A nurse on a medical-surgical unit 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 in the correct chronological sequence.
- 1Warm the prescribed enema solution and prime the administration tubing.
- 2Assist the client into a left lateral Sims' position with the right knee flexed.
- 3Lubricate the tip of the tubing and gently insert it 3 to 4 inches into the rectum.
- 4Elevate the solution container 12 to 18 inches above the anus and release the clamp.
- 5Temporarily clamp the tubing if the client reports sudden abdominal cramping.
Cevap
The correct sequence is: Warm the solution and prime the tubing, position the client in a left lateral Sims' position, lubricate and insert the tube 3 to 4 inches, elevate the container and release the clamp, and finally, clamp the tubing temporarily if cramping occurs.
Administering a cleansing enema requires a systematic, evidence-based approach. The nurse must first prepare the equipment by warming the solution to prevent cramping and priming the tubing to remove air. Next, the client is placed in the left lateral Sims' position to align with the anatomy of the descending colon. The lubricated tube is then inserted safely 3 to 4 inches. Once inserted, the container is raised to create a gentle gravity flow. Finally, the nurse monitors the client during the infusion and clamps the tubing if cramping occurs to allow the bowel to relax.
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Anahtar Kavram
The safe administration of a large-volume enema requires sequential preparation, precise anatomical positioning, correct insertion depth, and continuous monitoring to ensure basic care and comfort while promoting elimination.
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