The term enema is used to refer to the process of instilling fluid through the anal sphincter into the rectum and lower intestine for a therapeutic purpose. An enema administration 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. An enema can also be performed using a prepackaged solution that comes in a soft plastic bottle with a pre-lubricated rectal tip attached. Enema solutions are prepared using plain tap water or saline, soapsuds solutions, oil solutions, or various medication solutions.
The most common purpose for administering an enema is to stimulate peristalsis (involuntary contraction) and to evacuate stool from the rectum. A tap water or soapsuds enema dilates the bowel, stimulates peristalsis, and lubricates the stool to encourge a bowel movement. These types of enemas are instilled and held for five to 10 minutes, as tolerated. They are used to treat constipation, to cleanse the bowel before a bowel exam, and to cleanse the bowel before bowel surgery. Another type of enema, the oil retention enema, is prepared in a smaller volume and is retained in the bowel for 30–60 minutes. The purpose of the oil retention enema is to soften the hardened stool and allow normal elimination. Enemas are also used to deliver medication directly onto the rectal mucous membranes to be absorbed into the bloodstream. Steroid enema solutions can be administered to alleviate bowel inflammation in patients with ulcerative colitis. Antibiotic enema solutions can be administered to treat localized bacterial infections. Medicated hypertonic enema solutions can be used to pull excessive potassium or ammonia from the bloodstream through the rectal wall. These substances are then eliminated with the stool.
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. A patient with diarrhea may not be able to hold an enema. Enema administration 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 arrhythmia such as bradycardia. Enemas should not be given to patients with undiagnosed abdominal pain because the peristalsis of the bowel can cause an inflamed appendix to rupture. Enemas 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. Do not force the enema catheter into the rectum against resistance. This can cause trauma to the rectal tissue. Use only mild castile soap for soapsuds enemas because other soap preparations are too harsh and irritate the rectal tissue.
To administer an enema solution, the clinician should have the patient lie down on the left side, knees bent. Lift the upper buttock so that the rectal opening can be visualized. Place the lubricated tip of the enema catheter at the anal opening, and gently advance the catheter through the anal sphincter into the rectum toward the umbilicus (navel), 3–4 in (7.5–10 cm) for an adult. Insert the tubing 2 in (5 cm) for a child less than six years and 1 in (2.5 cm) for an infant. After alerting the patient, open the enema tubing to allow the solution to flow or squeeze premixed enema solutions slowly into the rectum. If the patient complains of cramping, slow or stop the enema flow and have the patient breathe slowly through the mouth to encourage relaxation. When giving fluid through an enema bag, start with the bag suspended from an IV pole at the patient's hip level. As the tubing is opened, slowly raise the IV pole to promote fluid flow until the bag is 12 inches (30.5 cm) above the hip for an adult. Continue to hold the rectal tube in place throughout the procedure or it will be expelled from the rectum. If the fluid will not flow in, gently rotate the tubing within the rectum to clear the holes of the tubing from the wall of the bowel or the impacted stool that may be occluding the flow. If ordered to give a high enema, slowly raise the bag no more than 18 inches (46 cm) above the adult patient's hip (12 inches (30.5 cm) above a child's hip and six inches (15 cm) above an infant's hip). This will increase the water pressure to deliver the fluid higher into the bowel. When all of the solution has been administered, clamp the tubing, remove the enema catheter, and release the buttock.
Before administering an enema, ensure the patient's privacy by closing the room door. The patient should be encouraged to empty both bladder and bowels before the procedure. 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. Place a waterproof pad under the patient's hips to protect the bedding and drape a sheet over the patient covering the entire body except the buttocks. Place a bedpan and toilet paper within quick access. Explain the procedure to the patient. Emphasize the importance of breathing slowly through the mouth to encourage relaxation of the rectal sphincter and to avoid oppositional pressure. Let the patient know that while he or she may feel the urge to defecate, most enemas need time to work and he or she should try to hold the fluid for at least five to 10 minutes after instillation (30–60 minutes for retention enemas and longer for some medicated enema solutions). Check the medication label if it is a medicated solution to avoid medication errors. Be sure it is the right medicine, the right dose (strength), the right time, the right person, and the right method. Verify the expiration date on the label. Do not use outdated medicine.
Wash hands thoroughly and put on gloves. To prepare for premixed disposable enema instillations, follow the directions on the package. Most premixed disposable enemas come with the tip already lubricated. Shake the solution bottle. Remove the cap from the tip and expel excess air from the apparatus before use. To prepare solutions to be administered using an enema bag, heat the solution to 105°F. Adult solutions are generally 750–1000cc of solution for a non-retention enema and 150–200cc of fluid for a retention enema. Children's solutions are 250–500cc of solution for a non-retention enema and 75–150cc of solution for a retention enema. Infants' solutions are 150–250cc of solution for a non-retention enema. If preparing a medicated solution, follow the physician's orders. Select a rectal tube appropriate
Anal sphincter —A ring-shaped muscle located at the bottom of the anal canal that maintains constriction to keep the anal canal closed to the outside of the body. The anal sphincter relaxes and opens during defecation.
Defecation —The process of eliminating stool from the body.
Hypertonic —A solution that has a higher osmotic pressure than a comparative solution.
to the patient's size (#14–30 French rectal tube for an adult, #12–18 for a child, #12 for an infant) and connect it to the tubing from the bag. Fill the enema bag with the solution and open the tubing. Run the solution through the tubing to the tip of the rectal tube to clear air from the line. Clamp the tubing and adjust the bag on an IV pole so that it will hang at the patient's hipline. Put water-soluble lubricant on a clean 4×4 gauze pad and roll the tip of the rectal tube in the lubricant. Coat all of the rectal tube that will be inserted into the rectum to avoid traumatizing the rectal tissue [3–4 inches (7.3–10 cm) for an adult, 2–3 inches (5–7.5 cm) for a child, 1–1 1/2 inches (2.5–4 cm) for an infant].
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. To assist the patient with retaining an enema after instillation, apply gentle pressure to the rectal opening using a 4×4 gauze pad or squeeze the buttocks together. Tuck a 4×4 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 five to 10 minutes or longer if a medicated solution or retention enema is administered. This will allow time for the solution to take effect. 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, and gloves in a trash bag, then seal and 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. Hands should be washed after performing the procedure. Note the results of the enema.
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.
Most enemas, because of their liquid state, are absorbed quickly and work rapidly. Retention enemas will take 30–60 minutes to achieve full therapeutic effect. Cleansing enemas usually work within 10–15 minutes to cleanse the bowel and relieve constipation. They may, however, need to be repeated one or two times to thoroughly cleanse the bowel in preparation for a bowel exam or bowel surgery. Medicated enemas, such as antibiotic or anti-inflammatory solutions, may need to be repeated daily over a period of a week or more for full therapeutic effect.
Health care team roles
Enemas are administered by a licensed nurse (R.N. or L.P.N.) in the health care setting. Unlicensed staff, however, may be trained to administer non-medicated enemas under the direction of a registered nurse in some settings. An alert and cooperative patient may also be allowed to self-administer non-medicated enemas in some health care settings under the direction of a nurse. The nurse should, however, assess the patient and the effectiveness of the enema. The patient, or members of the patient's family, can be taught to administer an enema in the home setting.
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Mary Elizabeth Martelli, R.N., B.S.