A nurse stops administering an enema because the patient develops bradycardia and hypotension. The nurse understands the response as a result of stimulating a specific nerve. Patient has had a
The Correct answer and Explanation is:
Answer: The patient has had a vagal response.
Explanation:
When a nurse observes bradycardia (slow heart rate) and hypotension (low blood pressure) during or after the administration of an enema, these symptoms are often indicative of a vagal response. The vagal response is caused by the stimulation of the vagus nerve, which is the tenth cranial nerve and plays a critical role in regulating heart rate and blood pressure.
The vagus nerve is part of the parasympathetic nervous system, which is responsible for the “rest and digest” functions of the body. It innervates various organs, including the heart, and helps regulate autonomic functions. When the vagus nerve is stimulated, it can lead to an increased parasympathetic output, which results in decreased heart rate (bradycardia) and a drop in blood pressure (hypotension).
In the context of enema administration, several factors can stimulate the vagus nerve. One common factor is the distention of the rectum and lower colon. As the enema fluid is introduced, it can stretch the rectal walls and stimulate the vagus nerve either directly or through reflex mechanisms. This can cause the reflexive slowing of the heart rate and a decrease in blood pressure.
The enema process itself can also be somewhat invasive and uncomfortable, which might lead to increased vagal tone, especially in sensitive or anxious patients. Additionally, the position of the patient during the procedure, such as lying on their back, can influence the degree of vagal stimulation.
To manage a vagal response, it is crucial to stop the enema procedure immediately and monitor the patient closely. Supporting measures might include placing the patient in a supine position (lying flat) with their legs elevated, ensuring their safety, and assessing vital signs regularly. If necessary, medical intervention may be required to stabilize the patient and address the bradycardia and hypotension.
Understanding this response helps nurses anticipate and manage potential complications associated with procedures that can stimulate the vagus nerve, ensuring patient safety and comfort.