ATI: Skills Module 2.0: Enemas

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older patient who has hyperkalemia. The nurse should insert the tip of the rectal tube

7.5 cm to 10 cm (3 to 4 in)

A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for

at least 30 minutes, but preferably as long as he can *The enema will be most effective in softening the stool and lubricating its passageway if the patient retains the oil for as long as he can - 1 to 3 hr if possible. It takes between 30 min and 3 hrs for the oil to exert its therapeutic effect.

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

Lower the enema fluid container *Some abdominal cramping is to be expected during enema administration. To ease the patient's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient?

Place the patient in the dorsal recumbent position on a bedpan *A patient who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the patient over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid likely to be expelled promptly and thus help maintain the patient's dignity.

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?

Left lateral with the right leg flexed *This 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.

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

Return flow *Return flow enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

A nurse who is administering a return flow enema to a patient should instill 100mL of enema fluid and then

Lower the container to allow the solution to flow back out *Return flow enemas involve moving 100-200 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 five or six times.

A nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure?

Warm the enema solution prior to instillation *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.