What are the key elements to assess before administering a cleansing enema?

Open Resources for Nursing (Open RN)

Use  the checklist below to review the steps for completion of “Rectal Medication Administration” using a rectal suppository.[1]  

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

Follow Steps 1 through 12 in the “Checklist for Oral Medication Administration.”

1.  
2.  
3.  
4.  
5.  
6.  
7.  
8.  
9.  
10.  
11.  
12.  
13. If possible, have the patient defecate prior to rectal medication administration.
14. Ensure that you have water-soluble lubricant available for medication administration.
15. Explain the procedure to the patient. If a patient prefers to self-administer the suppository/enema, give specific instructions to the patient on correct procedure.
16. Raise the bed to working height:
    • Position the patient on left side with the upper leg flexed over the lower leg toward the waist (Sims position).
    • Provide privacy and drape the patient with only the buttocks and anal area exposed.
    • Place a drape underneath the patient’s buttocks.
17. Apply clean, nonsterile gloves.
18. Assess the patient for diarrhea or active rectal bleeding.
19. Remove the wrapper from the suppository/tip of enema and lubricate the rounded tip of the suppository and index finger of the dominant hand with lubricant. If administering an enema, lubricate the tip of the enema.
20. Separate the buttocks with the nondominant hand and, using the gloved index finger of dominant hand, insert the suppository (rounded tip toward patient) into the rectum toward the umbilicus while having the patient take a deep breath, exhale through the mouth, and relax the anal sphincter. Insert the suppository against the rectal mucosa for optimal absorption, about 3 to 4 inches for an adult and 1 to 2 inches for a child. Do not insert the suppository into feces. If administering an enema, expel the air from the enema and then insert the tip of the enema into the rectum toward the umbilicus while having the patient take a deep breath, exhale through the mouth, and relax the anal sphincter. Roll the plastic bottle from bottom to tip until all solution has entered the rectum and colon. Remove the bottle.
21. Monitor the patient for signs of dizziness. Unintended vagal stimulation may occur, resulting in bradycardia in some patients. Be aware that the rectal route may not be suitable for certain cardiac conditions.
22. When administering a suppository, ask the patient to remain on side for 5 to 10 minutes.
    • When administering an enema, ask the patient to retain the enema until the urge to defecate is strong, usually about 5 to 15 minutes.
23. Discard gloves by turning them inside out before disposing them. Discard used supplies as per agency policy and perform hand hygiene.
24. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
25. Ensure safety measures when leaving the room:
    • CALL LIGHT: Within reach
    • BED: Low and locked (in lowest position and brakes on)
    • SIDE RAILS: Secured
    • TABLE: Within reach
    • ROOM: Risk-free for falls (scan room and clear any obstacles)
26. Perform hand hygiene.
27. Document medication administration and the related assessment findings. Report any unexpected findings according to agency policy.
28. Evaluate the patient’s response to the medication within the appropriate time frame.