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Zorluk: KolayBasic Care and Comfort

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

  1. 1Assist the client into the left lateral Sims position with the right knee flexed.
  2. 2Lubricate the tip of the enema tubing 2 to 3 inches.
  3. 3Insert the tubing gently 3 to 4 inches into the rectum, directing it toward the umbilicus.
  4. 4Raise the enema container 12 to 18 inches above the level of the anus and open the clamp.

Cevap

The correct procedural sequence is to first position the client in the left lateral Sims position, then lubricate the enema tubing, carefully insert the tubing into the rectum, and finally raise the container to begin the infusion.
Administering a cleansing enema safely requires a logical, step-by-step approach. The nurse must first place the client in the left lateral Sims position to align with the anatomy of the lower GI tract. Next, the equipment is readied by lubricating the tubing tip. The tube is then carefully inserted. Only after the tube is securely in the rectum should the nurse raise the bag to allow the fluid to flow via gravity.

Adım Adım Çözüm

1
Assist the client into the left lateral Sims position.
The client is in the safest and most effective anatomical position.
The left lateral Sims position utilizes gravity to help the fluid flow down into the sigmoid and descending colon.
2
Lubricate the tip of the enema tubing.
The tubing is prepared for safe insertion.
Lubrication minimizes tissue friction, preventing pain or damage to the sensitive rectal mucosa.
3
Insert the tubing 3 to 4 inches into the rectum.
The tube passes the internal sphincter and rests safely in the rectum.
Inserting the tube 3 to 4 inches in an adult, directed toward the umbilicus, ensures the fluid will be delivered appropriately without risking bowel wall perforation.
4
Raise the enema container and open the clamp.
Fluid begins to instill into the colon at a controlled rate.
The height of the bag controls the pressure and flow rate of the instillation. Raising it only after secure placement prevents spills and ensures a controlled, safe procedure.

Anahtar Kavram

Basic Care and Comfort: Enema Administration
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Konular

Basic Care and Comfort

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