Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

273

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 13-2

Administering a Small-Volume Cleansing Enema

Goal:The patient expels feces and reports a decrease in pain

and discomfort. Comments

1. Verify the order for the enema. Bring necessary equipment
   to the bedside stand or overbed table. Warm the solution
   to body temperature in a bowl of warm water.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient. Discuss where the patient
   will defecate. Have a bedpan, commode, or nearby
   bathroom ready for use.


5. Adjust bed to comfortable working height, usually elbow
   height of the caregiver (VISN 8 Patient Safety Center,
   2009). Position the patient on the left side (Sims’ position),
   as dictated by patient comfort and condition. Fold top
   linen back just enough to allow access to the patient’s rec-
   tal area. Place a waterproof pad under the patient’s hip.


6. Put on nonsterile gloves.


7. Remove the cap and generously lubricate end of rectal tube
   2 to 3 inches (5 to 7 cm).


8. Lift buttock to expose anus. Slowly and gently insert the
   rectal tube 3 to 4 inches (7 to 10 cm) for an adult. Direct
   it at an angle pointing toward the umbilicus, not bladder.
   Do not force entry of the tube.Ask patient to take several
   deep breaths.


9. Compress the container with your hands. Roll the end up
   on itself, toward the rectal tip. Administer all the solution
   in the container.


10. After solution has been given, remove tube, keeping the
    container compressed. Have paper towel ready to receive
    tube as it is withdrawn. Encourage the patient to hold the
    solution until the urge to defecate is strong, usually in
    about 5 to 15 minutes.


11. Remove gloves. Return the patient to a comfortable posi-
    tion. Make sure the linens under the patient are dry.
    Ensure that the patient is covered.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

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