An enema is a procedure that involves inserting a liquid into the rectum to induce bowel evacuation. There are several types of enemas that are used for different purposes. Cleansing enemas are most commonly used to remove feces from the bowel when a person is constipated. They work by irritating the intestinal lining and distending the colon to stimulate bowel movement. Retention enemas are used to introduce medications or oils into the lower bowel and are meant to be retained for longer periods of time. Precautions must be taken when giving an enema to avoid potential complications like fluid overload, electrolyte imbalances, or trauma to the rectal tissues.

1. ENEMA

2. Definition
A procedure of evacuation or washing out of waste
materials (feces or stool) from a person’s lower
bowel.
Enema administration involves in stilling a solution
into the rectum, colon & large intestines.
Is performed using a flexible plastic rectal tube
with several large holes in the tip.
This is connected to the tubing from a solution bag
or container.

3. What is Enema?
ENEMA is a solution introduced into the rectum and
large intestine. The action of an enema is to distend the
intestine and sometimes to irritate the intestinal mucosa,
thereby increasing peristalsis and the excretion of feces
and flatus.

4. Action
After introduction of solution, the intestine
becomes distended and there will be
irritation of intestinal mucosa which results
to increase peristalsis. Thus, excretion of
feces/flatus.

5. Types of Enema
Cleansing
Retention
Return Flow
Carminative

6. TYPES OF ENEMAS
A. CLEANSING ENEMA = are intended to remove feces.
They are given chiefly to:
1. Prevent the escape of feces during surgery.
2. Prepare the intestine for certain diagnostic tests
such as x –ray or visualization tests ( e.g. colonoscopy )
3. Remove feces in instances of constipation or
impaction.

7. Cleansing Enema uses a variety of solution :
SOLUTION
CONSTITUENT
S
ACTION
TIME
TO
EFFEC
T
ADVERSE
EFFECTS
Hypertonic 90-120ml of
solution e.g.
sodium
phosphate
Draws water into
the colon
5-10
mins.
Retention of
sodium
Hypotonic 500-1,000 ml of
tap water
Distends colon,
stimulates
peristalsis and
softens feces
15-20
mins.
Fluid and
electrolyte
imbalance, water
intoxication
Isotonic 500-1,000 ml of
normal saline (
9 ml to 1,000 ml
water)
Distends colon,
stimulates
peristalsis and
softens feces
15-20
mins.
Possible sodium
retention
Soapsuds 500-1,000 ml Irritates mucosa, 10 – 15 Irritates and may

8.  Tap water
 Normal saline solution
 Soapsuds solution
 Hypertonic solution
Common solution for cleansing enemas

9. B. RETENTION ENEMA = introduces oil or
medication into the rectum and sigmoid colon.
The liquid is retained for a relatively long period.
An oil retention enema acts to soften the feces
and to lubricate the rectum and anal canal, thus
facilitating passage of the feces. Antibiotic
enemas are used to treat infections locally,
anthelmintic enemas to kill helminths such as
worms and intestinal parasites and nutritive
enemas to administer fluids and nutrients to the
rectum.

10. Retention enemas are given to:
a. Softens the hardened stool & allow normal
elimination
b. Lubricate the inside surface of the lower
intestine
c. Soften the stool, if necessary
d. Ease the passage of feces without straining
e. Provide laxative benefits when oral laxatives
are not allowed
f. Soften fecal impaction when straining might
be harmful or painful.

11. C. RETURN – FLOW ENEMA = is used
occasionally to expel flatus Alternating flow of
100 to 200 ml of fluid into and out of the rectum
and sigmoid colon stimulates peristalsis. This
process is repeated five or six times until the
flatus is expelled and abdominal distention is
relieved.

12. D. CARMINATIVE ENEMA = is given primarily to
expel flatus. The solution instilled into the rectum
releases gas, which in turn distends the rectum
and the colon, thus stimulating peristalsis. For an
adult 60 to 80 ml. of fluid is instilled.

13. PRECAUTIONS
 Enemas should not be used as a first-
line treatment for constipation.
 Frequent use of enemas can lead to
fluid overload, bowel irritation, and
loss of muscle tone of the bowel and
anal sphincter.
 Never deliver more than three
consecutive enemas to treat a patient.
13

14. PRECAUTIONS
 A patient with diarrhea may not be able to
hold an enema.
 Must be used with caution in cardiac patients
who have arrhythmias or have had a recent
myocardial infarction.
 Insertion of the enema tube and solution can
stimulate the vagus nerve which may trigger
an arrythmias such as bradycardia.
14

15.  Enemas should not be given to patients with
undiagnosed abdominal pain because the
peristalsis of the bowel can cause an
inflamed appendix to rupture.
 Should be used cautiously in patients who
have had recent surgery on the rectum,
bowel, or prostate gland.
 If the patient has rectal bleeding or prolapse
of rectal tissue from the rectal opening,
cancel the enema and consult with the
physician before proceeding.
15
PRECAUTIONS

16.  Do not force the enema catheter into the
rectum against resistance. This can cause
trauma to the rectal tissue.
 Use only mild castile soap (hard white
unperfumed soap made from olive oil and
lye) for soapsuds enemas because other
soap preparations are too harsh and irritate
the rectal tissue.
16
PRECAUTIONS

17. Guidelines:
Adult Children Infant
Size of
rectal tube
Fr. # 22-30 Fr.# 14-18 Fr.# 12
Amount of
solution
500-1,000 ml 250-500 ml 250ml or less
Distance of
tube
insertion
7.5-10 cm
(3-4 in)
5-7.5 cm
(2-3 in)
2.5-3.75 cm
(1-1.5 in)
Solution
temperature
40.5-43 C 37.7 C

18. Purpose
 Enemas may be given for the following
purposes:
 to remove feces when an individual is
constipated or impacted,
 to remove feces and cleanse the rectum in
preparation for an examination,
 to remove feces prior to a surgical procedure to
prevent contamination of the surgical area,
 to administer drugs or anesthetic agents.

19.  water enemas can cause cardiovascular
overload and electrolyte imbalance. Similarly,
repeated saline enemas can cause increased
absorption of fluid and electrolytes into the
bloodstream, resulting in overload. Individuals
receiving frequent enemas should be
observed for over-load symptoms that include
dizziness, sweating, or vomiting

20.  Soap suds and saline used for cleansing
enemas can cause irritation of the lining of the
bowel, with repeated use or a solution that is
too strong. Only white soap should be used;
the bar should not have been previously used,
to prevent infusing undesirable organisms into
the individual receiving the enema. Common
household detergents are considered too
strong for the rectum and bowel. The
commercially prepared soap is preferred, and
should be used in concentration no greater
than 5 cc soap to 1, 000 cc of water.

21. Description
 Cleansing enemas act by stimulation of bowel
activity through irritation of the lower bowel, and
by distention with the volume of fluid instilled.
When the enema is administered, the individual
is usually lying on the left side, which places the
sigmoid colon (lower portion of bowel) below the
rectum and facilitates infusion of fluid. The length
of time it takes to administer an enema depends
on the amount of fluid to be infused. The amount
of fluid administered will vary depending on the
age and size of the person receiving the enema,
however general guidelines would be:

22.  Some may differentiate between high and low
enemas. A high enema, given to cleanse as
much of the large bowel as possible, is usually
administered at higher pressure and with larger
volume (1, 000 cc), and the individual changes
position several times in order for the fluid to
flow up into the bowel. A low enema, intended
to cleanse only the lower bowel, is
administered at lower pressure, using about
500 cc of fluid.

23.  Oil retention enemas serve to lubricate the
rectum and lower bowel, and soften the stool.
For adults, about 150–200 cc of oil is instilled,
while in small children, 75–150 cc of oil is
considered adequate. Salad oil or liquid
petrolatum are commonly used at a
temperature of 91°F (32.8°C). There are also
commercially prepared oil retention enemas.
The oil is usually retained for one to three
hours before it is expelled.

24.  The rectal tube used for infusion of the solution,
usually made of rubber or plastic, has two or more
openings at the end through which the solution
can flow into the bowel. The distance to which the
tube must be inserted is dependent upon the age
and size of the patient. For adult, insertion is
usually 3–4 in (7.5–10 cm); for children,
approximately 2–3 in (5–7.5 cm); and for infants,
only 1–1.5 in (2.5–3.75 cm). The rectal tube is
lubricated before insertion with a water soluble
lubricant to ease insertion and decrease irritation
to the rectal tissues.

25.  The higher the container of solution is
placed, the greater the force in which the
fluid flows into the patient. Routinely, the
container should be no higher than 12 in
(30 cm) above the level of the bed; for a
high cleansing enema, the container may
be 12–18 in (30–45 cm) above the bed
level, because the fluid is to be instilled
higher into the bowel.

26. Guidelines:
Adult Children Infant
Size of
rectal tube
Fr. # 22-30 Fr.# 14-18 Fr.# 12
Amount of
solution
500-1,000 ml 250-500 ml 250ml or less
Distance of
tube
insertion
7.5-10 cm
(3-4 in)
5-7.5 cm
(2-3 in)
2.5-3.75 cm
(1-1.5 in)
Solution
temperature
40.5-43 C 37.7 C

27. Equipments:
 1. A tray containing the following:
 Rectal catheter
 Enema can with tubing
 Lubricant
 Pitcher with hot and cold water
 Solution as ordered by the physician
 Toilet paper
 Kidney basin
 Working gloves
 2. Apron or gown to protect the uniform2. Bedpan with cover
 3. waterproof underpad
 4. irrigation stand or IV stand

28. Assessment:
1.Assess status of client: last bowel
movement, normal versus recent
bowel pattern, presence of
haemorrhoids, mobility, bowel
sounds, presence of abdominal pain.
(Determine factors indicating need for
enema and influencing the type of
enema used. Also establishes baseline
for bowel function.)

29. 2.Assess medical records for presence of
increased intracranial pressure, glaucoma,
or recent rectal or prostate surgery.
(Conditions contraindicate use of enemas)
3.Inspect abdomen for presence of
distention.
(Establishes a baseline for determining
effectiveness of enema.)

30. 4.Determining client’s level of
understanding of purpose of enema.
(Allows nurse to plan fro appropriate
teaching measure.)
5.Check client’s medical record to
clarify reasons for enema.
(Determines purpose of enema
administration: preparation for special
procedure or relief of constipation.)

31. 6.Review physician’s order for
enema.
(Order by physician is usually required
for hospitalized client. Used to
determine how many enemas client
will require, type of enema to be
given.)

32. PREPARATION
 The patient should be encouraged to empty both bladder and
bowels before the procedure.
 Before administering an enema, ensure the patient’s privacy by
closing the door of the room.
 Have the patient undress completely from the waist down.
 Position the patient on the bed on his or her left side with the
top knee bent and pulled slightly upward toward the chin.
32

33. 33

34. ENEMA
STEPS RATIONALE
1.Inform client about
the procedure
To promote
cooperation, to
minimize anxiety
(Evans-Smith)

35. STEPS RATIONALE
2.Wash hands
(medical hand
washing)
Hand hygiene deters
the spread of
microorganism
(Evans-smith)

36. STEPS RATIONALE
3.Organize the
equipment
For efficiency

37. STEPS RATIONALE
4. Place rubber sheet
under patient’s
buttocks
The waterproof
pad/rubber sheets
protects bed linen
(Evans-Smith)

38. STEPS RATIONALE
5.Prepare solution,
making sure that
temperature of
solution is lukewarm
(about 105-110 F)
Warming the solution
prevent chilling of the
patient, adding to the
discomfort of the
procedure (Evans-
Smith)

39. STEPS RATIONALE
6.Allow solution to
run through the
tubing so that air is
remove. Clamp
tubing
Although allowing air
to intestine is not
harmful, it may
further distend the
intestine (Evans-
Smith)

40. STEPS RATIONALE
7.Place container on
bedside IV stand not
more than 18-24
inches above
buttocks.
Gravity forces the
solution to enter the
intestine. The
amount of pressure
determines the rate
of flow and pressure
exerted on the
intestinal wall
(Evans-Smith)

41. STEPS RATIONALE
8.Position the patient
on side lying position
or Sim’s position with
knee flexed
Allows enema
solution to flow
downward by gravity
along natural curve
of sigmoid colon and
rectum, thus
improving retention
of solution.

42. STEPS RATIONALE
9.Place bedpan
within easy reach.
Place bedpan for the
desire to defecate

43. STEPS RATIONALE
10.Wear gloves.
Lubricate 4-5 inches
of catheter tip rectal
tube
Gloves protect
nurses from
microorganism in
feces. Lubrication
facilitates passage of
the rectal tube
through the anal
sphincter and
prevents injury to the
mucosa (Evans-
Smith)

44. STEPS RATIONALE
11. Gently spread the
buttocks. Instruct
patient to take slow
deep breaths through
mouth.
To relax the sphincter
which will ease
catheter insertion by
breathing into mouth.

45. STEPS RATIONALE
12.Insert rectal tube
into the rectum about
3-4 inches and hold
in place
The tube should be
inserted past the
external and internal
sphincters, but further
insertion may
damage intestinal
mucous membrane
(Evans-Smith)

46. STEPS RATIONALE
13.Release tubing
clamp. Allow solution
to flow into colon,
observing patient
closely
Introducing the
solution slowly will
help to prevent rapid
distention of the
intestine and
a desire to defecate
(Evans-Smith)

48. STEPS RATIONALE
14. If patient
complaints of
cramping, extreme
anxiety or inability to
retain solution:
a.Lower solution
container
b.Clamp or pinch
tubing for few
minutes
These techniques
help relax muscles
and prevent expulsion
of the solution.

49. STEPS RATIONALE
15.Administer all
solution or as much
as patient can
tolerate, be sure to
clamp tubing just
before solution
clears tubing
Delivers enough
solution for proper
effect
To avoid introducing
of air into the bowel

50. STEPS RATIONALE
16.Slowly remove
rectal tubing while
gently holding
buttocks together.
This amount of time
usually allows
muscle contraction to
become sufficient to
produce good
results.

51. STEPS RATIONALE
17. Reposition patient
on comfortable
position

52. STEPS RATIONALE
18.Documents the
results

53. EVALUATION
 Were desired outcomes achieved?
Example of evaluation include:
Desired outcome met. After enema the
rectum was free of hard stool, client
expelled gas, and abdomen is now soft.
Desired outcome met: Client states
abdominal pain relieved after enema

54. Documentation:
The following should be noted on patient’s chart
• Type and amount of solution used
• Color, consistency and amount of stool return
• Condition of anus and surrounding area
• Status of vital signs before and after enema
• Description of adverse reactions during enema
• Abdominal assessment before and after enema
• Presence of discomfort after enema
• Client teaching regarding prevention of
constipation

55. Sample documentation
Date
04/11/2011
Time
03:45pm
Soap suds enema (750 ml
given. Large, dark brown stool
returned from enema. No signs
of adverse effects. Bowel
sounds auscultated in four
quadrants. Abdomen soft and
nondistended. Discussed
factors for promoting normal
bowel evacuation with client.
Factors verbalized by client.

56.  Example:
 Date: 04/11/2011
 Time: 4:00pm
 Soap suds enema (750 ml) given. Anus intact
without irritation. Large amount of dark brown
stool returned after enema. No signs of adverse
effects. Bowel sounds auscultated in four
quadrants before and after procedure. Abdomen
soft and non distended. Vital signs stable before
and after enema. Client verbalized measures for
promoting normal bowel evacuation.

57. AFTERCARE
 After administering an enema, remain near
the patient in case he or she needs
assistance with the bedpan or to get to the
bathroom.
 Medicated enemas that are expelled
immediately may need to be repeated, using
fresh solution.
 Follow the directions or consult with the
physician.

58.  To assist the patient with retaining an enema
after instillation, apply gentle pressure to the
rectal opening using a 4X4 gauze pad or
squeeze the buttocks together.
 Tuck a 4X4 gauze pad between the buttocks
to collect seepage. This maneuver may help
the patient feel more secure.
 Cover the patient after the procedure and
instruct him or her to lie still for 5 to 10
minutes or longer if a medicated solution
or retention enema is administered. This will
allow time for the sol’n to take effect.

59.  Wash items that might be reused, such as
non-disposable enema bags and tubing, in
warm soapy water. Rinse and allow them to
air dry.
 Place disposable items, gauze pads, & gloves
in a trash bag, then seal & discard it.
 Assist the patient to the bathroom or with the
bedpan after he or she has held the enema
solution for the correct amount of time.

60.  Hands should be washed after
performing the procedure.
 Note the results of the enema (color,
consistency, content and amount of
feces produced).

61. COMPLICATIONS
 Complications of enema administration are not
common but can include irritation, swelling,
redness, bleeding, or prolapse of the rectal
tissue.
 If any of these symptoms are apparent, or if the
patient complains of pain or burning during
enema instillation, stop the procedure and
notify the physician.

62. Risks
 Habitual use of enemas as a means to
combat constipation can make the
problem even more severe when their
use is discontinued. Enemas should be
used only as a last resort for treatment of
constipation and with a doctor's
recommendation. Enemas should not be
administered to individuals who have
recently had colon or rectal surgery, a
heart attack, irregular heart beat.

63.  Both pregnant women and nursing
women have safely done enemas. Many
of them. No known risks are associated
with clean water enema, but if you are
pregnant, you should avoid enema
containing herbs.
Can we do an enema in
pregnant or nursing a baby?

64.  Giving enemas during labor doesn’t shorten labor or decrease the
risk of infection to mother or baby new study has revealed. The
study now calls for discouraging the practice of giving enemas
during delivery.
 Enemas are frequently given to women early in labor so that they
empty their back passage. The idea is that this will give more
room for the baby as it passes through the pelvis. It is also hoped
that it will reduce the chance of the woman leaking fecal material
while she is giving birth, a situation that is both embarrassing to
the woman and a potential source of infection to mother and child.
Giving Enemas During Delivery to Be Discouraged

65. Pictures!

66. ASSEMBLE THE MATERIALS NEEDED

67. POSITION THE CLIENT IN THE LEFT LATERAL POSITION WITH
THE RIGHT LEG SHARPLY FLEXED

69. PLACE SOLUTION INTO THE BUCKET AND ADD WATER AS NEEDED

70. LUBRICATE
2 INCHES
OF THE
RECTAL
TUBE WITH
LUBRICANT

71. GENTLY AND SMOOTHLY INSERT THE RECTAL TUBE INTO THE
RECTUM

72. RAISE THE
CONTAINER 12
TO 18 INCHES
ABOVE THE
RECTUM AND
INSTILL 200 CC
OF SOLUTION

73. LOWER THE CONTAINER 12 TO 18 INCHES
BELOW THE CLIENT’S RECTUM. OBSERVE FOR
AIR BUBBLES AS THE SOLUTION RETURNS.

74. CLEAN THE ANAL AREA TO
REMOVE EXCESS LUBRICANT

75. A COMMERCIAL ENEMA

76. POSITION THE CLIENT IN THE LEFT LATERAL POSITION WITH
THE RIGHT LEG SHARPLY FLEXED

77. ALTERNATIVELY,
YOU MAY POSITION
THE CLIENT IN THE
KNEE CHEST
POSITION

78. AFTER INSERTING THE
NOZZLE INTO THE ANUS,
SQUEEZE THE CONTAINER
UNTIL ALL THE SOLUTION IS
INSTILLED

79. REMOVE THE NOZZLE
AND CONTAINER AND
HAVE THE CLIENT
CONTINUE TO LIE ON
THE LEFT SIDE FOR THE
RPESCRIBED LENGTH
OF TIME. DISPOSE OF
THE EMPTY CONTAINER
IN THE TRASH
RECEPTACLE

81. …end