MEETING PATIENT NEEDS: BOWEL ELIMINATION: ENEMA

1. Enema
Procedure

2. Definition
An enema is an introduction of fluid into the
lower bowel through the rectum for the purpose
of cleansing or to introduce medication or
nourishment.

3. Purpose
To stimulate defecation & to treat constipation ex:
simple evacuant enema
To soften hard faecal matter ex: oil enema
To administer medication ex: sedative enema
To protect and soothe the mucus membrane of intestine
& to check diarrhoea ex : emollient enema
To destroy intestinal parasites ex : anthelminitic
enema
To relieve the gaseous distention ex : carminitive
enema

4. Purpose
 To administer the fluid and nutrients ex: nutritive enema
 To relieve inflammation ex : astringent enema
 To induce peristalsis ex : purgative enema
 To stimulate a person in shock and collapse ex: stimulant enema
 To reduce the temperature ex : cold enema or ice enema
 To clean the bowels prior to x-ray studies , visualization of the
bowel , surgery on the bowel or delivery of a baby ex : saline
enema
 To make diagnosis ex: barium enema
 To establish regular bowel functions during a bowel training
programme
 To induce anesthesia ex : anesthetic enema

5. Classification of
enema
Evacuant enema Retained enema

6. Evacuent
enema
Simple
Evacuent
enema
Medicated
Evacuent
enema
Oil enema
Purgative
enema
Astringent
enema
Anthelminthic
enema
Carminative
enema
Cold enema
Retained
enema
Stimulant
enema
Nutrient
enema
Emollient
enema
Sedative
enema
Anaesthetic
enema

7. Evacuent enema

8. Simple evacuant enema
 Purpose :
 To stimulate defecation & to treat constipation
 To relieve the gaseous distention by stimulating
the peristalsis
 To relieve the retention of urine by reflex
stimulation of the bladder
 To stimulate uterine contraction & to hasten
the child birth
 To cleanse the bowel prior to x-ray studies ,
visualization of the bowels
(ex: sigmoidoscopy) , surgery & retention enemas

9. Simple evacuant enema
 Solutions used :
 soap & water : soap jelly 50ml to 1 liter of water
 Normal saline : sodium chloride 1 teaspoon of half liter of
water
 Tap water
 Amount of solutions to be used :
 Adults : 500 to 1000 ml ( 1 to 2 pint )
 Children's : 250 to 500 ml ( 0.5 to 1 pint )
 Infants : 250 ml or less
 Temp of solution :
 Adults : 105 to 110 degree Fahrenheit
 Children : 100 degree Fahrenheit

10. Oil enema
 These are given to soften faecal matter in case of
severe constipation
 Before the 1st bowel movement after operation on the
rectum or perineum. To avoid straining & injury to the
sutures & wounds
 It should be retained for half an hour to 1 hour to
soften the faeces
 It should then be followed by a soap & water enema to
open the bowels

11. Oil enema
 Solutions used :
 Olive oil
 Gingerly oil or sweet oil
 Castor oil & olive oil (1:2)
 Amount of solution to be used : 115 to 175
ml
 Temperature of the solutions : 100
degree Fahrenheit

12. Purgative Enema
 These are given to cause the bowel to
contrast actively & to evacuate its contents
 Its acts by their irritating effect on the mucus
lining, stimulate peristalsis& cause the
evacuation of bowel
 The stretching of the intestine due to this inflow
of fluid causes the intestine to contract & leads
to the evacuation of bowels

13. Purgative Enema
 Solutions used :
 Pure glycerin – 15 to 30 ml
 Glycerin & water – 1:2
 Glycerin & caster oil – 1:1
 Magnesium sulphate : 60 to 120 ml with sufficient
amount of water to dissolve it
 1-2-3 enema : magnesium sulphate 30 ml, glycerin
60 ml, & water 90 ml
 Amount & temp of solution is that of oil enema

14. Anthelmintic enema
 This is given to destroy & expel the worms from the
intestines
 Before the treatment is given the bowel should be
cleansed by a soap water enema so that the drug may
come in direct contact with the worms & the lining of the
intestine
 The treatment is given until the worms are destroyed
Solution :
 Infusion of quassia : 15gms of chips to 600 ml of
water
 Hypertonic saline solution : sodium chloride 60 ml with
600 ml of water
 Amount of the solution : 250 ml

16. Carminitive enema (antispasmodic)
 These are given to relieve gaseous distention of the
abdomen by causing peristalsis & expulsion of
flatus &faeces
 It is given as simple evacuant enema
Solution :
 Turpentine : 8 to 16 ml of turpentine mixed thoroughly
with 600 to 1200 ml of soap solution
 Milk and molasses(granular sugar ) : 90 to 230 ml of
molasses well mixed with equal quantity of warm milk

17. Astringent enema
 It contracts the tissues & the blood vessels ,
checks bleeding & inflammation , lessens the
amount of mucus discharge & gives a
temporary relief in the inflamed area
 It is usually given in colitis & dysentery
 They are usually given in the form of rectal or
colonic irrigations
 The solution is allowed to run in slowly & return
quickly to avoid distension , pain & irritation of
the inflamed wall

18. Cold enema (ice enema)
 This is given to decrease the body temperature
in hyperpyrexia and heat stroke
 It is given in the form of colonic irrigation
 Complications :
 Hypothermia
 Abdominal cramps

19. Astringent enema
 Solutions :
 Tannic acid : 2 gms to 600ml of water
 Alum : 30 gms to 600ml of water
 Silver nitrate 2% : (silver nitrate is dissolved in
distilled water )
 Temperature of the solution : It is given as hot
as the client can stand

20. Retained enema

21. Stimulant enema
 A stimulant enema is given in the treatment of
shock and collapse
 It is also sometimes given in case of poisoning ex:
coffee enema is given in case of opium poisoning
 Solutions :
 Black coffee : 1 table spoon coffee powder to 300 ml of
water
 Brandy : 15 ml of brandy added to 120 to 180 ml of
glucose saline
 Amount of solution : 180 to 240 ml
 Temp of solution : 108 to 110 degree Fahrenheit

22. Sedative enema
 It is retention enema containing a sedative drug
given to induce sleep
 Drugs used :
 Paraldehyde
 Chloral hydrate
 Potassium bromide
 Dose :as ordered by the doctor

23. Emollient enema
 This is an introduction of bland solution into the rectum
for the purpose of checking diarrhoea or soothing &
relieving irritation on an inflamed mucus membrane
Solution used :
 Starch & opium : opium 1 to 2ml is added to 120 to
180 ml of starch mucilage or rice water
 Starch mucilage alone
 Amount of solution : 120 to 180 ml
 Temp of solution : 100 to 105 degree Fahrenheit (37.8 to
40.5 degree centigrade )

24. Anaesthetic enema
 It is a retention enema containing an
anesthetic drug to produce anesthesia in
client
 Drugs used :
 Avertin 150 to 300 mg per kg of body weight

25. Nutrient enema
 It is a retention enema to supply food & fluids to
the body
 Selection of the fluids depend upon the ability
of the colon to absorb it
 Nutrient enema is particularly useful in
conditions like haemophilia which makes I.V.
infusion difficult or undesirable

26. Nutrient enema
 Solutions :
 Normal saline
 Glucose 2 to 5%
 Peptonized milk 120 ml
 Amount of solution :
 1100 to 1700 ml in 24 hour or 180 to 270 ml at 4 hourly
interval
 Temperature of solution :
 100 degree Fahrenheit (37.8 degree Fahrenheit )

27. Procedure

28. Cleansing enema

29. Cleansing enema
 Definition
 Introduction of solution into the large intestine for
removing feces and cleansing the bowel
 Purposes
 To relive constipation or fecal impaction
 To prevent involuntary escape of fecal matter during
surgical procedure and delivery
 To promote visualization of the intestinal tract during
radiographic or instrumental examination
 To help establish regular bowel function during a bowel
training program
 Preoperative preparation for bowel surgeries
 To relieve retention of urine by reflex stimulation of
bladder

30. Solutions used
 Hypertonic :sodium phosphate, fleet enema
 Hypotonic : tap water
 Isotonic : physiological saline (one tsp of table salt in
500 ml of tap water)
 Others : 3-5 ml of concentrated soap solutions in
1000 ml water

31. Contraindications
 Acute renal failure
 Acute myocardial infarction and cardiac problems
 Appendicitis
 Obstetrical contraindications like antepartum
hemorrhage, leaking membranes
 Recent surgical procedures involving lower intestinal
tract
 Intestinal obstruction
 Inflammation and infection of abdomen

32. Principles applied for enema
Nursing principles
 Safety
 Therapeutic
effectiveness
 Comfort
 Use resources
 Good workmanship
 Individuality
Scientific principles
 Anatomy and
physiology
 Microbiology
 Nutrition
 Pharmacology
 Physics
 Chemistry
 Psychology
 Sociology

33. General instructions
 The appropriate size catheter or rectal tube need to be
used
 the rectal tube needs to be smooth and flexible
 The rectal tube is lubricated with water soluble lubricant
 The temperature of the solutions needs to be adjusted
according to the purpose of enema
 The amount of the solution to be administered depends
upon the type of the enema and the age & size of the
person
 When enema is administered, the client usually assumes
a left lateral position
 The distance to which the tube is inserted depends upon
the age and the size of the client
 The height f the can should be adjusted to regulate the
flow of the solution according to the type of the enema

34. General instructions
 The length of time that the enema solution is retained will
depend upon the purpose of enema and the ability of the
client to contract the external sphincter to retain the
solution
 Make sure the whole apparatus used for the
administration of enemas is in a good working condition
 Regulate the flow of fluid according to the type of the
enema, give retention enema very slowly, usually by a
Murphy drip.
 If the rectum is impacted, attempt to remove the faecal
matter with gloved finger.
 Listen to the complaints of the client and should not
ignore
 Prepacked enemas will have their own instructions which

35. Articles

36. Articles
 Enema can and tubing method
 A tray containing
 Disposable gloves
 Water soluble lubricant
 Bath thermometer
 Soap and water
 Toilet tissues
 Enema can
 Tubing and clamp
 Appropriate size rectal tube
 Adult : 22-30 Fr
 Child size : 12-18 Fr

37. Articles
 IV stand
 K . Basin(2)
 Solution as ordered
 Mackintosh/waterproof
under pad
 Bedpan
Temperature of solution
 Adult : 105-110 F (40-43
C)
 Child : 100 F(37.1 C)
Amount of solution
 Adult :750-1000 ml
 Adolescent :500-750 ml
 School age :300-500 ml
 Toddler :250-300 ml
 Infant :150-250 ml

38. Procedure
 Assess status of patient
 Last bowel movement
 Normal bowel pattern
 Mobility
 Abdominal pain etc.
 Determine the level of consciousness and understanding,
provide privacy
 Explain procedure purpose to the patient
 Assemble articles, wash hands and don gloves
 Raise the bed to appropriate height
 Assist patient to side lying position (sim’s position)
 Place mackintosh under hip and buttocks
 Cover the patient exposing only anal area, clearly
visualizing anus

39. Procedure
 Place bed pan or commode in easily accessible position
 Check temperature of solution on inner wrist
 Raise container, release clamp and allow solution to flow
long enough to fill tubing
 Clamp the tubing lubricate 6-8 cm of tip of rectal tube with
jelly
 Separate the buttocks and locate the anus. Instruct patient
to relax by breathing out slowly through mouth
 Insert –tip of rectal tube gently by pointing the tip in the
direction of patients umbilicus
Adult : 7.5-10 cm
Child : 5-7.5 cm
Infant : 2.5-3.7 cm
 Hold the tubing in place with one non- dominant hand.

40. Procedure
 Open regulatory clamp and allow solution to enter slowly
with the container at the patients hip level.
 Raise the enema can slowly to appropriate level above
the anus. Eg: for the infusion rate 1L in 10 mt.
 Lower container or clamp tubing for 30seconds.If patient
complaints of cramping or if fluid escapes around rectal
tube.
 Clamp tubing after all solution is instilled.
 Inform patient, that fluid instillation is over and the tube
will be removed.
 Place layers of toilet tissue around tube at anus and
gently withdraw rectal tube.
 Explain to patient that feeling of distention is normal and
ask patient to retain solution as long as possible (5-10
mts)while lying quietly in bed.

41. Procedure
 Discard the disposable, used items in proper receptacle. If
enema can needs to be reused. Rinse out thoroughly with
soap and warm water.
 Assist patient to toilet or help to position on bed pan.
 Observe the fecal matter and expelled solution.
 Assist as needed to wash anal area with soap and water.
 Remove and discard gloves and wash hands.
 Assess condition of patient abdomen may indicate serious
problems.
 Record type and volume of enema given and characteristics
of return flow.
 Report failure to defecate to the physician
 Clean and replace the reusable articles. Discard any waste
and disposable items.

42. Evacuant enema
(pre packed preparation)

43. Articles
 A tray containing
 Clean gloves
 Packet of enema
 Toilet tissues
 Soap and water
 Kidney tray
 Mackintosh
 Lubricant jelly
 Bedpan/commode

44. Procedure
 Assess status of patient
 Last bowel movement
 Normal bowel pattern
 Mobility
 Abdominal pain etc.
 Determine the level of consciousness and understanding,
provide privacy
 Explain procedure purpose to the patient
 Assemble articles, wash hands and don gloves
 Raise the bed to appropriate height
 Assist patient to side lying position (sim’s position)
 Place mackintosh under hip and buttocks
 Cover the patient exposing only anal area, clearly visualizing
anus
 Place bed pan or commode in easily accessible position

45. Procedure
 Remove plastic cap from rectal tip and lubricate the tip
 Gently separate the buttocks and locate the anus.
Instruct the patient to relax by breathing out through
mouth.
 Insert tip of the tube gently into rectum
 Adult :7.5 cm
 Child :5-7.5 cm
 Infant : 2.5-3.7 cm
 Squeeze the container until all solution has entered
rectum and sigmoid colon while squeezing container roll
it up as fluid is instilled
 Place toilet issue around the anus and withdraw the tube
 Discard the disposable items in proper receptacle
 Assist the patient to toilet or help to position on bedpan

46. Procedure
 Observe the fecal matter and expelled solution
 Remove gloves and discard, was hands.
 Assess condition of patient’s abdomen, cramping or
rigidity which can indicate problems.
 Record the enema given and characteristics of
result.
 Report any problem if noticed.

47. Giving enema with funnel or catheter

49. Giving enema with funnel or catheter
 Small enemas to be expelled are given using funnel &
catheter
 The oil is kept warm by placing the container in a bowl of
warm water
 During the administration , the height of the funnel should be
more than 8 inches from the anus
 Help the client to retain the solution either by raising the
foot end or by pressing buttocks
 The oil enema is to be retained for 2 to 6 hours to soften
the fecal matter
 It may be then followed by a soap & water enema to expel
the fecal contents
 The preparation & after care of the client & articles are same
as in soap & water enema

50. Giving enema using glycerin
syringe

52. Giving enema using glycerin syringe
 A glycerin syringe (metal syringe) and a rubber
catheter attached to its nozzle are used
 Air to be expelled, prior to the administration of the
fluids
 This method is particularly useful for giving enema to
children.

53. Giving enema by the drip
method
Eg: nutrient enema
(Proctoclysis or continuous retention enema )

54. Giving enema by the drip method
 Articles required
 All the articles used for an evacuant enema EXCEPT the
following
 A reservoir (this can be an enema can or a bottle with a
cork)
 Tubing attached to the reservoir
 Murphy drip and a clamp
 A fine catheter
 Bed blocks to raise the foot end

55. Giving enema by the drip method
 Procedure
 Administration of retention enema is done by the drip
method
 Purpose : to retain the solution and never to evacuate
 Fine catheter is used in place of rectal tube ( to prevent
defecation reflex)
 Flow is regulated by Murphy drip or and a clamp (less
than 40 drops per minute )
 Foot end is raised to retain the fluid
 Usually a retention enema is preceded by a simple
enema to keep the bowel free of faecal matter

56. Thank you