A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. Arrange the following actions in the correct sequence. (Place the first action at the top and the final action at the bottom.)
- 1Assist the client into the left Sims' position with the right knee flexed.
- 2Lubricate the tip of the enema tubing with a water-soluble lubricant.
- 3Insert the tubing tip 3 to 4 inches (7.5 to 10 cm) into the client's rectum.
- 4Elevate the enema bag 12 to 18 inches (30 to 45 cm) above the client's anus and open the clamp.
- 5Clamp the tubing temporarily if the client reports severe abdominal cramping.
Answer
The correct sequence is to first position the client, lubricate the tubing, insert the tubing into the rectum, elevate the enema bag to initiate flow, and finally, clamp the tubing if cramping occurs.
The proper sequence for administering an enema prioritizes anatomical alignment, safety, and client comfort. Placing the client in the left Sims' position uses gravity to aid fluid flow into the descending colon. Lubrication and proper insertion depth (3 to 4 inches) prevent tissue injury. Elevating the bag 12 to 18 inches ensures a controlled infusion rate. If cramping occurs, clamping the tubing is the correct immediate intervention to relieve spasms without aborting the care task.
Step-by-Step Solution
Key Concept
Basic Care and Comfort: Enema Administration Sequence and Safety