A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
A Hold the container of solution 30 cm (12 in) above the anus.
B Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
C Hold the container of solution level with the client’s upper hip.
D Keep the container of solution at a level to maintain client comfort.
The Correct Answer and Explanation is:
The correct answer is A) Hold the container of solution 30 cm (12 in) above the anus.
Explanation:
Administering a cleansing enema is a common nursing procedure to help relieve constipation or prepare a client for diagnostic tests or surgery. The technique involves introducing a solution into the rectum and colon, which stimulates peristalsis, encouraging the evacuation of bowel contents. Correct positioning and technique are essential for ensuring the enema is effective and minimizing discomfort for the client.
Why Answer A is Correct:
Holding the enema container 30 cm (12 in) above the anus allows gravity to assist in the steady and controlled flow of the enema solution into the rectum and colon. The height of 30 cm (or 12 inches) is considered optimal because it provides enough pressure for the fluid to flow at a rate that is effective without causing excessive discomfort or risk of injury. If the container is held too high, the solution may flow too rapidly, leading to cramping, discomfort, and even mucosal injury. On the other hand, if held too low, the flow might be too slow, and the enema might not be effective in promoting bowel evacuation.
Why the Other Options are Incorrect:
- B) Holding the container 15 cm (6 in) above the anus and then lowering it 15 cm below is not a standard practice. This would cause the flow of solution to be inconsistent and could lead to poor enema results.
- C) Holding the container level with the client’s upper hip would prevent the solution from flowing effectively. There wouldn’t be enough gravitational pressure to instigate bowel movement or adequately deliver the solution into the colon.
- D) Keeping the container at a level for client comfort is too vague. While client comfort is important, it’s also necessary to follow evidence-based guidelines to ensure the procedure is effective. Holding the container at random heights without standardization could lead to under- or over-administration of the enema solution.
Additional Considerations:
Before administering the enema, the nurse should explain the procedure to the client to alleviate anxiety. The client is usually positioned in the left lateral (Sim’s) position to facilitate the flow of the enema into the sigmoid colon. The nurse should also monitor the client for signs of discomfort, cramping, or any adverse reactions during the procedure.
By following proper guidelines, including maintaining the container height at 30 cm (12 inches), the nurse can ensure the enema is administered effectively and safely.