COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 416 Effective Date: August 31, 2006 SUBJECT: ENEMAS 1. PURPOSE: A. To relieve distention and gas by absorption, (carminative) B. To soothe or lubricate rectal mucosa, (emollient) C. To apply absorbable or local medications, (medicinal) D. To soften impacted feces, (lubricating) E. To supply nutrition or fluid for rectal absorption, (nutritive) 2. EQUIPMENT: Obtain from Central Supply: 1. Disposable enema set containing: a. Moisture proof pad b. 1500 cc bag with tip c. Soap packet (discard if not to be used) d. Tissues e. Disposable bedpan f. Bath thermometer g. Disposable exam gloves Obtain from Laundry: 1. Bed Sheet 2. Bath towel Obtain from Pharmacy: 1. Enema ordered 2. Lubricant 3. PROCEDURE: ACTION A. Prepare solution in bag (solution should be lukewarm). Take equipment to bedside B. Explain the procedure to the Individual; its purpose and how he can RATIONALE-PRECAUTIONS A. Explain procedure to the Individual as well as the necessity and purpose of retaining the solution B. Explanation will help to minimize anxiety and illicit cooperation -1-
participate C. Maintain a private environment D. Put on disposable gloves D. Prevent self-contamination E. Position the Individual on his left side, with right leg flexed if physically possible. Place moisture proof pad under the Individual and cover him with the bed sheet F. Clear air from tubing by running a small amount of fluid through and them clamp the tubing. Lubricate the tip of the rectal tube. G. Insert lubricated tip of tube gently four to six inches into the rectum. Have Individual bear down to relax the sphincter muscle while tube is being inserted. H. Unclamp the tubing. The bag is held no more than 8 to 12 inches above the rectum I. If the fluid does not flow readily, squeeze the tubing to milk the fluid through J. If the Individual complains of cramping stop the flow of fluid until the cramp ceases. Have the Individual breathe through his mouth K. When solution has run in, clamp the tubing. If the Individual is having difficulty retaining the fluid leave the tube in place. If the Individual is not experiencing difficulty, withdraw the tubing into the toilet tissue. L. Leave the Individual on his left side with the moisture proof pad in place. Make him comfortable and cover him. Instruct him to remain quiet and to relax, if possible. Leave a bedpan available. Place call light within his reach (if applicable). M. Bag contaminated disposable equipment in clean plastic bag. Tie with a single stranded knot and place in contraband trash for disposal. E. Anatomically the left side is more conducive to the gravity flow of the fluid. Provides Individual with warmth and privacy F. Air in tubing will distend the bowel and limit the space needed for fluid G. To avoid pressure on the anal sphincter H. To decrease or prevent stimulation of peristalsis and to introduce fluid slowly. The higher the container the faster the flow of fluid I. Do not increase the height of the container or move the tubing in and out as this will stimulate peristalsis J. Breathing through the mouth aids in the relaxation of the abdominal muscles K. Removing the tube will increase the stimulation of peristalsis. L. Encourage the Individual to retain the enema for the specified amount of time. The bedpan provides security if he is unable to retain the solution. M. All enema equipment is disposable and contaminated N. when solution is retained for the N. Provide for Individual comfort -2-
ordered amount of time, or when necessary, put the Individual on the bedpan or toilet. O. When enema has been expelled, provide the necessary articles for cleaning or if the Individual is unable to clean himself, clean and dry him. O. Provide for Individual comfort 4. VARIATION Oil Retention Enema ACTION RATIONAL- PRECAUTIONS A. Obtain from Pharmacy: Oil retention Enema commercially prepared. (given per physician s order and per instructions on package) B. Explain the procedure to the B. Explanation will help to minimize Individual, its purpose, and how we can anxiety and illicit cooperation participate C. Position the Individual on his left C. This position is the most helpful in side whenever possible aiding gravity flow of fluids D. Provide privacy for the Individual D. Minimize embarrassment, provide and cover with sheet or bath blanket. warmth and protect. Place moisture proof pad under the Individual E. Wear disposable gloves E. Prevent self-contamination. Standard Transmission-Based Precautions F. Insert and apply per instructions on F. Different brands may have slightly the package G. Continue with retention Enema from letter L. p. 2 different instructions G. Tube may be pre-lubricated. Facilitates entry of tube into the rectum 5. RECORDING: A. Note medication/treatment as administered on the Medication Record B. Record any unusual reaction/drainage in the IDNs C. Document any Individual education in the IDN Notes -3-
6. GENERAL INFORMATION: A physician s order is required. It must specify the type of enema and the time intervals. An enema may be given with a commercially prepared, disposable enema unit or by the bag and tubing which is attached to the rectal tube by a connecting tip. Both units are disposable. Types of Enemas Commonly Used for Adults Name Constituents Commercially prepared enema 90-120 ml of a hypertonic solution, such as sodium phosphate (see directions on the package) Saline 9 ml of sodium chloride to 1,000 ml of water Tap water 500-1000 ml of tap water Soap 20 ml of castile soap in 500-1000 ml of water Oil, e.g. olive oil 20-120 ml of oil (commercially prepared): mineral, olive or cottonseed 7. PURPOSE: To cleanse the bowel of feces by stimulating defecation 8. EQUIPMENT: Obtain from Central Supply: 1. Disposable enema set containing moisture proof pad, 2000 cc enema bag with pre-lubricated tip and soap packet 2. Disposable bedpan 3. Disposable gloves Obtain from Laundry: 1. Bath blanket or sheet 9. PROCEDURE: ACTIONS RATIONALE-PRECAUTIONS A. Explain to the Individual the procedure, its purpose, and how he A. to minimize anxiety and elicit cooperation can participate B. Put on gloves B. Prevent cross contamination C. Place waterproof pad under C. Protect bed Individual s buttock D. Position the Individual on his left D. Helpful in aiding gravity flow of fluid -4-
side, whenever possible, with knees flexed. E. Provide privacy for the Individual and cover with sheet. Place moisture proof pad under the Individual F. Prepare the equipment. Fill the bag with the ordered solution G. Clear the air from the tubing by running fluid through and then clamping the tubing E. Minimize embarrassment and provide warmth F. The solution should be warm but not over 41 degrees C or 105 degrees F G. Air in the tubing will distend the bowel and limit the space for fluid. H. Wear disposable glove H. Infection control measures I. Insert the lubricated tube 7.5 to 10- cm (3 to 4 inches) into the rectum. Ask the Individual to bear down, to relax sphincter muscle during insertion of tube and then relax J. Hold the container 14 to 18 inches above the level of the Individual K. Unclamp tubing to introduce the fluid. If the Individual complains of cramping, slow the rate of flow by lowering the container or by clamping the tubing. Have the Individual take deep breaths or flex his knee L. When the solution has been instilled, clamp the tubing and gently remove from rectum. Inform Individual to retain fluid as long as possible M. Place Individual on the bedpan or assist him to the bathroom. Allow him privacy. If he used the bathroom, instruct him not to flush the toilet and to call the nursing staff when he is finished N. Discard the enema equipment and gloves in the contaminated trash container I. Avoids unnecessary pressure on the anal sphincter J. Flow rate is determined by the height of the container. The higher the container the faster the rate of flow K. A slower flow rate will decrease the feeling of fullness. Deep breathing and flexing the knees will help relax the abdominal muscles L. Obtain better results M. The enema return must be checked and documented N. All enema equipment is contaminated and disposable O. Wash hands O. Prevent spread of infection P. Clean and dry the Individual or P. Maintain Individual comfort provide the material for him to use -5-
10. VARIATION: ACTION RATIONAL-PRECAUTIONS A. Following cleansing enema procedure in step 3. Prepare equipment B. Remove cap and attach B. Follow directions container administration tip C. Tip is pre-lubricated C. Facilitate entry of tube into rectum D. Wear disposable gloves E. Gently insert into rectum E. If fecal matter is presented remove tube, check to see that end of tube is not plugged and reinsert F. Squeeze or roll-up container from F. See directions on container bottom to expel liquid G. Encourage patent to retain enema G. Obtain better results until the urge to evacuate is strong. This usually occurs within five (5) minutes H. Continue with cleansing enema procedure beginning at number 10. 11. RECORDING: In the Wellness and Recovery Notes, record date, time, procedure, results (character and amount of feces returned), blood and/or mucus if present and the Individual s response. Document any teaching in the IDN notes. -6-