A nurse is preparing to administer a large-volume cleansing enema to a client experiencing severe constipation. Arrange the following steps in the correct sequence from first to last. All options must be used.
- 1Assist the client into a left lateral position with the right knee flexed.
- 2Apply water-soluble lubricant to the distal end of the rectal tube.
- 3Gently insert the tubing 3 to 4 inches into the rectum, directing it toward the umbilicus.
- 4Elevate the enema bag up to 18 inches above the client's hips and unclamp the tubing.
- 5Lower the fluid container or clamp the tubing temporarily if the client reports cramping.
Answer
The correct procedural sequence is to first position the client on their left side, lubricate the tubing tip, insert the tube into the rectum, initiate the fluid flow at the appropriate height, and finally, adjust the flow if the client develops cramping.
Administering an enema requires a strict sequence of steps to ensure patient safety and procedure efficacy. Positioning the client on their left side (Sims position) is the first priority to align with colon anatomy. Lubricating the tube must occur immediately before insertion to prevent mucosal tears. Once inserted 3 to 4 inches towards the umbilicus, the nurse elevates the bag (no more than 18 inches) to initiate flow by gravity. Finally, if the client experiences cramping during infusion, the nurse must intervene by lowering the bag or clamping the tubing to slow the flow and relieve spasms.
Step-by-Step Solution
Key Concept
Procedural Sequence: Cleansing Enema Administration