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.
- 1Assist the client into a left lateral Sims' position with the right knee flexed.
- 2Apply water-soluble lubricant to the distal 2 to 3 inches of the rectal tube.
- 3Instruct the client to breathe out slowly and gently insert the tube 3 to 4 inches into the rectum.
- 4Hold the enema container at the level of the client's hips and open the regulating clamp.
- 5Slowly elevate the container to a maximum height of 12 to 18 inches above the anus.
Answer
The correct sequence is to position the client on their left side, lubricate the tubing, gently insert the tube while the client exhales, initiate the fluid flow with the bag held at hip level, and finally elevate the bag to the appropriate height.
Safe and effective enema administration requires following a sequence that minimizes discomfort and maximizes fluid retention. The left lateral Sims' position is established first because it aligns with the anatomy of the descending colon. Next, lubrication is applied to prevent mucosal injury. Having the client exhale relaxes the sphincter for smooth insertion of the tube. Once inserted, initiating the flow with the bag at hip level prevents a sudden surge of fluid. Finally, gradually raising the bag to a maximum of 12 to 18 inches provides the appropriate hydrostatic pressure for instillation without causing severe bowel spasms.
Step-by-Step Solution
Key Concept
Safe Administration of a Cleansing Enema