ENEMA

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.
An enema involves inserting liquid or gas into the rectum, which is the lower part of the large intestine. The aim is to empty the bowels, allow for an examination, or administer medication.

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
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

Classification of enema

Evacuant enema
Retained enema

1. Evacuent enema

Simple Evacuent enema
Medicated Evacuent enema

Oil enema
Purgative enema
Astringent enema
Anthelminthic enema
Carminative enema

Cold enema

2. Retained enema

Stimulant enema
Nutrient enema
Emollient enema
Sedative enema
Anaesthetic enema

Evacuant Enema	Retention Enema
Evacuant enema are meant to be returned	Retained enemas are meant to be retained
A water-based formulation is used in this process	An oil-based formulation is used in this process
Evacuant enema has its use in increasing the water content of the stool.	The retention enema has its use in lubricating the bowel content so as to facilitate the softening of the stool
Evacuant Enema is used to eliminate different gaseous distension and also to increase the water content which is present in the stool.	Retention Enema is usually used in shock, collapse and some poisoning cases.
Evacuant enema is used in the rectum or in the lower colon.	On the hand, retention enema is usually used to lubricate the bowels

1. Evacuent enema

A. 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

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

B. Medicated Evacuent Enema

a. 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

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

b. 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

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

c. 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

d. 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

e. 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

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

C. 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

2. Retained enema

a. 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

er nitrate 2% : (silver nitrate is dissolved in distilled water

b. 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

c. 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 )

d. 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.

e. 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

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 )

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
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

Note-The placing or hanging your enema bucket or enema bag no more than 18 inches above your buttocks.

Articles

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

IV stand
K . Basin(2)
Solution as ordered
Mackintosh/waterproof under pad
Bedpan

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
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(3-4 Inch)
Child : 5-7.5 cm (2-3 Inch)
Infant : 2.5-3.7 cm (1-1.5 Inch)

Hold the tubing in place with one non- dominant hand.
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.
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.