A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? (Arrange from first to last)
- 1Position the client in the left lateral Sims' position.
- 2Lubricate the tip of the rectal tube with water-soluble jelly.
- 3Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the rectum.
- 4Elevate the enema container 12 to 18 inches (30 to 45 cm) above the anus.
- 5Clamp the tubing temporarily if the client reports abdominal cramping.
Cevap
The correct sequence is to first position the client, lubricate the tubing, insert it into the rectum, elevate the container to start the flow, and monitor the client by clamping the tube if cramping occurs.
Administering a cleansing enema requires a systematic approach to ensure safety and comfort. The client must first be positioned correctly in the left lateral Sims' position to allow gravity to assist the fluid flow into the sigmoid colon. Next, the nurse lubricates the tubing to prevent mucosal injury and gently inserts it safely into the rectum. Once the tube is securely in place, the container is elevated to the proper height to control the fluid's hydrostatic pressure. Finally, the nurse monitors the client continuously during instillation and clamps the tubing if cramping occurs to allow the colon to relax.
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Anahtar Kavram
The procedural steps for administering a large-volume cleansing enema prioritize anatomical alignment, safety, and client comfort.