A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)
- 1Assist the client into the left lateral Sims position with the right knee flexed.
- 2Lubricate the tip of the rectal tube with a water-soluble lubricant.
- 3Instruct the client to take slow, deep breaths through the mouth.
- 4Gently insert the rectal tube 3 to 4 inches (7.5 to 10 cm) into the rectum.
- 5Unclamp the tubing and hold the enema bag 12 to 18 inches (30 to 45 cm) above the rectum.
Answer
The correct sequence is: assist the client into the left lateral Sims position, lubricate the tip of the rectal tube, instruct the client to take deep breaths, gently insert the tube into the rectum, and finally unclamp the tubing and elevate the bag.
Administering an enema requires a systematic approach to ensure safety, comfort, and efficacy. The procedure begins with proper anatomical positioning (left lateral Sims) to utilize gravity for fluid flow. Next, the equipment must be prepared by lubricating the tip of the tube. Immediately before insertion, the nurse instructs the client to take deep breaths to relax the external anal sphincter. Once relaxed, the tube is safely inserted to the correct anatomical depth of 3 to 4 inches. Finally, the solution is administered by unclamping the tubing and holding the bag at the correct height (12 to 18 inches) to ensure steady, safe hydrostatic pressure.
Step-by-Step Solution
Key Concept
Enema Administration Protocol
Estimated Time:1m 0s