An adult client requires a large-volume cleansing enema for the treatment of severe constipation. The nurse has gathered all necessary supplies and warmed the solution. In what order must the nurse execute the following procedural steps to safely administer the enema? (Arrange the steps in the correct chronological sequence.)
- 1Assist the client into the left lateral Sims position with the right knee flexed.
- 2Apply water-soluble lubricant to the distal 2 to 3 inches of the rectal tube.
- 3Gently advance the rectal tube 3 to 4 inches into the rectum, aiming toward the umbilicus.
- 4Secure the enema fluid container 12 to 18 inches above the level of the client's anus.
- 5Release the regulating clamp to initiate a slow flow of the solution.
Answer
The correct sequence is: position the client in the left lateral Sims position, lubricate the rectal tube, insert the tube into the rectum, elevate the container to the proper height, and finally release the clamp.
Administering an enema requires a logical sequence prioritizing anatomical alignment, client safety, and comfort. Proper positioning (left lateral Sims) must occur first. The tube is then lubricated to prevent tissue injury before being gently inserted into the rectum. Once the tube is correctly placed, the container is elevated to the appropriate height to establish safe hydrostatic pressure. Only after these preparatory and positioning steps are complete should the nurse release the clamp to begin fluid instillation.
Step-by-Step Solution
Key Concept
Cleansing Enema Administration Sequence