colon to relax.
Step-by-Step Solution
Key Concept
Safe procedural sequencing for enema administration