3. 1. Introduces self and verifies the client's identity. Explains the
procedure to the client why it is necessary, and how the client can
cooperate. Tells to the client that he or she might experience a
feeling of fullness while the solution is being administered.
There are 3 verifiers, so maam what is your name? check the wrist
band then birthdate
Maam, this procedure will cleanse or stimulate the emptying of your
bowel and you may feel full while the solution is being administered.
Ask the patient consent
Explaining the procedure will gain trust and to reduce patient’s
anxiety.
4. 2. Performs hand hygiene and observes other
appropriate infection control procedures.
3. Provides for client's privacy (to avoid
embarrassment if the patient ) and puts on clean
Gloves.
4. Raises the bed to appropriate working height
for the nurse and raises side rails on opposite
side (To promote good body mechanics and in
the patient’s part, it promotes clients safety)
5. Assists client into left-side lying position with right knee flexed.
(this position will allow to flow downward by the gravity and to
improve the retention of the solution)
Children may also be placed in a dorsal recumbent position
and elderly client over a bed pan.
5. Places water proof pad under the hips and buttocks.
(It will prevent the linen from soiling)
6. Covers the client with bath blanket exposing only the
rectal area, clearly visualizing the anus.
(Covering with blanket will allow the patient relax and
comfortable)
6. 7. Places bedpan in easily accessible position.
if the client is able to expel contents in the toilet,
be sure that the toilet is free. But If the client
prefers the toilet put the bathrobe and slipper
within his/her reach.
8. Add water solution to enema bag, warms up
as it flows from faucet, place saline container in
basin of hot water before adding saline to enema
bag, check temperature of solution.
7. (if the water is too hot, it can burn the intestinal
mucosa and if the water too cold , it can be result into
abdominal cramping)
Use the wrist for checking the temperature
(I will pour a bit of solution on my wrist to check the
temperature of it, so that if we will be carrying out the
procedure it won’t be too hot or too cold for the patient)
Since the patient is adult, I will be preparing 750ml
(clamp)
8. 9. Raises container, releases clamp and allows
solution to flow long enough to fill tubing. Re-clamps
tubing.
10. Lubricates 6-8 cm of tip of rectal tube with water
soluble lubricant.
(Release then let the solution reach in the tip and re-
clamp)
Lubrication
(It smooths the insertion in the anus to avoid irritation
or trauma to mucosa)
9. 11. Separates buttocks gently and locate anus.
Instructs the client to relax by breathing slowly through
mouth.
12. Inserts tip of the rectal tube slowly by pointing tip
in direction of client's umbilicus.
Carefully insert the tube and insert slowly in rotating
motion to prevent trauma.
Insertion beyond improper limit may result bowel
perforation
10. 13. Asks the client to take a deep breath, and then run a
small amount of solution through the tube if resistance is
encountered at the internal sphincter.
14. Places the container at the hip level, then opens the
regulating clamp then raises the container gradually up to a
while to appropriate level above the anus.
15. Administers the fluid slowly.
If the client complains of fulness, pain, or cramping or if fluids
escape around rectal tube lower the container, or use clamp
to stop the flow for 30 seconds, and then restart the flow at a
slower rate.
If too high it will flow too fast
11. 16. Closes the clamp after all solution has been instilled, or when the
client cannot hold anymore and feel the desire to defecate, and places
layers of tissue around tube at anus and gently withdraw rectal tube.
17. Asks the client to remain lying down. Tells the client to retain the
solution as long as possible while lying quietly in bed. For infants and
young children, gently hold the buttocks together for a few minutes.
18. Explains to client that feeling of distension is normal.
(Maam it is normal to feel distended, as long as you can retain the
solution, the longer, the better)
19. Discards enema container and tubing in proper receptacle or
rinse out thoroughly with warm water if container is to be reused.
12. 20. Assists the client to defecate. Helps the client to a sitting
position on the bedpan, commode or toilet.
If the client prefers to defecate using the toilet, advise the
client not to flush the toilet.
If a specimen of feces is required, ask the client to use a
bedpan or commode.
Sitting position will promote defecation properly
21. Observes character of feces and solution.
The return flow should be same solution that you instilled.
13. 22. Assists client as needed to wash anal areas with warm soap and
water.
Hygiene promote client’s comfort
23. Remove and discard the water proof pad.
24. Remove and discard gloves. Performs hand hygiene.
25. Documents the type and volume if appropriate of enema given,
type of solution; length of time solution was retained; the amount,
color, consistency of the returns; and the relief of flatus and abdominal
distension in the client’s record
26. Observes condition of abdomen: cramping, rigidity, or distension.
(Maam how are you feeling? How do you feel? It is still pain?)
15. 1. Introduces self and verifies the client’s
identity. Explain to the client the procedure, why it
is necessary and how the client can cooperate
There are 3 verifiers, so maam what is your
name? check the wrist band then birthdate
Maam, this procedure will change, empty & clean
your pouch system and to prevent stoma related
complications.
16. 2. Performs hand hygiene and observes the
other appropriate infection control procedure
3. Prepares equipment and supplies
4. Assist the client to assume a comfortable
position, preferably siting, reclining or
standing position and provide privacy
17. 5. Removes pouching system.
5.1. Wears non-sterile gloves
(Maintains universal precautions)
5.2. Pushes down gently the skin while lifting up
the wafer (ostomy adhesive remover may be
used).
(Minimizes skin trauma)
5.3. Discards soiled pouch and wafer in indoor
proof plastic bag. Saves tail closure for reuse.
(Removes room odor)
18. 6. Cleanses the skin.
6.1. Uses toilet tissue to remove feces from stoma and
skin if needed.
6.2. Cleanses stoma and peristomal skin with soft cloth
and water, soap (optional).
(Minimizes skin breakdown and promote hygiene)
*The patient may shower with or without pouching
system in place.
6.3. Clips or shaves peristomal hair if appropriate.
6.4. Rinses and dries the area thoroughly by patting
with a towel. (To remove residue)
19. 7. Assesses the site and peristomal skin.
7.1. Inspects the stoma for color size shape, and
bleeding.
7.2. Inspects peristomal skin for any redness,
ulceration, or irritation.
8. Places a piece of tissue or gauze over the stoma
and changes it as needed.
(It should be wet in normal saline solution)
20. 9. Applies wafer:
9.1. Uses measuring guide or pattern to determine
stoma size.
9.2. Traces correct size onto back of wafer and cut
stoma size.
(Avoid wafer rubbing in the stoma)
*Cuts out the trace stoma pattern to make an
opening in the skin barrier. It is acceptable to cut 1
/6-1/8 inch larger than stoma.
21. 9.3. Applies a line of skin barrier paste around stoma
or on lip or wafer opening.
(This paste acts as “caulking” to prevent undermining
feces)
9.4. Removes the paper backing from the wafer, center
opening of the stoma and press water down onto
peristomal skin.
10. Snaps pouch onto the flange of wafer according to
manufacturer’s directions.
22. 9.3. Applies a line of skin barrier paste around stoma
or on lip or wafer opening.
(This paste acts as “caulking” to prevent undermining
feces)
9.4. Removes the paper backing from the wafer, center
opening of the stoma and press water down onto
peristomal skin.
10. Snaps pouch onto the flange of wafer according to
manufacturer’s directions.
(This is to check if the pouch is sealed and if attached
properly, there will be no leakage or odor)
23. 11. Applies tail closure to pouch tail, if drainable
pouch is used.
12. Disposes waste materials into a plastic bag.
13. Cleans drainable pouch with soap and water, if
appropriate. Drainable pouches may be reused several
times (used it for 5-7 days)
A commercial deodorant can be placed in the
pouch to remove odor. Never make a pinhole in
the in the pouch to release gas.
(controls odor)
24. 14. Removes gloves and perform hand hygiene.
15. Documents the amount, consistency, and color of
the stool.
