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

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

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 13-3

Administering a Retention Enema

Goal:The patient retains the solution for the prescribed,

appropriate length of time and experiences the expected

therapeutic effect of the solution. 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. 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 dic-
   tated by patient comfort and condition. Fold top linen back
   just enough to allow access to the patient’s rectal area. Place
   a waterproof pad under the patient’s hip.


6. Put on nonsterile gloves.


7. Remove cap of prepackaged enema solution. Apply a gen-
   erous amount of lubricant to the tube.


8. Lift buttock to expose anus. Slowly and gently insert rectal
   tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an
   angle pointing toward the umbilicus. Ask patient to take
   several deep breaths.


9. If resistance is met while inserting the tube, permit a small
   amount of solution to enter, withdraw tube slightly, and
   then continue to insert it. Do not force entry of tube.


10. Slowly squeeze enema container, emptying entire contents.
    11.Remove container while keeping it compressed.Have
    paper towel ready to receive tube as it is withdrawn.
    12.Instruct patient to retain enema solution for at least
    30 minutes or as indicated, per manufacturer’s direction.


11. Remove your gloves. Return the patient to a comfortable
    position. Make sure the linens under the patient are dry
    and ensure that the patient is covered.


12. Raise side rail. Lower bed height and adjust head of bed to
    a comfortable position.

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

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