A client requires a large-volume cleansing enema to relieve severe constipation. In what chronological sequence should the nurse perform the steps of this procedure?
- 1Position the client on their left side with the right knee flexed.
- 2Apply water-soluble lubricant to the distal tip of the rectal tube.
- 3Insert the tubing 3 to 4 inches into the rectum, directing it toward the umbilicus.
- 4Elevate the solution bag 12 to 18 inches above the level of the anus.
- 5Release the tubing clamp and instill the fluid slowly, monitoring for cramping.
Answer
The correct sequence is: position the client on their left side, apply lubricant to the tube, insert the tube 3 to 4 inches, elevate the bag 12 to 18 inches, and release the clamp to instill the fluid.
The correct sequence ensures both client safety and the physiological effectiveness of the enema. Positioning the client appropriately must occur first to align the anatomy. Lubricating the tube is necessary immediately prior to insertion to prevent mucosal tears. Once inserted properly towards the umbilicus, the bag is elevated to the recommended height to control fluid pressure. Finally, the flow is initiated while actively monitoring the client's physical tolerance.
Step-by-Step Solution
Key Concept
Enteral Elimination Procedures and Enema Administration