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Difficulty: MediumBasic Care and Comfort

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.

  1. 1Assist the client into a left lateral Sims position.
  2. 2Lubricate the distal tip of the enema tubing.
  3. 3Insert the enema tubing 3 to 4 inches (7.5 to 10 cm) into the rectum.
  4. 4Elevate the enema solution container 12 to 18 inches (30 to 45 cm) above the anus.
  5. 5Open the roller clamp to initiate the flow of the solution.

Answer

The correct sequence is: assist the client into the left lateral Sims position, lubricate the tubing tip, insert the tubing 3 to 4 inches, elevate the container 12 to 18 inches, and finally open the roller clamp.
Administering a cleansing enema requires a systematic and safe procedural flow. The nurse must first place the client in the left lateral Sims position to align the anatomy with gravity for optimal fluid flow. Next, the tubing tip is lubricated to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches into the rectum. After secure insertion, the container is elevated 12 to 18 inches to establish safe hydrostatic pressure, preventing rapid infusion and cramping. Finally, the clamp is opened to initiate the slow flow of the solution.

Step-by-Step Solution

1
Position the client appropriately.
The client is in the left lateral Sims position.
This specific position exposes the anus and uses gravity to help the fluid flow naturally into the descending and sigmoid colon.
2
Prepare the equipment for insertion.
The enema tube tip is lubricated.
Lubrication is necessary immediately prior to insertion to prevent tissue injury and ensure a smooth entry.
3
Insert the tube into the rectum.
The tube is inserted 3 to 4 inches.
This depth passes the internal and external anal sphincters safely. Inserting it further could damage the intestinal wall.
4
Set the appropriate hydrostatic pressure.
The enema bag is elevated 12 to 18 inches above the anus.
Holding the bag too high causes the fluid to infuse too rapidly, which can trigger severe cramping and premature expulsion of the fluid.
5
Begin the infusion.
The roller clamp is opened.
Once all safety measures (position, insertion depth, and pressure head) are established, the fluid can be safely administered.

Key Concept

Safe administration of a large-volume cleansing enema (Hygiene and Elimination)
Estimated Time:1m 30s
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Topics

Basic Care and Comfort

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