The nurse is preparing to administer a large-volume cleansing enema to an adult client. Arrange the following procedural steps in the correct chronological order.
- 1Assist the client into the left lateral Sims' position with the right knee flexed.
- 2Lubricate the distal 2 to 3 inches (5 to 7.5 cm) of the enema tubing.
- 3Direct the tubing toward the umbilicus and gently insert it 3 to 4 inches (7.5 to 10 cm).
- 4Elevate the enema container 12 to 18 inches (30 to 45 cm) above the client's anus.
- 5Unclamp the tubing to allow the solution to flow slowly into the rectum.
Answer
The correct sequence is to first position the client, then lubricate the tubing, insert the tubing into the rectum, elevate the container to the correct height, and finally unclamp the tubing to instill the solution.
The chronological sequence prioritizes client safety and procedural efficacy. First, the client must be anatomically positioned to receive the fluid. Next, the equipment is prepared for insertion by lubricating the tip. The tube is then carefully inserted into the rectum. After placement is secured, the container is elevated to create the correct hydrostatic pressure before unclamping the flow.
Step-by-Step Solution
Key Concept
Safe administration of a large-volume enema requires a systematic approach prioritizing anatomical alignment, prevention of tissue trauma, and controlled fluid pressure.