A nurse is preparing to administer a large-volume cleansing enema to an adult client to relieve constipation. Arrange the following procedural steps in the correct chronological order from first to last.
- 1Position the client in a left lateral Sims position with the right knee flexed.
- 2Lubricate the distal 2 to 3 inches of the enema tubing tip.
- 3Insert the enema tube gently 3 to 4 inches into the rectum, directing it toward the umbilicus.
- 4Elevate the fluid container 12 to 18 inches above the client's anus and unclamp the tubing.
- 5Withdraw the tube smoothly and encourage the client to retain the enema fluid as prescribed.
Answer
The correct sequence is: Position the client, lubricate the tubing, insert the tubing, elevate the container to administer fluid, and finally withdraw the tube while encouraging retention.
Administering a cleansing enema requires a systematic approach to ensure safety and effectiveness. The nurse must first place the client in the left lateral Sims position to align the sigmoid colon with gravity. Next, the equipment is prepared by lubricating the tip to prevent mucosal trauma. The tube is then inserted 3 to 4 inches into the rectum, aiming toward the umbilicus to follow the bowel's contour safely. Following correct placement, the fluid container is elevated 12 to 18 inches above the anus to initiate a steady, low-pressure flow. Finally, the tube is removed, and the client is instructed to retain the fluid to maximize the therapeutic outcome.
Step-by-Step Solution
Key Concept
Safe administration of a large-volume cleansing enema