ENEMA

MEETING PATIENT NEEDS: BOWEL ELIMINATION: ENEMA

1. Enema Procedure

2. Definition An enema is an introduction of fluid into the lower bowel through the rectum for the purpose of cleansing or to introduce medication or nourishment.

3. Purpose To stimulate defecation & to treat constipation ex: simple evacuant enema To soften hard faecal matter ex: oil enema To administer medication ex: sedative enema To protect and soothe the mucus membrane of intestine & to check diarrhoea ex : emollient enema To destroy intestinal parasites ex : anthelminitic enema To relieve the gaseous distention ex : carminitive enema

4. Purpose To administer the fluid and nutrients ex: nutritive enema To relieve inflammation ex : astringent enema To induce peristalsis ex : purgative enema To stimulate a person in shock and collapse ex: stimulant enema To reduce the temperature ex : cold enema or ice enema To clean the bowels prior to x-ray studies , visualization of the bowel , surgery on the bowel or delivery of a baby ex : saline enema To make diagnosis ex: barium enema To establish regular bowel functions during a bowel training programme To induce anesthesia ex : anesthetic enema

5. Evacuent enema

6. Simple evacuant enema Purpose : To stimulate defecation & to treat constipation To relieve the gaseous distention by stimulating the peristalsis To relieve the retention of urine by reflex stimulation of the bladder To stimulate uterine contraction & to hasten the child birth To cleanse the bowel prior to x-ray studies , visualization of the bowels (ex: sigmoidoscopy) , surgery & retention enemas

7. Simple evacuant enema Solutions used : soap & water : soap jelly 50ml to 1 liter of water Normal saline : sodium chloride 1 teaspoon of half liter of water Tap water Amount of solutions to be used : Adults : 500 to 1000 ml ( 1 to 2 pint ) Children's : 250 to 500 ml ( 0.5 to 1 pint ) Infants : 250 ml or less Temp of solution : Adults : 105 to 110 degree Fahrenheit Children : 100 degree Fahrenheit

8. Oil enema These are given to soften faecal matter in case of severe constipation Before the 1 st bowel movement after operation on the rectum or perineum. To avoid straining & injury to the sutures & wounds It should be retained for half an hour to 1 hour to soften the faeces It should then be followed by a soap & water enema to open the bowels

9. Oil enema Solutions used : Olive oil Gingerly oil or sweet oil Castor oil & olive oil (1:2) Amount of solution to be used : 115 to 175 ml Temperature of the solutions : 100 degree Fahrenheit

10. Purgative Enema These are given to cause the bowel to contrast actively & to evacuate its contents Its acts by their irritating effect on the mucus lining, stimulate peristalsis& cause the evacuation of bowel The stretching of the intestine due to this inflow of fluid causes the intestine to contract & leads to the evacuation of bowels

11. Purgative Enema Solutions used : Pure glycerin – 15 to 30 ml Glycerin & water – 1:2 Glycerin & caster oil – 1:1 Magnesium sulphate : 60 to 120 ml with sufficient amount of water to dissolve it 1-2-3 enema : magnesium sulphate 30 ml, glycerin 60 ml, & water 90 ml Amount & temp of solution is that of oil enema

12. Anthelmintic enema This is given to destroy & expel the worms from the intestines Before the treatment is given the bowel should be cleansed by a soap water enema so that the drug may come in direct contact with the worms & the lining of the intestine The treatment is given until the worms are destroyed Solution : Infusion of quassia : 15gms of chips to 600 ml of water Hypertonic saline solution : sodium chloride 60 ml with 600 ml of water Amount of the solution : 250 ml

13. Carminitive enema (antispasmodic) These are given to relieve gaseous distention of the abdomen by causing peristalsis & expulsion of flatus &faeces It is given as simple evacuant enema Solution : Turpentine : 8 to 16 ml of turpentine mixed thoroughly with 600 to 1200 ml of soap solution Milk and molasses(granular sugar ) : 90 to 230 ml of molasses well mixed with equal quantity of warm milk

14. Astringent enema It contracts the tissues & the blood vessels , checks bleeding & inflammation , lessens the amount of mucus discharge & gives a temporary relief in the inflamed area It is usually given in colitis & dysentery They are usually given in the form of rectal or colonic irrigations The solution is allowed to run in slowly & return quickly to avoid distension , pain & irritation of the inflamed wall

15. Cold enema (ice enema) This is given to decrease the body temperature in hyperpyrexia and heat stroke It is given in the form of colonic irrigation Complications : Hypothermia Abdominal cramps

16. Astringent enema Solutions : Tannic acid : 2 gms to 600ml of water Alum : 30 gms to 600ml of water Silver nitrate 2% : (silver nitrate is dissolved in distilled water ) Temperature of the solution : It is given as hot as the client can stand

17. Retained enema

18. Stimulant enema A stimulant enema is given in the treatment of shock and collapse It is also sometimes given in case of poisoning ex: coffee enema is given in case of opium poisoning Solutions : Black coffee : 1 table spoon coffee powder to 300 ml of water Brandy : 15 ml of brandy added to 120 to 180 ml of glucose saline Amount of solution : 180 to 240 ml Temp of solution : 108 to 110 degree Fahrenheit

19. Sedative enema It is retention enema containing a sedative drug given to induce sleep Drugs used : Paraldehyde Chloral hydrate Potassium bromide Dose :as ordered by the doctor

20. Emollient enema This is an introduction of bland solution into the rectum for the purpose of checking diarrhoea or soothing & relieving irritation on an inflamed mucus membrane Solution used : Starch & opium : opium 1 to 2ml is added to 120 to 180 ml of starch mucilage or rice water Starch mucilage alone Amount of solution : 120 to 180 ml Temp of solution : 100 to 105 degree Fahrenheit (37.8 to 40.5 degree centigrade )

21. Anaesthetic enema It is a retention enema containing an anesthetic drug to produce anesthesia in client Drugs used : Avertin 150 to 300 mg per kg of body weight

22. Nutrient enema It is a retention enema to supply food & fluids to the body Selection of the fluids depend upon the ability of the colon to absorb it Nutrient enema is particularly useful in conditions like haemophilia which makes I.V. infusion difficult or undesirable

23. Nutrient enema Solutions : Normal saline Glucose 2 to 5% Peptonized milk 120 ml Amount of solution : 1100 to 1700 ml in 24 hour or 180 to 270 ml at 4 hourly interval Temperature of solution : 100 degree Fahrenheit (37.8 degree Fahrenheit )

24. Procedure

25. Cleansing enema

26. Cleansing enema Definition Introduction of solution into the large intestine for removing feces and cleansing the bowel Purposes To relive constipation or fecal impaction To prevent involuntary escape of fecal matter during surgical procedure and delivery To promote visualization of the intestinal tract during radiographic or instrumental examination To help establish regular bowel function during a bowel training program Preoperative preparation for bowel surgeries To relieve retention of urine by reflex stimulation of bladder

27. Solutions used Hypertonic :sodium phosphate, fleet enema Hypotonic : tap water Isotonic : physiological saline (one tsp of table salt in 500 ml of tap water) Others : 3-5 ml of concentrated soap solutions in 1000 ml water

28. Contraindications Acute renal failure Acute myocardial infarction and cardiac problems Appendicitis Obstetrical contraindications like antepartum hemorrhage, leaking membranes Recent surgical procedures involving lower intestinal tract Intestinal obstruction Inflammation and infection of abdomen

29. Principles applied for enema Nursing principles Safety Therapeutic effectiveness Comfort Use resources Good workmanship Individuality Scientific principles Anatomy and physiology Microbiology Nutrition Pharmacology Physics Chemistry Psychology Sociology

30. General instructions The appropriate size catheter or rectal tube need to be used the rectal tube needs to be smooth and flexible The rectal tube is lubricated with water soluble lubricant The temperature of the solutions needs to be adjusted according to the purpose of enema The amount of the solution to be administered depends upon the type of the enema and the age & size of the person When enema is administered, the client usually assumes a left lateral position The distance to which the tube is inserted depends upon the age and the size of the client The height f the can should be adjusted to regulate the flow of the solution according to the type of the enema administered

31. General instructions The length of time that the enema solution is retained will depend upon the purpose of enema and the ability of the client to contract the external sphincter to retain the solution Make sure the whole apparatus used for the administration of enemas is in a good working condition Regulate the flow of fluid according to the type of the enema, give retention enema very slowly, usually by a Murphy drip. If the rectum is impacted, attempt to remove the faecal matter with gloved finger. Listen to the complaints of the client and should not ignore Prepacked enemas will have their own instructions which need to be followed

32. Articles

33. Articles Enema can and tubing method A tray containing Disposable gloves Water soluble lubricant Bath thermometer Soap and water Toilet tissues Enema can Tubing and clamp Appropriate size rectal tube Adult : 22-30 Fr Child size : 12-18 Fr

34. Articles IV stand K . Basin(2) Solution as ordered Mackintosh/waterproof under pad Bedpan Temperature of solution Adult : 105-110 F (40-43 C) Child : 100 F(37.1 C) Amount of solution Adult :750-1000 ml Adolescent :500-750 ml School age :300-500 ml Toddler :250-300 ml Infant :150-250 ml

35. Procedure Assess status of patient Last bowel movement Normal bowel pattern Mobility Abdominal pain etc. Determine the level of consciousness and understanding, provide privacy Explain procedure purpose to the patient Assemble articles, wash hands and don gloves Raise the bed to appropriate height Assist patient to side lying position (sim’s position) Place mackintosh under hip and buttocks Cover the patient exposing only anal area, clearly visualizing anus

36. Procedure Place bed pan or commode in easily accessible position Check temperature of solution on inner wrist Raise container, release clamp and allow solution to flow long enough to fill tubing Clamp the tubing lubricate 6-8 cm of tip of rectal tube with jelly Separate the buttocks and locate the anus. Instruct patient to relax by breathing out slowly through mouth Insert –tip of rectal tube gently by pointing the tip in the direction of patients umbilicus Adult : 7.5-10 cm Child : 5-7.5 cm Infant : 2.5-3.7 cm Hold the tubing in place with one non- dominant hand.

37. Procedure Open regulatory clamp and allow solution to enter slowly with the container at the patients hip level. Raise the enema can slowly to appropriate level above the anus. Eg: for the infusion rate 1L in 10 mt. Lower container or clamp tubing for 30seconds.If patient complaints of cramping or if fluid escapes around rectal tube. Clamp tubing after all solution is instilled. Inform patient, that fluid instillation is over and the tube will be removed. Place layers of toilet tissue around tube at anus and gently withdraw rectal tube. Explain to patient that feeling of distention is normal and ask patient to retain solution as long as possible (5-10 mts )while lying quietly in bed.

38. Procedure Discard the disposable, used items in proper receptacle. If enema can needs to be reused. Rinse out thoroughly with soap and warm water. Assist patient to toilet or help to position on bed pan. Observe the fecal matter and expelled solution. Assist as needed to wash anal area with soap and water. Remove and discard gloves and wash hands. Assess condition of patient abdomen may indicate serious problems. Record type and volume of enema given and characteristics of return flow. Report failure to defecate to the physician Clean and replace the reusable articles. Discard any waste and disposable items.

39. Evacuant enema (pre packed preparation)

40. Articles A tray containing Clean gloves Packet of enema Toilet tissues Soap and water Kidney tray Mackintosh Lubricant jelly Bedpan/commode

41. Procedure Assess status of patient Last bowel movement Normal bowel pattern Mobility Abdominal pain etc. Determine the level of consciousness and understanding, provide privacy Explain procedure purpose to the patient Assemble articles, wash hands and don gloves Raise the bed to appropriate height Assist patient to side lying position (sim’s position) Place mackintosh under hip and buttocks Cover the patient exposing only anal area, clearly visualizing anus Place bed pan or commode in easily accessible position

42. Procedure Remove plastic cap from rectal tip and lubricate the tip Gently separate the buttocks and locate the anus. Instruct the patient to relax by breathing out through mouth. Insert tip of the tube gently into rectum Adult :7.5 cm Child :5-7.5 cm Infant : 2.5-3.7 cm Squeeze the container until all solution has entered rectum and sigmoid colon while squeezing container roll it up as fluid is instilled Place toilet issue around the anus and withdraw the tube Discard the disposable items in proper receptacle Assist the patient to toilet or help to position on bedpan

43. Procedure Observe the fecal matter and expelled solution Remove gloves and discard, was hands. Assess condition of patient’s abdomen, cramping or rigidity which can indicate problems. Record the enema given and characteristics of result. Report any problem if noticed.

44. Giving enema with funnel or catheter

45. Giving enema with funnel or catheter Small enemas to be expelled are given using funnel & catheter The oil is kept warm by placing the container in a bowl of warm water During the administration , the height of the funnel should be more than 8 inches from the anus Help the client to retain the solution either by raising the foot end or by pressing buttocks The oil enema is to be retained for 2 to 6 hours to soften the fecal matter It may be then followed by a soap & water enema to expel the fecal contents The preparation & after care of the client & articles are same as in soap & water enema

46. Giving enema using glycerin syringe

47. Giving enema using glycerin syringe A glycerin syringe (metal syringe) and a rubber catheter attached to its nozzle are used Air to be expelled, prior to the administration of the fluids This method is particularly useful for giving enema to children.

48. Giving enema by the drip method Eg: nutrient enema (Proctoclysis or continuous retention enema )

49. Giving enema by the drip method Articles required All the articles used for an evacuant enema EXCEPT the following A reservoir (this can be an enema can or a bottle with a cork) Tubing attached to the reservoir Murphy drip and a clamp A fine catheter Bed blocks to raise the foot end

50. Giving enema by the drip method Procedure Administration of retention enema is done by the drip method Purpose : to retain the solution and never to evacuate Fine catheter is used in place of rectal tube ( to prevent defecation reflex) Flow is regulated by Murphy drip or and a clamp (less than 40 drops per minute ) Foot end is raised to retain the fluid Usually a retention enema is preceded by a simple enema to keep the bowel free of faecal matter

51. Thank you