Prior to an endoscopic procedure, a client requires the administration of a large-volume cleansing enema. The supplies are at the bedside, and the client's identity has been verified. In what sequence should the nurse perform the administration steps? Arrange the actions from first to last.
- 1Assist the client into the left lateral Sims position with the right knee flexed.
- 2Place a waterproof pad under the client's buttocks and put on clean examination gloves.
- 3Lubricate the distal 5 to 7.5 cm (2 to 3 inches) of the enema tubing tip.
- 4Gently insert the tube 7.5 to 10 cm (3 to 4 inches) into the anal canal, directing it toward the umbilicus.
- 5Release the tubing clamp and elevate the solution container 30 to 45 cm (12 to 18 inches) above the client's anus.
Answer
The correct sequence is to first position the client in the left lateral Sims position, then place a protective pad and don gloves, lubricate the tip of the enema tubing, safely insert the tube into the rectum, and finally release the clamp while elevating the container to the correct height.
Safe enema administration requires following a logical sequence that prioritizes anatomical alignment, infection control, and trauma prevention. Positioning the client properly on the left side ensures gravity assists the fluid. Once positioned, the nurse ensures hygiene and lubricates the tubing to protect the mucosa. After safely inserting the tube following the bowel's anatomical curve, the nurse initiates the fluid flow at a controlled height to prevent sudden cramping and maximize retention.
Step-by-Step Solution
Key Concept
Procedural safety and client positioning for large-volume enema administration