The nurse is preparing to administer a large-volume cleansing enema to an older adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.
- 1Fill the enema container with warmed solution and flush the administration tubing to remove air.
- 2Position the client in a left lateral Sims position with the upper knee flexed.
- 3Lubricate the distal tip of the rectal tube generously with a water-soluble jelly.
- 4Instruct the client to exhale slowly while inserting the tube 3 to 4 inches toward the umbilicus.
- 5Raise the enema container no higher than 18 inches above the client's anus and initiate the flow.
Answer
First, prepare the solution and prime the tubing. Second, position the client in the left lateral Sims position. Third, lubricate the rectal tube. Fourth, have the client exhale while inserting the tube toward the umbilicus. Finally, raise the container to the proper height and begin the flow.
Administering a large-volume enema requires a systematic sequence to ensure safety, comfort, and efficacy. The nurse must first prepare the solution and prime the tubing to eliminate air that causes cramping. Next, the client is placed in the left lateral Sims position to take advantage of gravity for fluid flow into the descending colon. After positioning, the nurse lubricates the tube to prevent mucosal trauma. The tube is then inserted gently while the client exhales, following the natural anatomical angle toward the umbilicus. Finally, the container is raised to the correct height (no higher than 18 inches) to establish a safe hydrostatic pressure for the infusion.
Step-by-Step Solution
Key Concept
Administration of a Large-Volume Cleansing Enema