The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.

Question

Quizplus · Accepted Answer

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option A). Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (Option C). Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (Option B). Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration (Option E). (Option D) Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational objective: When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

The Nurse Prepares to Administer a Cleansing Enema to a Client