ENEMA

ENEMA – BOWEL ELIMINATION (Purpose, Contraindications, Classification, Methods of Giving Enemas, General Instructions, Preliminary Assessment, Preparation of the Patient and Environment, Equipment, Procedure and After Care)

Enema (clysis) is defined as an introduction of the fluid into the rectum.

An enema is an introduction of fluid into the bowel through the rectum for the purpose of cleansing or to introduce nourishment

An enema is an introduction of fluid into the lower bowel through the rectum for the purpose cleaning, medicinal, diagnostic or such other purpose

PURPOSE

To remove fecal matter
To relieve flatulence
To relieve constipation
To prevent involuntary defecation during surgery
To reduce temperature, e.g. cold edema
To check diarrhea, e.g. starch opium enema
To stimulate peristalsis, e.g. purgative enema
To make diagnosis, e.g. barium enema
To cleanse the bowel before X-ray studies
To induce anesthesia, e.g. anesthetic enema
To administer medications
To destroy intestinal parasites, e.g. anthelmintic enema
To administer fluids and nutrients
To relieve inflammation
To establish regular bowel functions during bowel training program

CONTRAINDICATIONS

Acute myocardial infarction and cardiac problems
Acute renal failure
Appendicitis
Obstetrical and gynecological contraindications

CLASSIFICATION OF ENEMA

Soap water enema: it is otherwise called saline enema. In this normal saline (sodium chloride 1 teaspoon) to half liter of water

The amount of solution used for adult 500 to 1000 ml, children 250 to 500 ml and infants 250 ml or less. The temperature of the solution in adult 105 to 110 degree F and children 100 degree F

Oil enema: it is given to soften fecal matter in cases of serve constipation. The enema must be retained ½ or 1 hour to soften the feces

Carminative enema: It is also called antispasmodic enema. It is given to relieve gaseous distension of abdomen by increasing peristalsis and expulsion of flatus. The solution used is 8 to 16 ml of turpentine mixed thoroughly with 600 to 1200 ml of soap solution. Milk and molasses 90 to 230 ml well mixed with equal quantity of warm milk

Anthelmintic Enema: It is given to destroy and expel worms from the intestine cleansing enema must be given prior to anthelmintic enema so that the drug comes in direct contact with worms and the lining of intestine.

The solution used is infusion of quassia 15g of chips to 600 mL of water or hypertonic saline solution sodium chloride 60 mL with 600 mL of water. The amount of solution given is 250mL.

Cold Enema: Cold enema or ice-water enema is given to reduce body temperature in hyper pyrexia and heat stroke. It is given in the form of colonic irrigations. The temperature of the solution is 80 to 90 degree Fahrenheit (27 to 32 degree Celsius).

Glycerin Enema: Glycerin enema is given to children to fever patients and postoperative patient. Pure glycerin and water 1:2 are used.

Astringent Enema: Astringent enema contracts the tissues and blood vessels checks bleeding and inflammation lessens the amount of mucus discharge and gives a temporary relief in the inflamed area. It is usually given in colitis and dysentery.

The solution used are tannic acid – 25g to 600 mL water, alum 30g to 600 mL of water and silver nitrate 2% (silver nitrate is dissolved in the distilled water).

Sedative Enema: Sedative enema contains an anesthetic drug to produce anesthesia in the patient. The commonly used drugs are paraldehyde and over tin. Dose is given as per doctor’s order.

Stimulant Enema: Stimulant enema is given in the treatment of shock and collapse. Coffee enema is given in case of opium poisoning. Solution used are black coffee – 1 tables spoon coffee powder to 300mL of water and 15mL of brandy added to 120 to 180mL of glucose saline. The amount of solution used is 180 to 240mL and the temperature of solution used is 180 to 240mL and the temperature of solution is 108 to 110 degree Fahrenheit (42 to 43 degree Celsius).

Emollient Enema: Emollient enema or starch enema is given in case of diarrhea to relieve irritation in an inflamed mucus membrane. The solution used is starch and opium Tr. Opium 1 to 2mL added to 120 to 180mL of starch mucilage or rice water. The temperature of the solution is 100 to 105 degree Fahrenheit (37.8 to 40.5 degree Celsius).

Nutrient Enema: It is given to supply food and fluids to the body. Selection of the fluids depends upon the ability of the colon to absorb it. Nutrient enema is particularly useful in conditions like hemophilia.

The solution used is normal saline; Glucose saline 250mL 5% peptonized milk 120mL. The amount of solution used is 110 to 1700mL in 24 hours or 180 to 270mL at 4 hourly intervals. The temperature of solution is 100 degree Fahrenheit (37.8 degree Celsius).

METHODS OF GIVING ENEMAS

Enema can and tube method – when large amounts of fluids are to be given, this method is used, e.g. soap and water enema
Funnel and catheter method – when a small quantity of fluids is to be given, this method is used, e.g. oil enema
Glycerin syringe and catheter method when a small quantity of fluid is to be given, this method is used, e.g. Purgative enema
Rectal drip method – when the fluid is to be administered very slowly in order to aid in its absorption, e.g. nutrient enema

GENERAL INSTRUCTION

The appropriate size of rectal catheter or rectal tube of cleansing enema is 22 French for adults, 12 French for infant and 14 to 18 French for children (School-age child)
The rectal tube need to be smooth and flexible
The rectal tube is lubricated with a water soluble lubricant or Vaseline to facilitate insertion and to decrease irritation of the rectal mucosa
The temperature of the solution needs to be adjusted according to the purpose of the enema
The amount of the solution to be administered depends up on the type of enema and the age and size of the person
The patient usually placed in left lateral position, when an enema is administered. In this position, sigmoid colon is below the rectum, thus facilitating instillation of the fluid
The distance to which the tube is inserted depends upon the age and the size of the patient. For an adult, it is normally inserted 7.5 to 10 cm (3 to 4 inches), for children it is 2.5 to 3.75 cm (into 1 ½ inches)
The height of the enema can should not be above 18 inches (20 cm) from the anus
The length of time that the enema solution is retained will depend up on the purpose of enema oil retention enema are usually retained for 2 to 3 hours. Other cleansing enemas are normally retained 5 to 10 minutes
Prepacked enema will have their own instruction which need to be followed
Prevent air from entering into rectum, by expelling air from the tube
If the rectum is impacted, attempt to remove the fecal matter with a gloved finger
Make sure the whole apparatus use for the administration of enemas is in a good working condition
Regulate the flow of fluid according to the type of enema
Listen to the complaints of the patients and should not ignore any discomfort however small they are

PRELIMINARY ASSESSMENT

Doctors order for any specific precautions
Diagnosis of the patient
Abilities and limitations concerning movements
Level of consciousness to follow directions
Availability of the articles
Extra help needed
Lesions on the rectal and perineal area
Nature of enema ordered

PREPARATION OF THE PATIENT AND ENVIRONMENT

Explain the sequence of the procedure
Arrange the articles at the bed side
Provide privacy
Cover the patient with bed sheet
Place the Mackintosh and towel under the patient’s buttocks
Place the patient in the left lateral position
Keep the bedpan under the bed over a stool
Adjust the IV pole to hold the enema can at the required height

EQUIPMENT

A clean tray containing:

Enema cans, rubber tubing, glass connection, screw clamp
Mackintosh and towel
Rectal tube (adjusts) or rectal catheter placed in a kidney tray
Vaseline
Pint measure
Soap jelly in a bottle
IV stand
Toilet tray
Bedpan – 2
Clean linen if needed
Bath thermometer
Rag pieces and K-basin

PROCEDURE

Wash hands thoroughly
Attach tubing to enema can and clamp tube
Prepare solution at required temperature and check temperature with bath thermometer
Attach rectal tube to tubing, expel air and clamp tube. Air entry into rectum may cause discomfort
Hang enema can with solution on IV stand and adjust height to 18 inches from bed
Lubricate tip of rectal tube
Use rag pieces to separate patients buttocks and visualize anus clearly. Insert rectal tube gently to a distance of 2-4 inches
Encourage patient to take a deep breath while inserting tube. Note level of fluid and make sure ther is free flow
Encourage patient to take deep breaths during administration of fluid
Clamp or pinch the rectal tube if the fluid is about to get over
Use rag pieces to remove the rectal tube

AFTER CARE