SKILL 13-4 Administering a Retention Enema Goal: The patient retains the solution for the prescribed, appropriate

length of time and experiences the expected therapeutic effect of the solution. 1. Verify physicians orders. Identify the patient. Explain to patient procedure and rationale for enema, including where he or she will defecate, and have a bedpan, commode, or nearby bathroom ready for use. ather e!uipment. "llow solution to warm to room temperature. #. $erform hand hygiene. %. $ull the curtains around the bed and close the room door. If bed is ad&ustable, place it in high position. '. $osition the patient on the left side ()ims position*, as dictated by patient comfort and condition. +old top linen bac, &ust enough to allow access to the patients rectal area. $lace a waterproof pad under the patients hip. -. $ut on nonsterile gloves. .. /emove cap of prepac,aged enema solution and ensure that rectal tube is prelubricated. If not, apply a generous amount of lubricant to the tube. 0. 1ift buttoc, to expose anus. )lowly and gently insert rectal tube %2 to '2 (0314 cm* for an adult. 5irect it at an angle pointing toward the umbilicus. "s, patient to ta,e several deep breaths. 6. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of tu e! 7. )lowly s!uee8e enema container, emptying entire contents.

14. Remo"e container #$ile %ee&ing it com&ressed! 9ave paper towel ready to receive tube as it is withdrawn. 11. Instruct &atient to retain enema solution for at least 3' minutes or as indicated! 1#. /eturn the patient to a comfortable position. :a,e sure the linens under the patient are dry. /emove your gloves and ensure that the patient is covered. 1%. /aise side rail. 1ower bed height and ad&ust head of bed to a comfortable position. 1'. /emove any remaining e!uipment. $erform hand hygiene. 1-. ;hen patient has a strong urge to defecate, place him or her in a sitting position on bedpan or assist to commode or bathroom. )tay with patient or have call light readily accessible. 1.. /emind patient not to flush commode before nurse inspects results of enema. /ecord character of stool and patients reaction to enema. 10. "ssist patient if necessary with cleaning of anal area (putting on gloves if necessary*. <ffer washcloths, soap, and water for handwashing. 16. 1eave patient clean and comfortable. =are for e!uipment properly. 17. $erform hand hygiene.