Copyright 2007, F. A.

Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing

PROCEDURE CHECKLIST
Chapter 28: Administering a Cleansing Enema

Check () Yes or No

PROCEDURE STEPS Yes No COMMENTS
1. Determines patients ability to retain the enema
solution.

2. Places a bedpan or bedside commode nearby for the
patient with limited mobility.

3. Warms the solution to 105110F not in a
microwave. Checks temperature with bath thermometer.

4. Opens the enema kit or obtains supplies.
5. Attaches tubing to the enema bucket if a bucket is being
used (the 1-liter enema bag comes with preconnected
tubing).

6. Closes the clamp on the tubing and fills the container
with 5001100 mL of warm solution (40150 mL for
infants; 250350 mL for toddlers; 300500 mL for school-
age children).

7. Checks water with a bath thermometer. Temperature
should be 105110 degrees F (lukewarm).

8. Adds Castile soap or soap solution used by the facility,
if a soapsuds enema was ordered.

9. Hangs the container on the IV pole.
10. Holding the end of the tubing over a sink or waste can,
opens the clamp and slowly allows the tubing to prime (fill)
with solution. Reclamps when filled.

11. Has the patient turn or assists to turn to a left side-lying
position with the right knee flexed. (Elevates head of the
bed very slightly for patients who have shortness of
breath.)

12. Drapes patient with bath blanket, leaving only the
buttocks and rectum exposed.

13. Dons clean procedure gloves.
14. Places a waterproof pad under the patients
buttocks/hips.

15. Places the bedpan flat on the bed directly beneath the
rectum, up against the patients buttocks; or places the
bedside commode near the bed.

16. Generously lubricates the tip of the enema tubing.
17. If necessary, lifts the superior buttock to expose the
anus.

18. Slowly and gently inserts tip of the tubing
approximately 3 to 4 inches (7 to 10 cm) into the rectum;
asks patient to take slow, deep breaths during this step.


Copyright 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing

19. If tube does not pass with ease, does not force; allows a
small amount of fluid to infuse and then tries again.

20. Removes the container from the IV pole and holds it at
the level of the patients hips. Begins instilling the solution.

21. Slowly raises the level of the container so that it is 12 to
18 inches (3045 cm) above the level of the hips. Adjusts
the IV pole and rehangs the container.

22. Continues a slow, steady instillation of the enema
solution.

23. Continuously monitors the patient for pain or
discomfort. If pain occurs or resistance is met at any time
during procedure, stops and consults with primary care
provider.

24. Assesses ability to retain the solution. If the patient has
difficulty with retention, lowers the level of the container,
stops the flow for 1530 seconds, and then resumes the
procedure.

25. When the correct amount of solution has been instilled,
clamps the tubing and slowly removes the tubing from the
rectum.

26. If there is stool on the tubing, wraps the end of the
tubing in a washcloth or toilet tissue until it can be rinsed
or disposed of.

27. Cleanses the patients rectal area.
28. Re-covers the patient.
29. Instructs patient to hold the enema solution for 5 to 10
minutes.

30. Places call light within reach.
31. Disposes of enema supplies or, if reusable, cleans and
stores in an appropriate location in the patients room.

32. Removes gloves; washes hands.
33. Depending on the patients mobility status, assists onto
the bedpan, to the bedside commode, or to the toilet when
she feels compelled to defecate.

34. After the patient has defecated, inspects the stool for
color, consistency, and quantity.





Recommendation: Pass ______ Needs more practice ______

Student: Date:

Instructor: Date: