Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [178], C).
2. 2.Show
   Wash hands with soap and water or use an alcohol‐based handrub.
   For infection prevention and control (NHS England and NHSI [161], C).
3. 3.Show
   Draw curtains around the patient or close the door.
   For privacy, to avoid unnecessary embarrassment and to promote dignified care (NMC [178], C).
4. 4.Show
   Allow the patient to empty their bladder first if necessary.
   A full bladder may cause discomfort during the procedure (Peate [192], E).
5. 5.Show
   Ensure that a bedpan, commode or toilet is readily available.
   In case the patient feels the need to expel the enema before the procedure is completed. P

Procedure

1. 6.Show
   Warm the enema to room temperature by immersing it in a jug of hot water.
   Heat is an effective stimulant of the nerve plexi in the intestinal mucosa. An enema at room temperature or just above will not damage the intestinal mucosa. The temperature of the environment, the rate of fluid administration and the length of the tubing will all have an effect on the temperature of the fluid in the rectum (Peate [192], E).
2. 7.Show
   Assist the patient to lie on their left side with knees well flexed, the upper knee higher up the bed than the lower one, and with the buttocks near the edge of the bed. See Problem‐solving table 6.11 if the patient is unable to lie on their left.
   This allows easy passage into the rectum by following the natural anatomy of the colon. In this position, gravity will aid the flow of the solution into the colon. Flexing the knees ensures a more comfortable passage of the enema nozzle or rectal tube (Peate [192], E).
3. 8.Show
   Place a disposable incontinence pad beneath the patient's hips and buttocks.
   To reduce potential infection caused by soiled linen. To avoid embarrassing the patient if the fluid is ejected prematurely following administration. P
4. 9.Show
   Decontaminate hands with soap and water or an alcohol‐based handrub and put on disposable gloves.
   For infection prevention and control (NHS England and NHSI [161], C).
5. 10.Show
   Place some lubricating gel on a gauze square and lubricate the nozzle of the enema or the rectal tube.
   This prevents trauma to the anal and rectal mucosa, which reduces surface friction (Peate [192], E).
6. 11.Show
   Expel excessive air from the enema and introduce the nozzle or tube slowly into the anal canal while separating the buttocks. (A small amount of air may be introduced if bowel evacuation is desired.)
   The introduction of air into the colon causes distension of its walls, resulting in unnecessary discomfort for the patient. The slow introduction of the lubricated tube will minimize spasming of the intestinal wall (evacuation will be more effectively induced due to the increased peristalsis). E
7. 12.Show
   Slowly introduce the tube or nozzle to a depth of 10–12.5 cm.
   This will bypass the anal canal (2–3 cm in length) and ensure that the tube or nozzle is in the rectum. E
8. 13.Show
   If a retention enema is used, introduce the fluid slowly and leave the patient in bed with the foot of the bed elevated by 45° for as long as prescribed. Ask the patient to retain the fluid for the prescribed time. Now skip to step 20.
   To avoid increasing peristalsis. The slower the rate at which the fluid is introduced, the less pressure is exerted on the intestinal wall. Elevating the foot of the bed aids retention of the enema by the force of gravity. C
9. 14.Show
   If an evacuant enema is used, introduce the fluid slowly by rolling the pack from the bottom to the top to prevent backflow, until the pack is empty or the solution is completely finished.
   The faster the rate of flow of the fluid, the greater the pressure on the rectal walls. Distension and irritation of the bowel wall will produce strong peristalsis that is sufficient to empty the lower bowel (Peate [192], E).
10. 15.Show
    If using a funnel and rectal tube, adjust the height of the funnel according to the rate of flow desired.
    The forces of gravity will cause the solution to flow from the funnel into the rectum. The greater the elevation of the funnel, the faster the flow of fluid. E
11. 16.Show
    Clamp the tubing before all the fluid has run in.
    To avoid air entering the rectum and causing further discomfort. E
12. 17.Show
    Slowly withdraw the tube or nozzle.
    To avoid reflex emptying of the rectum. E
13. 18.Show
    Dry the patient's perineal area using gauze squares.
    To promote patient comfort and avoid excoriation. P
14. 19.Show
    Ask the patient to retain the enema for 10–15 minutes before evacuating the bowel.
    To enhance the evacuant effect. P
15. 20.Show
    Ensure that the patient has access to the nurse call system; is near to a bedpan, commode or toilet; and has adequate toilet paper.
    To enhance patient comfort and safety. To minimize the patient's embarrassment. P

Post‐procedure

1. 21.Show
   Remove and dispose of equipment, gloves and apron. Decontaminate hands using soap and water or an alcohol‐based handrub.
   For infection prevention and control (NHS England and NHSI [161], C).
2. 22.Show
   Record in the appropriate documents that the enema has been given, the effect on the patient and the result (colour, consistency, content and amount of faeces produced), using the Bristol Stool Chart (see Figure 6.3).
   To monitor the patient's bowel function (Peate [192], C).
3. 23.Show
   Observe the patient for any adverse reactions.
   To monitor the patient for complications (Peate [192], C).