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Bowel care part 4. Administering an enema

An enema is a liquid preparation that is introduced into the body via the rectum for the purposes of producing a bowel movement or administering medication.

Kyle, G. (2007) Bowel care part 4. Administering an enema. Nursing Times; 103: 45, 26-27.

Keywords: Gastrointestinal, enema, bowel care

Author
Gaye Kyle, MA, BA, RGN,
is senior lecturer, Faculty of Health and Human Science, Thames Valley University.

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Introduction

An enema may be required for the following:

  • Acute disimpaction of the bowel;

  • Bowel clearance before bowel investigations or surgery;

  • To soothe and treat bowel mucosa in chronic inflammatory bowel disease such as ulcerative colitis and Crohn’s disease.

There are two main types of enemas - evacuant and retention.

Evacuant
An evacuant enema is designed to prompt the bowel to expel faecal matter or flatus, together with the contents of the enema. Phosphate and sodium citrate (Microlette) are the most common types.

Possible risks associated with phosphate enemas have been raised (Davies, 2004) so an assessment of need is vital. A recent systematic review of the adverse effects of phosphate enemas (Mendoza, 2007) found an absence of conclusive evidence. Those aged under five and over 65 appear to be most at risk,especially older people with chronic renal failure and/or diseases that alter intestinal mobility.

Retention
A retention enema is designed to be retained in the rectum. The most common are:

  • Steroid and aminosalicylate preparations;

  • Arachis oil enemas, which soften and lubricate impacted faeces. They contain groundnut and peanut oil, which means they should be avoided in patients with a nut allergy.

Nurses must have a sound knowledge of the use, action, dose and possible ill effects of administrating an enema. Volume retention enemas are contraindicated in all spinal injury patients.

Equipment

  • Incontinence sheet;

  • Disposable gloves;

  • Gauze swabs;

  • Lubricating jelly;

  • Enema;

  • Jug.

Preparation

The use of enemas in clinical practice for bowel evacuation is declining because of the availability of a range of oral alternatives. The procedure is invasive and patients often find it uncomfortable and embarrassing.

Nevertheless, for some patients, an enema may still be the preferred method of treatment.

A careful assessment of need for an evacuant enema is required, which may necessitate a digital rectal examination to assess faecal loading.

The procedure

  • Explain the procedure and any potential risks to the patient. Document that consent has been given.

  • Encourage the patient to empty bladder as fluid entering the rectum may cause discomfort to an already full bladder.

  • Ensure the patient has privacy.

  • Make sure that a commode or toilet is nearby because inserting an enema often gives the patient urgency to defecate.

  • Remove any clothing below the waist and ensure that the patient is covered with a blanket.

  • Help the patient to adopt, if possible, the left lateral position with knees flexed to expose the anus and allow easy insertion of the enema (Fig 1). The left side is preferred for this procedure because of the position of the rectum. However, this position is not essential - for example it should be avoided if the patient has a left-sided weakness.

  • Warm the enema in a jug of water to a hand-hot temperature (Fig 2). A cold enema is unpleasant and uncomfortable.

  • Check the perineal and perianal area. Document the findings and report any abnormalities observed.

  • Wash hands, then put on a disposable apron and non-latex gloves. Place a plastic-backed absorbent sheet under the patient.

  • Remove the cap from the enema, place lubricating jelly on a swab and lubricate the end of the nozzle (Fig 3).

  • Expel any excess air, as air in the colon may cause distension and abdominal discomfort (Fig 4).

  • Part the buttocks and gently insert the enema into the anus, or into the anal canal and then on to the rectum (Fig 5). The anal canal is approximately 5cm in length so the insertion of more than this length ensures that the nozzle of the enema is in the rectum. Slowly introduce the contents of the enema.

  • Slowly withdraw the nozzle in order to avoid a reflex emptying of the bowel
    (Fig 6). Wipe the perianal area with a clean swab.

  • Ask the patient to retain the enema for up to 10-15 minutes before using the commode or lavatory. Patients often find this easier if they remain lying down. Ensure the patient has access to a call bell, commode and/or lavatory with a supply of toilet paper.

  • The patient may complain of light-headedness during the insertion of an enema or during evacuation of the bowel. This is due to vagal nerve stimulation, which can slow the heart rate and alter its rhythm.

  • Remove and dispose of equipment. Remove gloves and apron, and wash hands. Inform the patient of the outcome and ensure that the procedure and its result are documented using the Bristol Stool Chart.

References

Davies, C. (2004) The use of phosphate enemas in the treatment of constipation. Nursing Times; 100: 18, 32-35.

Mendoza, J. et al (2007) Systematic review: the adverse effects of sodium phosphate enema. Alimentary Pharmacology and
Therapeutics
; 26: 9-20.

Professional responsibilities
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

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