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Zorluk: OrtaBasic Care and Comfort

An older adult client is prescribed a large-volume cleansing enema to treat severe constipation. Which of the following actions should the nurse take when preparing and administering this intervention?

  1. Position the client in a left lateral position with the right knee flexed.Cevap
  2. B
    Place the client in a right lateral position to align with the anatomical structure of the colon.
  3. C
    Assign the unlicensed assistive personnel (UAP) to perform the pre-procedure abdominal assessment.
  4. D
    Document the client's recent episodes of fecal seepage as an expected age-related physiological change.

Cevap

The nurse should position the client in a left lateral position with the right knee flexed (Sims' position).
The correct action is to place the client in the left lateral Sims' position. Because the descending colon is located on the left side of the body, this position allows gravity to help the enema solution flow smoothly into the sigmoid and descending colon, maximizing the effectiveness of the treatment and minimizing client discomfort.

Adım Adım Çözüm

1
Evaluate the anatomy of the lower gastrointestinal tract.
The descending colon and sigmoid colon are located on the left side of the abdomen.
Understanding anatomy dictates the positioning required for gravity to assist in fluid flow.
2
Determine the optimal client position for enema administration.
The left lateral position with the right knee flexed (Sims' position) is selected.
This position places the descending colon at the lowest point, allowing the enema solution to flow easily by gravity into the sigmoid colon and descending colon.

Anahtar Kavram

Basic Care and Comfort: Bowel Elimination and Enema Administration
Tahmini Süre:1m 0s
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Konular

Basic Care and Comfort

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