Enema.pptx

Bowel Elimination
BY: Mulualem
8/20/2023 1
BY:mulualem(BSC,msc adult health nursing)
Elimination

Objectives
• Upon completion of this chapter, you will be able to do the
following:
 Identify factors that affect bowel elimination.
 Define what enema is.
 List the indications and purposes of enema.
 Identify and discuss the types of enema.
 Demonstrate administration of enema
8/20/2023 2

8/20/2023 BY:mulualem(BSC,msc adult health nursing) 3

Bowel Elimination
 The elimination of waste from the bowel is an essential body
function.
 Defecation is the process by which the solid waste products
of digestion, known as feces or stool, are eliminated from the
bowel.
 The major nursing responsibilities associated with bowel
elimination include assessing bowel function, promoting
normal bowel health, and intervening to manage alterations
in bowel function

Normal bowel function
Motility
Absorption
Defecation

Factors affecting bowel elimination
 Nutrition
 Fluid intake
 Activity and exercise
 Body position
 Pregnancy
 Medication
 Diagnostic procedure

ALTERED BOWEL FUNCTION
Constipation
Fecal impaction
Diarrhea
Fecal incontinence
Flatulence
Distention

Normal Pattern Identification
• To determine the patient’s current bowel elimination
pattern, obtain the following information from current
medical records, the patient, or the caregiver:
 What is the patient’s usual pattern of bowel elimination?
 What are the usual characteristics of the patient’s stool?
 Which aids, if any, does the patient routinely use for
defecation?
 When was the patient’s last bowel movement?
 Are there any recent changes in the patient’s normal bowel
pattern?

Physical Assessment
 Visual inspection of the feces and physical assessment
of the abdomen and perirectal area provide objective
data on the patient’s bowel elimination status.
Inspection, auscultation, percussion, palpation, and
measurement of abdominal girth are used

Measures to Promote Bowel Elimination
 Nurses commonly use two interventions:
 inserting suppositories and administering enemas:
 to promote elimination when it does not occur naturally
or when the bowel must be cleansed for other purposes,
such as preparation for surgery and endoscopic or x-ray
examinations

Inserting a Rectal Suppository
 Medications released from the suppository can have
local or systemic effects.
 Depending on the drug, local effects may include
softening and lubricating dry stool, irritating the wall of
the rectum and anal canal to stimulate smooth muscle
contraction, and liberating carbon dioxide, thus
increasing rectal distention and the urge to defecate.
14 8/20/2023

Enema Administration
Enema:
 Is the introduction of fluid into rectum and sigmoid colon for
cleansing, therapeutic or diagnostic purposes.
 the procedure of introducing liquids into the rectum and colon via the anus.
Indication
 To evacuate the bowel prior to surgery or investigation
 To administer medication
 For the treatment of sever constipation
 treatment for encopresis/ impacted stool in the colon and
rectum
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………Enema
• Purpose:
For emptying – soap solution enema
For diagnostic purpose (Barium enema)
For introducing drug/substance (retention enema)
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Solution used:
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…..Enema
• Mechanisms of some solutions used in enema
 Tap water: increase peristalsis by causing mechanical
distension of the colon.
 Soap solution: increases peristalsis due to irritating effect of
soap to the luminal mucosa of the colon.
 Epsum salt: The concentrated solution causes flow of ECF
(extra cellular fluid) to the lumen causing mechanical
distension resulting in increased peristalsis.
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Types of enema
Cleansing(evacuation)
Retention
Carminative
Return flow
8/20/2023 19

….Types of enema
20
1. Cleansing enema
 administered to remove feces from the colon.
 Hot – cause injury to the bowel mucous
 Cold – uncomfortable and may trigger a spasm of the
sphincter muscles
 High enema is given to clean as much of the colon as
possible. up to 1000 ml of fluid for adult
 Low enema is administered to clean the rectum and
sigmoid colon only. Approximately 150ml of fluid is used.
8/20/2023

Purpose
21
 To stimulate peristalsis and remove feces or flatus.
 To relieve constipation or fecal impaction
 To prevent involuntary escape of fecal matter during surgical
procedure or a delivery.
 For incontinent patients to keep the colon empty
 To help establish regular bowel function.
 For diagnostic test
 Before certain x-ray exam – barium enema
 To promote visualization of intestinal tract by x-ray Colonoscopy
8/20/2023

Cont..
22
 types of solutions used for cleansing enema are
 Tap water( most time)
 Normal saline solution,
 Soap solution, and
 Hypertonic solutions.
8/20/2023

Cont..
23
 The amount of solution to be administered depends
on:
The Kind of enema
The age of the person and
The person’s ability to retain the solution
8/20/2023

Cont..
24
 The large volume of solution for adult is 500-1000ml and
for infant is 150-250ml.
 The rectal tube is measured in French scale
 Age Size
 Infants 10-12 fr
 School age child 16-18 fr
 Adults 22-30 fr
8/20/2023

Equipment
25
 Enema cans
 Rectal tube
 Enema solution
 IV –stand
 Screen
 Lubricant
 Swab in gallipots
 Bedpan
 Rubber sheet
 Gloves
8/20/2023

Equipment
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Procedure
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27
1. Assemble the needed equipment in one place.
Rationale: It is more efficient to assemble equipment in one
place.
2. Prepare solution. Check temperature of solution
by pouring some over your inner wrist
2. Fill enema bag with 750 to 1,000 mL lukewarm
solution (105 to 110F; for child, 500 mL or less,
100F
Rationale: Intestinal mucosa can be damaged if the solution is too warm. Cold solutions are
difficult to retain and can
cause abdominal cramping.
3. Open clamp on tubing and allow solution to flow
through tubing to remove the air (Fig. 3 ). Reclamp
tubing. Rationale: Air in the rectum causes discomfort

…..procedure
4. Provide privacy by closing curtains or room door
5. Identify patient .Position patient on left side
(Sims’ position) with right knee flexed.
6. Cover patient with bath blanket, exposing only the
buttock
7. Put on disposable gloves. Place waterproof pad under patient’s buttocks
8. Lubricate 2 to 3 inches of the tip of the rectal tube
with water-soluble lubricant
9. Separate the buttocks to visualize the anus. Observe
for external hemorrhoids. Ask patient to take a slow,
deep breath. Gently insert the tube, directing the tip
toward the umbilicus (7-10 cm in an adult smoothly and slowly, 5-7.5 cm in the child, and 2.5-3.75 cm in an
infant
8/20/2023
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…..procedure
10.Continue holding the tube in the rectum With other hand, open the clamp and allow
solution to slowly enter the patient. Raise container 18 inches above the anus, allowing
solution to flow slowly over 5 to 10 minutes; if patient complains of cramping or pain, have
patient breathe deeply and lower bag until the sensation stops
11. Reclamp tubing when desired amount of solution
has infused.
12.Remove tube gently and have patient squeeze buttocks together firmly for several
minutes.
8/20/2023
29

…..procedure
13. Have patient retain solution as long as possible.
14. Assist patient to bathroom, commode, or bedpan
15. Visually inspect character of the feces and solution
16. Assist patient into comfortable position. Assist with cleansing as needed. Provide
materials for patient to wash hands. Open windows or provide air freshener if needed.
Clean and dispose of equipment as necessary. Remove gloves and wash hands
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30

2. Retention Enema
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31
 Administration of solution to be retained in rectum for
short or long period
 for local or general effects
 E.g. oil retention enema

Cont…
8/20/2023
32
 Is given slowly by means of a rectal tube
 The amount of fluid is usually 150-200 cc
 Cleansing enema is given after the retention time is
over
 Temperature of enema fluid is 37.4 c or body

Purpose
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 To supply the body with fluid.
 To give medication
 To soften impacted fecal matter.

Procedure
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34
 Similar with the cleansing enema but the enema should
be administered very slowly and always be preceded by
passing a flatus tube

Cont.…
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35
 Most medicated retention enema must be preceded by a
cleansing enema. ( ½ hrs before giving retention enema
 Elevate foot of bed to help patient retain enema
 Kinds of solution used to supply body with fluid are
plain H2O,
normal saline,
glucose 5%
Olive oil 100-200 cc to be retained for 6-8 hrs is given
for sever constipation

3.PASSING A FLATUS TUBE
8/20/2023
36
 It is a process of introducing a tube rectally to relieve
abdominal distention caused by accumulation of gas
(flatulence).
 The tube stimulates peristalsis and provide
passageway for gases to escape from the intestine.
Purpose
 To decrease flatulence (severe abdominal distention)
 Before giving the retention enema

Procedure
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 Place the patient in a left lateral position
 Lubricate the tube about 15cm
 Separate the buttock & insert 12-15cm
 The end of the tube should reach the tap water solution in the
bowl.
 The amount of air passed can be seen bubbling through the
solution.
 Leave the tube in place for a period of time, no longer than 20min.
 Reinsert the tube every 2-3 hrs if the distention has been
unrelieved or reaccumulates.

4. Rectal Washout (Siphoning Enema) (Colon
irrigation or colonic flush)
8/20/2023
38
 Is the process of introducing large amount of fluid into
large bowel for flushing purpose and allow return or
wash out fluid
 Purpose
 To prepare the patient for x-ray exam and
sigmoidoscopy
 To prepare the patient for rectum and colon operation

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39
 Solution Used
 Normal saline
 Soda-bi-carbonate solution (to remove excess
mucus)
 Tap water

Procedure
8/20/2023
40
 Insert the tube like the cleansing enema
 Open the clamp and allow to run about 1,000 cc of fluid in
the bowel, then drain off back into the bucket
 Carry on the procedure until the fluid return is clear

Note:
8/20/2023
41
 The procedure should not take > 2 hrs
 Should be finished 1 hr before exam or x-ray – to give
time for the large intestine to absorb the rest of the
fluid
 Allow the fluid to pass slowly
 Amount of solution
 5-6 liters or until the wash out rectum fluid becomes clear

Contraindications of enema
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42
 Acute abdominal pain
 some abdominal surgery
 CHF
 Intestinal intussusceptions
 uncontrolled hypertension
 Rectal or abdominal tumors
 Intestinal perforation
 Pregnancy

8/20/2023
43

…Types of enema
• Similar with cleansing enema but the enema should be
administered very slowly.
• Is given slowly by means of rectal tube and the should be
lower than leg
• The tube for retention enema is smaller
• Indicated to relieve constipation by softening fecal
impact.
• Solution is usually oil, retained for up to 3hrs and
followed by cleansing enema
8/20/2023 44

• Carminative Enema
• A small volume enema given to release flatus. Traditionally the
enema consisted of two ounces of glycerin, one ounce of
magnesium sulfate (Epsom salts) and three ounces of water.
• The combination of ingredients stimulated peristalsis resulting
in a bowel movement in which feces and flatus are expelled.
• The advantage in times past of using the carminative enema
was that the low volume made it comfortable for the patient to
retain, and it took little time to administer.
8/20/2023 45

• When using the traditional carminative enema,
instruct the patient to try to retain the enema for five
to ten minutes before expelling.
• For adult, 60-180ml of fluid is installed.
8/20/2023 46

Enema…Types of enema
• Return flow
– Also called rectal washout or colonic irrigation
– Alternating flow of 100 to 200ml of fluid into and out
of the large intestine stimulates peristalsis and the
expulsion of feces.
– The container is then lowered and the solution flow
back through the enema tubing to the container.
– Flatus also return.
8/20/2023 47

procedure
• Enema for adults are usually given at 40-430c and for
children at 37.70c
• Hot – cause injury to the bowel mucous
• Cold – uncomfortable and may trigger a spasm of
the sphincter muscles
• The amount of solution given depends on:
– Kind of enema
– The age of the person
– The person ability to retain the solution
8/20/2023 48

Enema
• Amount of solution and size of the tube
inserted should be age appropriate
Age Amount of fluid
–18month 50-200ml
–18monz-5 yrs 200-300ml
–5-12 yrs 300-500ml
–> 12 yrs 500-1000ml
8/20/2023 49

Enema
• Amount of solution and size of the tube
inserted should be appropriate…
• Age Size of the tube
–Infant/small child 10-12fr
–Toddler 14-16fr
–School age child 16-18fr
–Adult 22-30fr
8/20/2023 50

Enema: Administering a Large Enema
• Equipment
– Enema bag
– Enema tube
– Water-soluble lubricant
– Glove
– Soap solution(1000ml)
– Rubber sheet
– Gauze or soft paper(for perineal care)
– Bed pan
– Forceps(to clamp) and Thermometer
8/20/2023 51

• Assemble equipment, explain the procedure to the
patient, screen , hand wash and position(left or sim’s
with right leg flexed) the patient including drape.
• Prepare the solution, assure temperature within
range of 99° to 102°F(40-43oc) by using a
thermometer or placing a few drops on your wrist.
• Wash hands and don gloves
8/20/2023 52

• Assist patient to left side-lying position, with right knee bent.
• In high cleansing enema the client changes from the left lateral to
the dorsal recumbent position and then to the right lateral position
during the administration so that the fluid can follow the large
intestine
• Hang bag of enema solution 12 to 18 inches above anus.
• Lubricate 4 to 5 inches of catheter tip.
• Place bedpan, commode, robe and slippers within easy reach.
• Separate buttocks, insert catheter tip into anal opening, slowly
advance catheter approximately 4 inches(7-10cm).
8/20/2023 53

• Slowly infuse solution via gravity flow; bag
height may be increased but not to exceed 18
inches above anal opening.
8/20/2023 54

• If client complains of increased pain or
cramping, or if fluid is not being retained, stop
procedure, wait a few minutes, then restart.
• Clamp tubing when fluid finishes infusing;
remove catheter tip.
• Assist client to bedpan, commode, or toilet
• Discard equipment in proper place.
• If equipment is reusable, properly clean and
store it.
8/20/2023 55

• Remove gloves and wash hands.
• Instruct client to call for assistance when finished
eliminating, or if untoward feeling occurs, such
as lightheadedness or dizziness.
• Assist client with washing if needed
• Documentation
8/20/2023 56

Contraindications / Precautions / Warnings
• Never use an enema if rectal bleeding is present.
• Never give children under ten more than one enema daily, as
this may cause hyponatremia, where blood sodium levels drop
to dangerously low due to increased water intake.
• Patients who are bleeding or experiencing a prolapse from the
rectum should also not be given enemas of any kind.
Likewise, people with unresolved abdominal pain can be at
risk because distension of the colon could be dangerous.
• Enema is also contra indicated in acute gastro intestinal
gastric obstruction

 retention enema is contraindicated.
• For severe kidney problem patients
• For cardiac patients
 If you use tape water for enema it should not
greater than 500 ml.
More than 3 tap water enemas is not given
consecutively.

Complications / Risks of Enema
• Main dangers are:
• Irritation of the rectal mucosa by too much soap or
an irritating soap.
• Osmosis (fluid drawn into colon from surrounding
tissues) if hypertonic solution is used.
• Water intoxication if hypotonic solution is used.
• Electrolyte imbalances.

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