AdministeringaCleansingEnema-checklist(1).

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AdministeringaCleansingEnema-documentation(1).pdf
AdministeringaCleansingEnema-equipment(1).pdf
AdministeringaCleansingEnema-procedure(1).pdf

Mosby: Mosby's Nursing Video Skills

Student _________________________________________
Instructor _______________________________________

Date ___________________
Date ___________________

PERFORMANCE CHECKLIST FOR ADMINISTERING A CLEANSING ENEMA

S

NP

Comments

1. Gathered all needed supplies.

2. Performed hand hygiene.
3. Introduced self to patient and family.
4. Noted patients name, type of enema ordered,
and time of administration, compared record
against label on the enema.
5. Checked accuracy and completeness of each
MAR with health care providers written
order if necessary, compared MAR with label
on solution.
6. Identified patient using two identifiers,
compared identifiers with information on ID
bracelet.
7. Provided for patient privacy, raised bed to
appropriate working height, lowered side rail
on working side of bed.
8. Helped patient to appropriate position,
encouraged patient to remain there until
procedure is through, ensured patient was
draped properly.
9. Applied clean gloves.
10. Placed bedpan in easily accessible position or
ensured toilet is available and robe and
slippers were accessible.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

11. Placed waterproof pad under patients hips

and buttocks.
12. Administered prepackaged disposable enema:
A. Removed plastic cap from container,
applied water-soluble lubricant as needed.
B. Separated patient buttocks, examined
perineal region for abnormalities.
C. Instructed patient to relax by breathing
slowly through the mouth.
D. Expelled any air from enema container.
E. Inserted lubricated tip properly into
patients anal canal, adjusted insertion depth
based on patients age.
F. Did not force tip if resistance was felt,
stopped procedure, notified health care
provider.
G. Rolled bottle from bottom to tip until all
solution has entered patients rectum.
H. Placed toilet tissue around rectal tube and
anus, withdrew tip and discarded properly.
I. Instructed patient to retain solution until
urge to defecate occurs.
13. Administered enema using a standard enema
bag:
A. Added warmed solution to enema bag if
ordered, checked temperature on wrist.
B. Added castile soap to water if ordered.
C. Raised container, released clamp, allowed
solution to fill tubing.
D. Reclamped tubing, positioned and draped

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

patient properly.
E. Lubricated tip of rectal tube with lubricating
gel.
F. Separated patients buttocks, instructed
patient to relax by breathing through mouth,
touched patients skin next to anus with tip of
rectal tube.
G. Inserted top of rectal tube slowly, adjusted
insertion length based on patients age.
H. Opened regulating clamp while holding
tube in rectum, allowed solution to enter, kept
container at level of patients hips.
I. Held tube in place constantly.
J. Raised height of enema container slowly.
14. Used IV pole to hand enema bag, lowered
container or clamped tubing if patient
complained or if fluid escaped around rectum,
instilled all of solution, clamped tube, told
patient when procedure was completed.
15. Placed toilet tissue around tube at anus,
withdrew rectal tube and tip.
16. Explained that distention and cramping are
normal, asked patient to retain solution as
long as possible, stayed by bedside, discarded
enema container and tubing appropriately.
17. Helped patient to bathroom or helped patient
assume near normal position over bedpan.
18. Observed character of patients stool and
solution, cautioned patient not to flush.
19. Assisted patient as needed with washing anal

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

area, applied gloves if necessary.

20. Removed and discarded gloves, performed
hand hygiene.
21. Assessed patients abdomen for distention.
22. Raised side rails and lowered bed to ensure
patient safety.
23. Helped patient to comfortable position,
placed personal items within reach.
24. Placed call light within reach, ensured patient
knows how to use it.
25. Documented and reported patients response
and outcomes, documented type and volume
of edema, time of administration, and
characteristics of stool.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

Sample Documentation for Administering a Cleansing Enema
2000 Last BM 5 days ago. C/O abdominal fullness and rectal pressure. Abdomen
distended, firm. 1000-mL soap suds enema given with mild abdominal cramping
during administration. Solution returned with large amount of dark-brown, soft-formed
stool. S. Halpern, RN 10/25/13

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

Equipment for Administering a Cleansing Enema
Clean gloves
Water-soluble lubricant
Waterproof absorbent pads
Toilet tissue
Bedpan, bedside commode, or access to toilet
Basin, washcloths, towel, and soap
Intravenous (IV) pole
Enema Bag Administration
Enema container with tubing and clamp
Appropriate-size rectal tube:
Adult: 22 to 30 Fr
Correct volume of warmed (tepid) solution:
Adult: 750 to 1000 mL
Prepackaged Enema Administration
Prepackaged enema container with lubricated rectal tip

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby: Mosby's Nursing Video Skills

Procedural Guidelines for Administering a Cleansing Enema
1.
2.
3.
4.

Gather all needed supplies.

Perform hand hygiene.
Introduce yourself to the patient and family, if present.
Note the patients name, type of enema ordered and time of administration. Compare
the record against the label on the enema.
5. If the enema is medicated, check the accuracy and completeness of each medication
administration record (MAR) with the health care providers written order. Check the
patients name, type of enema, and time of administration. Compare the MAR with
the label on the enema solution.
6. Identify the patient using two identifiers, such as name and date of birth or name and
account number, according to agency policy. Compare these identifiers with the
information on the patients identification bracelet.
7. Provide for the patients privacy by drawing the bedside curtain or closing the door.
Raise the bed to an appropriate working height; raise the side rail on the patients left
side. Lower the side rail closest to you.
8. Help the patient into a left side-lying or Sims position with the right knee flexed.
Encourage the patient to remain in this position until the procedure is complete.
Cover the patient with a bath blanket, making sure that only the rectal and anal area is
exposed.
9. Apply clean gloves.
10. Place a bedpan or bedside commode in an easily accessible position. If the patient
will be expelling the contents of the enema into the toilet, ensure that the toilet is
available and place the patients slippers and bathrobe in an easily accessible position.
(If leaving the patient to do this step, raise the rail on your side).
11. Place a waterproof pad, absorbent side up, under the patients hips and buttocks.
12. To administer a prepackaged disposable enema:
A. Remove the plastic cap from the tip of the container. The tip may already be
lubricated. Apply more water-soluble lubricant as needed.
B. Separate the patients buttocks and examine the perianal region for abnormalities,
including hemorrhoids, anal fissures, and rectal prolapse.
C. Gently separate the patients buttocks and locate the anus. Instruct the patient to
relax by breathing in and out slowly through the mouth.
D. Expel any air from the enema container.
E. Gently insert the lubricated tip of the container gently into the patients anal canal
in the direction of the umbilicus: Adjust insertion depth based on the patients
age.
Adult: 7.5 to 10 cm (3 to 4 inches)
F. Do not force the tip if you feel resistance. Stop the procedure, and notify the
health care provider.
G. Once properly inserted to proper depth, roll the plastic bottle from the bottom to
the tip until all of the solution has entered the patients rectum and colon.
H. To remove the enema, place toilet tissue around the rectal tube and anus and

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2
gently withdraw the tube and tip. Discard into proper waste receptacle.
I. Instruct the patient to retain the solution until the urge to defecate occurs, usually
2 to 5 minutes. Instruct the patient again to remain in this position.
13. To administer an enema using a standard enema bag:
A. Warm the tap water as it flows from the faucet. Add the warmed solution to the
enema bag. If saline is ordered, place the container of saline in a basin of warm
water before adding it to the enema bag, and check the temperature of the solution
by pouring a small amount of it over your inner wrist. The water should be warm,
not hot.
B. If a soap suds enema is ordered, add castile soap after the water is placed in the
enema bag.
C. Raise the container, release the clamp, and allow the solution to fill the tubing.
This removes the air from the tubing.
D. Reclamp the tubing. Prepare the patient in the proper position and draping as done
above.
E. Lubricate 6 to 8 cm (2.5 to 3 inches) of the tip of the rectal tube with lubricating
gel.
F. Gently separate the patients buttocks and locate the anus. Instruct the patient to
relax by breathing in and out slowly through the mouth. Then touch the patients
skin next to the anus with the tip of the rectal tube.
G. Insert the tip of the rectal tube slowly by pointing the tip in the direction of the
patients umbilicus. The length of insertion varies based on patients age:
Adult: 7.5 to 10 cm (3 to 4 inches)
H. Holding the tubing in the rectum, open the regulating clamp and allow the
solution to enter slowly, keeping the container at the level of the patients hips.
This prevents the solution from flowing out of the bag too rapidly.
I. Constantly hold the tube in place until all the solution has been instilled.
J. Gradually raise the height of the enema container slowly to the appropriate level
above the anus. The amount of time needed to instill the solution will vary with
the volume of solution to be administered:
30 to 45 cm (12 to 18 inches) for a high enema
30 cm (12 inches) for a regular enema
7.5 cm (3 inches) for a low enema
14. Once the flow of the fluid has been established, you may use an IV pole to hang the
enema bag.
A. Lower the container or clamp the tubing if the patient complains of cramping or if
fluid escapes around the rectal tube.
B. Instill all of the solution, and clamp the tubing. Tell the patient that youve
completed the procedure and that youll be removing the tubing.
15. Place layers of toilet tissue around the tube at the anus, and gently withdraw the rectal
tube and the tip.
16. Explain to the patient that some distention and abdominal cramping afterward is
normal. While continuing to lie on their left side, ask the patient to retain the solution
for as long as possible until the urge to defecate occurs. This usually takes a few
minutes. Stay at the bedside. Have the patient lie quietly in bed if possible. Discard
the enema container and tubing in the proper receptacle.

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3
17. Help the patient to the bathroom or commode if possible. If using a bedpan, help the
patient assume as near the normal position for evacuation as possible.
18. Observe the character of the patients stool and solution. Caution the patient not to
flush the toilet before you have a chance to inspect the patients stool.
19. Assist the patient as needed with washing the anal area with warm soap and water. If
you will be providing such care, remember to wear gloves.
20. Remove and discard your gloves. Perform hand hygiene.
21. Assess the patients abdomen for distention.
22. To ensure the patients safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
23. Help the patient into a comfortable position, and place toiletries and personal items
within reach.
24. Place the call light within reach, and make sure the patient knows how to use it to
summon assistance.
25. Document and report the patients response and expected or unexpected outcomes.
Also document the type and volume of enema, time of administration and
characteristics of stool.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.