A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. Arrange the following steps of the procedure in the correct chronological order.
- 1Assist the client into the left lateral Sims position with the right knee flexed.
- 2Don clean gloves and apply a water-soluble lubricant to the tip of the enema tubing.
- 3Instruct the client to breathe out slowly while inserting the tip 3 to 4 inches into the rectum.
- 4Elevate the enema container 12 to 18 inches above the level of the anus and unclamp the tubing.
- 5Clamp the tubing temporarily if the client reports fullness or abdominal cramping.
Answer
The correct sequence is to first position the client, then prepare for insertion by donning gloves and lubricating the tip. Next, the nurse inserts the tip while the client exhales, elevates the bag to the correct height to begin infusion, and finally manages any potential cramping by clamping the tubing.
This sequence ensures patient safety, anatomical alignment, and procedure effectiveness. Positioning the client first ensures the descending colon is optimally oriented. Donning gloves and lubricating immediately prior to insertion prevents contamination. Exhaling during insertion relaxes the sphincter, and properly elevating the bag controls the fluid pressure. Finally, anticipating and reacting to cramping by clamping the tube represents safe intra-procedure monitoring.
Step-by-Step Solution
Key Concept
Safe administration of a large-volume cleansing enema
Estimated Time:1m 30s