A practical nurse is assigned to care for a client who is experiencing severe constipation and requires a large-volume cleansing enema. In what sequence should the nurse perform the following administration steps?
- 1Assist the client into a 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.
- 3Instruct the client to exhale slowly while gently inserting the rectal tube 3 to 4 inches (7.5 to 10 cm) toward the umbilicus.
- 4Elevate the solution container 12 to 18 inches (30 to 45 cm) above the level of the client's anus.
- 5Release the tubing clamp to allow the warm solution to instill slowly into the colon.
Answer
The correct sequence is: assist the client into the left lateral Sims' position, lubricate the tube, insert the tube while the client exhales, elevate the solution container, and finally release the tubing clamp.
Administering a cleansing enema requires a systematic approach to ensure both client safety and procedural efficacy. First, the client must be placed in the left lateral Sims' position because the descending colon is on the left side, allowing gravity to assist fluid flow. Next, the tube must be lubricated to prevent tissue trauma during entry. The tube is then gently inserted 3 to 4 inches past the internal sphincter. After the tube is safely in place, the container is elevated 12 to 18 inches above the anus to establish safe hydrostatic pressure (preventing fluid from entering too forcefully). Finally, the clamp is opened to allow the fluid to instill slowly and comfortably.
Step-by-Step Solution
Key Concept
Cleansing Enema Administration Sequence