ATI - Bowel Elimination (17)
in what position are enemas given to a pt in
sim's position orl left lateral position with right knee flexed - allows solution to drain through gravity
Soapsuds
stimulate peristalsis through intestinal irritation Considered safe as long as pure castile soap used
Can enema administration be delegated
yes, first you must assess vital signs
do not administer more than ____ enemas
3
Return-flow (flush)
Administered to expel intestinal gas; stimulates peristalsis After instilling solution lower below pt and allow to flow back into container (can be done 7 times?)
Length of enema inserted per age (adult, adolescent, child, infant)
Adult - 3-4 in Adolescent - 3-4 in Child - 2-3 in Infant - 1-1.5 in
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? A)2.5 cm to 3.75 cm (1 to 1.5 in) B)5 cm to 7.5 cm (2 to 3 in) C)7.5 cm to 10 cm (3 to 4 in) D)10 cm to 12.5 cm (4 to 5 in)
C)7.5 cm to 10 cm (3 to 4 in) Explanation 2.5 cm to 3.75 cm (1 to 1.5 in)This is the appropriate length of insertion for an infant, rather than an adult. 5 cm to 7.5 cm (2 to 3 in)MY ANSWERThis is the appropriate length of insertion for a child, rather than an adult. 7.5 cm to 10 cm (3 to 4 in)This is the appropriate length of insertion for an adult client. 10 cm to 12.5 cm (4 to 5 in)This length of insertion puts the client at risk for bowel perforation.
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A)Measure the client's vital signs. B)Notify the primary care provider. C)Lower the enema fluid container. D)Stop the enema instillation.
C)Lower the enema fluid container. Explanation Measure the client's vital signs.This assessment will not relieve the client's discomfort. Notify the primary care provider.This intervention will not relieve the client's discomfort. Lower the enema fluid container.Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container. Stop the enema instillation.MY ANSWERDiscontinuing the enema is indicated if the client's abdomen becomes rigid and distended or if there is evidence of bleeding.
A nurse is preparing an adult client for an enema. the nurse should assist that client into which of the following positions? A)Prone B)Dorsal recumbent C)Right lateral with both knees at chest D)Left lateral with the right leg flexed
D)Left lateral with the right leg flexed Explanation ProneThe prone position does not allow adequate visualization of the anus for safely inserting the rectal tube. Dorsal recumbentThis position is used for infants and small children during enema administration, but it is not optimal for adults. Right lateral with both knees at chestThis position is difficult for clients to maintain, and it is unnecessarily extreme for enema administration. Left lateral with the right leg flexedMY ANSWERThis position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.
oil-retention enema give to
Feces absorb oil make them softer and easier to pass
volume guidelines for retention-flow
Infant - 150-250 mL Toddler - 250-350 mL Child 300-500 mL Adolescent 500-750 mL Adult - 750 - 1000 mL
How to position bedpan
Place upper end underneath the clients buttocks and lower end under upper thighs Place waterproof pad underneath client before positioning bedpan
types of enemas
-Cleansing -Oil retention -return-flow (flush) -medicated
Assistive devices for bowel elimination
-bedside commode -bedpans: regular and fracture
Hypotonic solutions
-exert osmotic pressure causing water to move from colon to interstitial space (tap water) -Should not be repeated due to potential water toxicity or circulatory overload
Medicated enema can be given for
-local effect they exert on rectal mucosa -produce systemic affect
Carminative enemas
-used to relieve flatus and abdominal distention -Small amt fluid instilled into rectum normally with things like magnesium, glycerin which helps to distend rectum and colon to stimulate peristalsis
cleansing enemas normally take effect in
10-15 min
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. which of the following actions should the nurse take? A) Place the client in the dorsal recumbent position on a bedpan. B)Administer the enema while the client sits on the toilet. C)Administer an antidiarrheal medication 3 hr prior to the enema. D) Instill 200 mL of fluid over an hour at 15-min intervals.
A) Place the client in the dorsal recumbent position on a bedpan. Explanation A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled. Administer the enema while the client sits on the toilet.MY ANSWERThe angle of insertion of the rectal tube with the client in this position could result in abrasion of the rectal wall. Administer an antidiarrheal medication 3 hr prior to the enema.An antidiarrheal medication will not correct poor sphincter control and might be counterproductive to the purpose of the enema. Instill 200 mL of fluid over an hour at 15-min intervals.This would unnecessarily prolong the procedure and would have little or no effect on sphincter control.
A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following type of enemas? A)Cleansing B)Return-flow C)Medicated D)Oil-retention
B) Return flow Explanation CleansingMY ANSWERCleansing enemas remove feces when a client is constipated, has a fecal impaction, or is undergoing preparation for surgery or diagnostic procedures. This type of enema would not address this client's immediate need. Return-flowReturn-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention. MedicatedMedicated enemas are given for a variety of reasons, such as to reduce bacteria in the colon prior to surgery or to exert a systemic effect. This type of enema would not address the client's immediate need. Oil-retentionOil-retention enemas lubricate the rectum and the colon, making feces softer and easier to pass. This type of enema would not address the client's immediate need.
Bedside commode
Client able to get out of bed but cannot walk to bathroom
Bedpan: Fracture
For pt who are in body or leg casts, have lower-extremity fracture, or are unable to lift their hips Made of hard plastic and has flat upper end that makes sliding under client easier
Bedpans
For those on bed rest, immobilized and cannot use bathroom or bedside commode
Bedpan: Regular
Hard plastic and curved, smooth upper end and a tapered lower end For pts who are able to lift their hips and have no mobility restrictions of lower extremities
What happens in cleansing enema
Large or small when instilled bowel wall stretched which stimulates peristalsis
what can harsher soaps cause
bowel inflammation
Small-volume uses
hypertonic solutions and draw fluids into colon from interstitial space; stimulating peristalsis
Contraindications for enema
increased intracranial pressure, glaucoma, rectal or prostate surgery
Hypertonic solutions (sodium phosphate)
pull fluid from interstitial space into colon
Why enemas are used
relieve constipation, expel flatus, empty bowels before diagnostic procedure or surgery, instill medication, or initiate bowel training program
Solutions that can be placed in enemas
tap water (hypotonic), normal saline, soap suds, hypertonic carminative, medicated, or oil
Solutions that can be used in cleansing enema
tap water, normal saline, soapsuds
enema
the placement of a solution into the rectum and colon to empty the lower intestine through bowel activity
solution: 0.9% sodium chloride
isotonic so it doesn't pull electrolytes form body or shift fluids in or out of colon
retain enema for at least
30 min
For large-volume cleansing enema hang no higher than
45 cm (18 in) above level of anus
Mixing ___mL castile soap to ____ liter solution
5, 1
A nurse is preparing to administer the first of two large-Volume, cleansing enemas prescribed for a client in preparation for diagnostic procedure. Which of the following actions should the nurse take? A)Warm the enema solution prior to instillation. B)Prepare 1,500 mL of enema fluid. C)Use tap water as the enema fluid. D)Hang the enema container 24 inches above the anus.
A)Warm the enema solution prior to instillation. Explanation It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa. Prepare 1,500 mL of enema fluid.MY ANSWERFor a large-volume cleaning enema, the recommended amount of fluid to instill for an adult client is 750 to 1,000 mL. Use tap water as the enema fluid.Tap water is a hypotonic solution that moves fluid from the colon into the interstitial spaces and can cause circulatory overload and electrolyte imbalances. For this reason, tap water enemas cannot be given more than once, and two enemas have been prescribed for this client. Hang the enema container 24 inches above the anus.The height of the fluid container affects the speed of instillation. The maximum recommended height is 18 inches. Hanging the container higher than that can cause rapid instillation and painful distention of the colon.
A nurse is administering a return-flow enema to a client. after instilling 100 mL of enema fluid, which of the following actions should the nurse take? A)Instruct the client to retain the fluid. B)Lower the container to allow the solution to flow back out. C)Help the client to the toilet or bedside commode. D)Wait 5 min and instill another 100 mL of fluid.
B)Lower the container to allow the solution to flow back out. Explanation Having the client retain the fluid is appropriate for a retention enema, not for a return-flow enema. Lower the container to allow the solution to flow back out.MY ANSWERReturn-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times. Help the client to the toilet or bedside commode.Assisting the client to the toilet or commode or providing a bedpan is appropriate for a cleansing enema, not for a return-flow enema. Wait 5 min and instill another 100 mL of fluid.This is inappropriate during the administration of a return-flow enema.
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A)The duration of the procedure B)10 to 15 min C)Until the client feels the urge to defecate D)At least 30 min
D) at least 30 min Explanation The duration of the procedureThis might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. 10 to 15 minThis might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. Until the client feels the urge to defecateMY ANSWERThis instruction is too vague to ensure the effectiveness of the enema. The client might feel an immediate need to defecate, which might result in straining because the oil has not had enough time to penetrate and soften the feces for easy elimination. At least 30 minThe enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min.
if you feel resistance or pt reports pain when inserting stop
ask them to take a deep breath and then instill a small amt of fluid